Defrosting frozen shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition that causes pain and then progressive stiffness in the shoulder joint to where it eventually becomes “frozen” and almost immovable. No precise cause has been identified, but we know that inflammation is involved, followed by fibrosis of the joint lining. The condition sometimes follows an injury to the joint but often occurs spontaneously, with no obvious provoking factors.

Frozen shoulder occurs more commonly in women than in men, tends to present in middle age, occurs in 1 in 5 diabetics, and can sometimes occur in both shoulders.

The good news is that the condition usually resolves or “thaws” spontaneously. The bad news is that this recovery can take from 6 months to over 2 years and some patients report that their shoulder never recovers fully.

Fortunately, several treatment options are available that may ease the symptoms of this debilitating condition and even hasten the recovery to a full, pain-free range of motion. In this article, we’ll explore the pros and cons of the most common treatment options ranked from most conservative to most invasive.

1. Physiotherapy

For most patients, enrolling in a physical therapy program is the backbone of frozen shoulder treatment and the key to recovery.

Patient education is one of the most vital components of the physiotherapist’s role. By gaining an understanding of your own condition and realising your progress, you can better manage your expectations, reduce your frustration and be more compliant with your home exercise programme.

Physiotherapists will invariably employ some manual muscle release techniques, passive and active mobilisations, and various stretches. Depending on the stage of the condition, the physiotherapist may choose to include dry needling, TENS machines, or kinesiotherapy techniques.

2. Hot and cold therapy

In the initial “freezing” stage of frozen shoulder, the joint is inflamed and painful. Applying a heat pack might well make things worse. Choose a cold compress or ice pack instead to ease the pain. In the latter adhesive or “thawing” stages, heat packs can be very effective when used before a stretching or home exercise session to promote an increased range of motion.

3. Topical creams and lotions

Various warming and cooling gels are available over the counter. Although these ointments might feel pleasant or tingly when applied, they will not impart any significant benefit.

In the initial painful phase, gels and patches containing non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac may help to ease pain and inflammation.

4. Oral medication

Non-steroidal anti-inflammatory drugs have traditionally been prescribed to patients with frozen shoulder, but there is no high-level evidence that confirms their effectiveness. Many patients report they provide relief during painful phases.

Oral corticosteroids have also been utilised in patients with frozen shoulder and many patients report some improvement in function after their use. Long-term oral steroid use risks significant side effects and so we should use these drugs in short bursts, if at all. 

5. Corticosteroid injections

By injecting a corticosteroid medication directly into the shoulder joint, the powerful anti-inflammatory effects of the steroid are concentrated where needed most. If performed early in the disease process, inflammation within the joint can be lessened, leading to less severe fibrosis and adhesion formation. For this reason, we consider corticosteroid injections more effective in the painful and freezing stage of the condition. The corticosteroid is almost always mixed with a local anaesthetic agent that will also reduce pain and aid with improving the motor control of the shoulder complex.

Success rates range from 44 to 80% and many patients report rapid pain relief and improved function within the first few weeks of the injection. You should consider corticosteroid injection as a first-line treatment if pain is your predominant complaint during the early stages of frozen shoulder. By combining a corticosteroid injection with ongoing physiotherapy, you can give yourself the best chance at a rapid recovery with no surgery.

6. Manipulation under anaesthesia (MUA)

This involves going to an operating theatre and undergoing a general or regional anaesthetic. Once anaesthetised, the surgeon forcefully moves the shoulder in all planes to stretch and disrupt the capsule to regain range of motion. It is not without risk of complications such as dislocation or fractures or even nerve injuries.

MUA is a last resort and reserved for patients who are resistant to physical therapy. After manipulation, an extensive post-manipulation programme is necessary to preserve any range of motion gained.

7. Hydrodilatation

Also known as distension arthrography, hydrodilatation has emerged as a potential non-surgical option in the management of frozen shoulder. It involves the injection of a large volume of fluid (usually containing some steroid and local anaesthetic) into the shoulder joint under x-ray guidance. The goal is to stretch and expand the joint capsule like a water balloon.

There is no high-level evidence to support the technique yet, but some studies have shown that it can provide short-term pain relief and improved function for up to 3 months.

8. Arthroscopic capsular release

We almost never perform open shoulder surgery for frozen shoulder anymore. However, arthroscopic surgery, or so-called “key-hole surgery”, is a reliable and effective method for restoring range of motion in non-responsive patients. It allows a controlled release of tight capsular structures under direct vision and avoids many of the side effects associated with MUA (although nerve injuries remain a concern).

You should consider arthroscopic treatment if your symptoms have been unresponsive to at least 6 months of good conservative treatment.

Conclusion

Frozen shoulder is a debilitating condition that can grumble on for years. That said, there are many treatment options available that can speed up the journey to healing. 

Early diagnosis is vital so that a corticosteroid injection can extinguish the inflammatory process. Ongoing physiotherapy can then restore any lost range of motion. 

Keep up hope if you don’t respond to conservative measures - more invasive treatments including MUA, hydrodilatation or arthroscopy can be effective at treating this frustrating condition.