Frozen Shoulder

What actually is a Frozen Shoulder?

Lets start with what it isn’t because there is an awful lot of confusion about this condition and we don’t even all call it by the same name! A lot of medical professionals use the name Adhesive Capsulitis but this is historical and completely wrong for two reasons. The first is that there are no adhesions in a Frozen Shoulder and the second is that there is no inflammation (the ‘itis’ bit means inflammation). So let’s stick to Frozen Shoulder.

 

Why did I get it? I don’t remember doing anything to it.

I believe there is always a trigger that causes your shoulder to freeze but it doesn’t have to be anything dramatic and often that trigger was pulled weeks or even months before you realise there is something wrong with your shoulder. So reaching over the back seat of the car to pick up a bag; pulling down a garage door – something as simple as that can cause it. The shoulder can also freeze up for a more obvious reason; after surgery on the upper limb; after a fall and that sort of thing and we call that Secondary Frozen Shoulder.

How do I know if it is a Frozen Shoulder?

As a shoulder surgeon the biggest problem I face is that so many people with a painful shoulder or a stiff shoulder are told that they have a Frozen Shoulder when in fact they don’t.

Ok. The way to know that you definitely have a Frozen Shoulder is to try this. Lie flat on the floor and bring your straight arms up and over your head towards the carpet behind you. If the good hand gets there and the bad hand doesn’t then you have a stiff shoulder. Bring your arms down to your side and bend your elbows to 90 degrees and then try and swing your hands out sideways and see if there is a difference between the two sides.  Again, if there is a difference then you have a stiff shoulder. The chances are that this is  Frozen Shoulder but remember –  you HAVE to have a normal x-ray before anyone can say you have a Frozen Shoulder.

Those are the medical definitions and unless you have limited passive anterior elevation and/or limited passive external rotation in the presence of a normal x-ray you cannot and should not be told you have a Frozen Shoulder.

How does it affect me?

It doesn’t start out being frozen straight away. It usually starts gradually and insidiously with pain using the arm over head height, pain at night, catching pain dressing – that sort of thing. And this is very like, if not identical to, Tendonitis so in the early stages it can be hard to tell the two apart.

As the weeks and months pass the shoulder starts to freeze or lose movement –the Freezing Phase. The good bit about this is that often the pain lessens as the shoulder fully freezes up  so that after a couple of months you have a stiff shoulder but one that doesn’t hurt. This is the Frozen Phase and the one that can last a very long time.

It’s not all good news in the Frozen Phase though. That agonising, tears in the eyes, pain you get if you jar the shoulder or fling it out quickly (to stop something falling off the desk perhaps) or someone grabs your arm and pulls it: sound familiar? That is still going to happen and it doesn’t matter what pain-killers you are taking because nothing will stop that sudden movement being very, very painful.

And then one day you will realise that you have been able to reach something you couldn’t the week before whether that is a shelf, the car seat-belt or the back of your head. And at that point your shoulder is entering the Defrosting Phase and you are on the home straight.

No one can predict exactly how long each of these phases will last. In fact no one can predict even approximately how long each will last. But once you start getting the movement back then you know you will be getting your life back again.

What happens in the shoulder? Is it tight ligaments?

There is only one part of the shoulder affected in a Frozen Shoulder. It all happens to the inner lining of the joint – the capsule. The muscles, tendons and ligaments are not involved directly.

The capsule is normally a very, very thin lining and the analogy I use is that it is a bit like Lycra – thin, flexible and elastic – so it can stretch as the arm moves. In a Frozen Shoulder something happens to the capsule and the Lycra slowly changes into canvas –it becomes thick and tight and loses its elasticity. And you can’t move your arm.

The capsule is normally like lycra – stretchy.

The capsule becomes thick like canvas – no stretch.

What else causes a stiff shoulder?

In the more elderly patient the stiffness and pain is often due to arthritis of the ball and socket joint. That’s why you need the x-ray.

You could have eroded through the main tendon that lifts up the shoulder. So whilst you can’t lift your arm all the way up because that tendon pulley isn’t working, the doctor or therapist can because the shoulder isn’t actually stiff.

And the commonest mistake is that the shoulder will go all the way up –it is just pain that is stopping it. So you don’t like lifting it overhear but with a bit of gentle persuasion (me shoving it hard!) it will go and therefore it is not Frozen!

My GP said it wasn’t a Frozen Shoulder but you said it was. Why the disagreement and who is right?

In the early stages a Frozen Shoulder can be a difficult thing to diagnose because the symptoms can be identical to tendonitis – the shoulder is mainly painful but actually still moves fully so it is freezing up rather than being frozen. This means that Frozen Shoulder is misdiagnosed three times out of four! 75% of people who are told they don’t have a Frozen Shoulder actually do and vice versa.

Often by the time you get to see me the condition has progressed and it is much clearer what is going on and I can demonstrate to you that the shoulder has stiffened up.

But even I can get it wrong sometimes and if I am not sure whether your shoulder is freezing up or has tendonitis then I will do a steroid injection to see whether that works or not.

My friend says her Frozen Shoulder was cured with a steroid injection so why won’t you inject mine?

