Frozen Shoulder – Still a bit of a mystery

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By Mr Harry Brownlow, December 2017

Frozen Shoulder used to be a diagnosis that was given to anyone with a painful shoulder. Nowadays we have a better understanding of the condition and how to make the correct diagnosis. But we still have no idea about why it comes on and why it then gets better naturally. And there is still a great deal of debate, within the shoulder community, about how it is best treated.

The diagnosis of frozen shoulder is made from the history and examination. The story is typically one of gradually worsening pain for no good reason or after a fairly trivial incident. The characteristic  pain is an excruciating discomfort when the shoulder is suddenly, and unexpectedly, over stretched. This causes a wave of nauseating discomfort which slowly subsides over a few minutes leaving a low dull background ache. Examination of the shoulder typically reveals reduced movement in all directions but with well maintained strength. Xrays should be normal. Ultrasound scans and MRIs can be used to rule out other diagnoses but there are no specific findings on scans which define the diagnosis.

One thing is clear; frozen shoulder gets better eventually.

The treatment is hotly debated at every shoulder conference around the world. We don’t have a unified answer because the necessarily big clinical trials have not been performed. Currently our best evidence comes from weak studies and from clinical experience. However, one thing is clear; frozen shoulder gets better eventually. The natural history of the condition is about 18 months from start to end although, if you are diabetic, it can take twice as long.

What are your options?
So, one perfectly valid treatment is, to do nothing, understanding that you have a self-limiting condition that will eventually go away. While waiting for spontaneous resolution it is a simple matter of managing the pain with painkillers and trying to avoid doing things which hurt!

The role of physiotherapy is contended. Most people find physiotherapy to be very painful and therefore stop doing the exercises. Towards the later stages of the disease, when the painful stage has settled, there may be a role for physiotherapy but it is unproven.

I am a strong advocate of one or two cortisone injections into the glenohumeral joint. Cortisone is a powerful anti-inflammatory drug with minimal side effects. Since frozen shoulder is principally an inflammatory condition it makes good sense to try an injection. Only occasionally is a second injection required. Reducing the inflammation will settle the pain and improve sleeping, but it cannot help with the tightness of the shoulder.

Watch a video of a cortisone injection being given using ultrasound below:

There has been recent press attention on the role of distension hydrodilatation. This is a technique that was popular in Australia a few years ago. It involves injecting enough fluid to cause the shoulder joint to burst and to also inject cortisone. The jury is very much out on this treatment. I remain sceptical. In my experience it is a very painful procedure and I believe all the benefit derives from the cortisone injection rather that the bursting of the capsule.

Some people choose to have an operation because they want to regain movement as well as being free of pain.

Some people choose to have an operation because they want to regain movement as well as being free of pain. The two operations to consider are a manipulation under anaesthetic (MUA) or an arthroscopic capsular release (ACR). Yet again there is great debate as to which is better. I prefer the MUA for most people as it is an operation performed without any cutting. It is a matter of stretching the shoulder while you are asleep. It is a really safe and reliable way to improve the movement. If you have a super tight shoulder or if your bones or tendons might be vulnerable to injury, then I would advocate the ACR. This is an invasive keyhole operation but which is also very successful and safe.

Watch a video of a manipulation under anaesthetic procedure below:

So, in my opinion, there are 3 basic ways to manage a frozen shoulder.

  1. Wait for natural resolution over 18 months
  2. Have a cortisone injection to relieve pain, accepting it will not improve movement
  3. Have an MUA to improve pain and movement

Given these options most people come to a quick decision as to which is best for them. One option is no better than another and they all have pros and cons. However it is always sensible to have discussed these with a shoulder specialist as there may be other factors, particular to you, which should be considered in the treatment plan.