Frozen Shoulder

What is frozen shoulder?

Frozen shoulder is a painful, disabling condition of the shoulder characterized by increasing stiffness of the joint. It typically goes through three stages.

An initial, very painful, inflammatory phase (approximately 3 months), followed by a less painful but stiff frozen phase (3-9 months) followed by a thawing phase (9-12 months) during which movement is recovered. The whole process can last for up to two years, although occasionally longer.

What causes frozen shoulder?

Frozen shoulder usually comes on 'out of the blue' but occasionally it can follow a minor 'wrenching' injury of the joint. It is more common in diabetics and patients with other endocrine problems such as thyroid disease.

It is not know what exactly triggers a frozen shoulder but the capsule (the lining) of the joint becomes very inflamed and then gradually scars leading to a contracture.

It is the inflammation that causes the intense pain, particularly at night, and the contracture of the capsule that causes the restriction of movement.

How is frozen shoulder diagnosed?

The first step is to make the correct diagnosis. Frozen shoulder can be confused with arthritis, impingement, acromioclavicular joint pain and rotator cuff tears.

The diagnosis is made by taking a careful history, particularly around the onset of the symptoms and the sorts of activities which cause the pain. A thorough examination is very important assessing the range of movement of the joint, strength of the individual tendons and the manoeuvres that cause pain.

Typically in frozen shoulder the range of movement of the joint is significantly reduced compared to the normal shoulder whilst the strength of the muscles/ tendons is preserved. An x-ray is helpful to exclude underlying arthritis, which can also cause pain and restricted movements of the shoulder. An MRI scan is seldom indicated.

What are the treatment options?

Frozen shoulder is usually a 'self limiting' condition. This means it will generally get better by itself.

The whole process, however, from onset of pain to recovery of function and resolution of the pain can take up to two years. If you are managing with the level of discomfort and restricted movement then, once the diagnosis is made, you can continue with gentle exercises to keep the joint mobile. It is important not to overstretch the joint as this will aggravate your pain.

We tend to recommend that you avoid physiotherapy in the early stages for this reason. Once you are in the 'frozen' phase then gentle physiotherapy can be helpful. If you are experiencing a lot of pain then an injection into the shoulder joint can be very helpful at alleviating the pain.

The best results are obtained if the injection is into the ball and socket joint itself so we recommend a guided injection given by a specialist radiologist under x-ray or ultrasound control. About 80% of patients notice a significant improvement in their pain after injection but the joint will remain stiff until the capsule contracture resolves. If your shoulder does not respond to the guided injection and remains stiff and painful then the choice is between a procedure called 'hydrodilatation' (injecting 30-40mls of saline into the joint to rupture the capsule) or key hole release of the contracture. We will discuss the pros and cons of each procedure with you in clinic.

What does surgery involve?

The operation for frozen shoulder is called Arthroscopic Release followed by gentle manipulation of the joint to stretch up the released tissue.

The operation is 'key hole' and involves release of the contracted capsule circumferentially around the ball and socket. This reduces the risk of damage to important structures when the shoulder is then manipulated.

Sometimes the procedure is combined with subacromial decompression (see Impingement Syndrome). The operation is typically performed as a day case under a general anaesthetic with a nerve block (which helps the pain for the first 12-16 hours) and takes about 45-60 minutes.

You will usually be admitted to hospital early in the morning and be home by early or mid afternoon.

What can I expect after surgery?

You will wake up from surgery with your arm in a sling but you can remove this over the next couple of days. Your arm will feel numb and 'heavy' whilst the nerve block is working during the first night.

The shoulder will become a bit sore after that but you will be provided with painkillers which you should take regularly for the first few days. You should aim to start moving your shoulder as soon as you are comfortable. You will be provided with a 'rehabilitation' sheet showing you the appropriate exercises or you can download the instructions from the Exercises and Rehabilitation section of this website.

Most patients will have recovered quite good movement by 6 weeks post surgery, will be able to return to driving by 3-4 weeks, will be able to return to light manual work by 4-6 weeks and heavier duties, including sports, by 8-12 weeks. By 6 months 80% patients can expect to have had a good or excellent outcome.

Occasionally the shoulder may begin to 're-stiffen' after release in which case a second guided injection can be very effective.