Frozen Shoulder

It starts with inflammation of the inner lining of the joint which is very painful. This is followed by the
formation of scar tissue within the joint capsule that restricts all shoulder movements. It can occur
spontaneously due to unknown reasons or it can develop after a shoulder injury, shoulder surgery, breast
surgery or a stroke due to disuse of the shoulder. It occurs most commonly in patients aged 40-60 years old and is more common in women. Diabetic patients and patients with thyroid problems have an increased risk of developing frozen shoulder. After it has resolved, frozen shoulder will usually not develop again in the same shoulder. However, there is a 16% risk of developing frozen shoulder in the opposite shoulder.

Presentation:

Shoulder pain develops gradually and is usually first noticed in certain positions such as reaching back with the arm. Within weeks, all shoulder movements become progressively more painful, especially sudden
quick movements. The pain may start to improve after a few months, but shoulder movement becomes
progressively more limited. Stiffness can last up to 18-24 months but will resolve in 90% of patients
without the need for surgery.

Non-operative management:

As mentioned above, frozen shoulder is normally self-limiting in nature and most patients can be treated
without surgery. Treatment is focussed on pain management initially as well as maintenance of shoulder
range of motion. Options include:

• Simple pain-killers.
• Anti-inflammatory medication.
• Intra-articular cortisone injections: These are best administered under ultrasound guidance to
  enhance the accuracy of the injections. They are mainly effective early in the disease process when
  there is a lot of inflammation and pain.
• Physiotherapy or home based shoulder stretching exercises: The shoulder should be stretched
  within the pain threshold. Excessive stretching causing severe pain can worsen a frozen shoulder
  due to additional inflammation and scarring.

Surgical management:

Surgery is only considered as a last resort after the failure of at least 6 months’ non-operative
management. There are 2 options that are generally considered:

• Manipulation under anaesthesia: The shoulder can be stretched forcefully in all directions while the
  patient is under general anaesthesia (asleep). This manoeuvre tears the shoulder capsule but
  carries a risk of causing a fracture, especially when the bone has weakened due to disuse of the
  shoulder.
• Capsulotomy: The shoulder capsule is cut arthroscopically (key-hole surgery) with or without a
  gentle manipulation. This procedure is more controlled than performing a “blind” manipulation
  which therefore reduces the fracture risk. Key-hole surgery is also more effective in ensuring a
  complete capsular release. Most patients have significant pain relief and functional improvement
  following surgery. However, some degree of stiffness normally returns at about 6 weeks after
  surgery. This can occur even with excellent post-operative rehabilitation. Fortunately, the range of
  motion will continue to improve over the following months.