I’m afraid to say your friend did not have a Frozen Shoulder at all because they simply cannot be cured by a subacromial bursal injection of steroids (the sort of injection given by your GP) Instead they were one of the 75% who were misdiagnosed and had tendonitis – which can be cured by that injection. What happens is that when you see the GP with a painful shoulder and tell them that it’s painful and doesn’t move properly they may not examine the shoulder well enough to pick up the fact that it really doesn’t move fully. Sadly in some cases the shoulder isn’t examined at all and the GP assumes it is frozen whereas if they had tried to move it they would have found it moved fully but just didn’t like moving. So they give you an injection for an assumed Frozen Shoulder and you get better because what you actually had was tendonitis – which does get better with steroids.

So I don’t use sub-acromial steroid injections in Frozen Shoulder because they don’t work. In fact many patients will have had an unsuccessful steroid injection for an assumed Frozen Shoulder before they get to me so they now know that it doesn’t work!

You mentioned an injection into the joint – is that not the same thing?

The injection into the joint is a very different sort of injection to the one either a GP might give you or that I might give for tendonitis. It is a steroid injection but it goes right into the gleno-humeral joint (ball and socket joint) where all the freezing activity is actually taking place. It is usually done by a radiologist ( a Consultant specialising in imaging) in the X-ray department and they use either the Ultra-sound scanner or an Image Intensifier (a moving x-ray machine) to guide the needle into the right place. For NHS patients I do it as a day-case in the operating theatre with you sedated.

This injection is useful in the early ‘freezing’ phase of the condition and it’s main benefit is to reduce pain. There is some evidence that it can also alter the progression of the freeze and possibly reverse it as well as an added bonus.

So I am offering these injections more frequently and they do seem to be working. However, once the shoulder is fully frozen then they don’t have any effect.

A dye that can be seen on x-ray is injected to make sure the steroid goes into the joint.

My other friend had a Frozen Shoulder which was cured by her physiotherapist so why have you told me to stop physio?

I’m afraid we have to go back to the misdiagnosis issue and, again, often times what has been cured is tendonitis.  Most of the physiotherapists I work with understand that there is no place for them in the freezing or frozen stages of the condition and the evidence backs this up. In fact there is some evidence that intensive physiotherapy can make it last longer! And the same holds for chiropractors and osteopaths. Soft tissue massages can help with associated neck stiffness and pain so I have no problem with that.

However there is an extremely important role for physiotherapists (or osteopaths or chiropractors) either after surgery or when the shoulder has nearly defrosted by itself. They can really help you regain full control of your shoulder and achieve those last few degrees of movement.

So what are my options then?

We know that a Frozen Shoulder will get better by itself eventually. However it’s the length of that eventually that can be the issue. The statistics would suggest that from start to finish that takes 18 months on average. Some people will go through the whole freezing/frozen/defrosting thing much quicker than that but, sadly, for some it can take 3 or more years.

If the shoulder isn’t too painful and isn’t stopping you doing the things you want to do or interfering with your sleep then you could chose to live with it. Wait it out patiently and it will get better. Eventually!

If it is very painful in either the Freezing or, occasionally, the Frozen phases then the gleno-humeral joint injection is worth a go. This could leave you with a pain-free but stiff shoulder and you may be happy with that. It may also change the progresion of the condition and start a rapid defrost and that is an excellent added extra.

On the other hand if the restriction in movement has put your life on hold and you are struggling to work, to play with your children, to do your sports or to sleep then the surgical option could be the better choice for you.

When can I have the surgery?

My experience is that the best time to do the operation is when the shoulder has fully frozen up and not before. If I operate during the frozen phase then the risk of re-freezing is higher because the shoulder sort of feels it still has some freezing up to do and didn’t like being interrupted. So it starts off great after the surgery and then freezes up again. So thats why we are offering the injection during this phase.

So, at the point when you have a stiff shoulder that has stopped freezing up then surgery is your choice. We will go through all the pros and cons and you can make an informed decision about the operation.

I don’t fancy the sound of this manipulation thing my doctor told me about though.

Well that’s ok because I don’t do that operation anymore. Instead I do an arthroscopic (keyhole) procedure in which I cut the capsule (remember – the inner lining that has become thick and stiff) and free up the shoulder.

And Hydrodilatation? I’ve heard a bit about that. Is that worth trying?

Yes – but only in the very early stages of the condition and even then it only works in about 33% of patients. It simply does not work in the frozen phase so if you’ve got that far then there is no point in trying this.

There are a few possible outcomes after the hydrodilataion/hydrodistension injection. In some people it completely eliminates the freeze getting rid of all the pain and getting back all the movement. Result!

In some though that can be a false dawn and a few weeks later you can be back where you started. That is very disappointing but it’s not usually worth trying it again because your shoulder clearly has decided it is going to freeze up.

In some cases the injection just eliminates the pain though that’s probably the effect of the steroid (see above) but a stiff shoulder that doesn’t hurt can be a lot easier to live with.

And sadly in quite a lot of people it doesn’t make any difference at all.

So, if I get to see you in the early stages of the condition then I will discuss this option and you can make a sensible decision about whether you want to give it a go.

 

Frozen Shoulder is a very common condition but there is a constant problem with getting the diagnosis correct so many people are told they do when they don’t and vice versa. This confusion has lead to a vast array of treatments being proposed to cure it but these are nearly all healing some other condition. It is the view of the shoulder specialist community that you either  leave it to defrost by itself, consider the hydrodistenison/steroid injection to the joint or you have surgery because that thick capsule isn’t going to release with water injections or exercise.