This is perhaps the most common diagnosis when a patient presents with shoulder pain. However, painful shoulder with limited movements is not always a true frozen shoulder. Frozen shoulder means that the movements are physically restricted, usually due to mechanical causes.
The pathology can be primary (idiopathic) or secondary. By far the commonest secondary pathology is diabetes, trauma or arthritis. Other relatively rare causes may include thyroid or parathyroid disorders, Parkinsonism, and cardiac conditions. Pain can also arise from a variety of other causes like tendon tear, bursitis, impingement or muscle incoordination that can cause restricted movements due to pain inhibition, which frequently gets misdiagnosed as frozen shoulder.
Historically, three stages of adhesive capsulitis have been defined, although in reality, these are not distinct and overlap significantly:
- Freezing (painful) stage – This is the acute inflammatory phase that is usually extremely painful, and the symptoms in this stage that can last between 3-9 months. (pic)
- Frozen (stiff) stage – This is when the acute pain settles down, but patients are left with varying degree of stiffness. There are two distinct subtypes: one with a ‘hard’ end point when there is no further gain beyond the end point, or with a ‘soft’ end point, wherein the tissues appear slightly more pliable allowing some more passive movements beyond the active range. The frozen stage can last 12 – 18 months in total.
- Thawing (resolution/ return of mobility) stage – This is when tissues begin to loosen up, and movements begin to improve towards normal. Most patients however are left with slight deficit towards the end range, but this does not hamper any activities of daily living. The stage can last another 12-18 months.
Overall, the natural cycle of frozen shoulder can last 2-4 years, there is considerable variation in individual presentation, and examination is important to establish the diagnosis.
It is a clinical diagnosis, but other investigations may be used to aid the diagnosis. Plain X-ray should be obtained to rule out arthritis, and sometimes MRI scan may be necessary to rule out cuff tear or an occult fracture.
- Physiotherapy: Most patients benefit from physiotherapy input in the frozen or resolution stage.
- Hydrodistension: It is an outpatient procedure done under local anaesthesia with a success rate of about 50% in suitable patients.
- Arthroscopic release: Done as a day case surgery, it involves releasing the thickened and tight capsule to restore the joint mobility. This is followed by early aggressive physiotherapy. The red inflamed tissue seen in the picture below is typical of adhesive capsulitis.
The second picture below shows release of the capsule whilst taking care to preserve the important structures like tendons, and cartilage.
The operation is done as a day case under regional block with or without GA. The shoulder can be intensely painful after releasing the tough capsule, and the block is very useful for the first 24-48 hours when the pain can be at its worst. It is a fairly common procedure with good outcomes. Success rates vary between 80-95%.
Here is a short video of the arthroscopic procedure. Please contact using the details on this website if you need a consultation.