Taking the chip out of Frozen Shoulder: Evidence-based Treatment

  • Wednesday 14 January 2015

Frozen shoulder or adhesive capsulitis is a common cause of shoulder pain that I see frequently in my practice. Frozen shoulder occurs in about 5% of the population and is more common in females between the ages of 40 and 60. In about 20% of cases, this condition affects both shoulders at the same time.

Most cases of frozen shoulder occur without a cause but a common finding is a history of a fall or trauma to the shoulder preceding the onset of pain. Other triggers include recent shoulder surgery (frozen shoulder is common after tendon repair especially in middle-aged females) and medical conditions such as diabetes, heart conditions, thyroid disease and immune disorders.

Diagnosis of frozen shoulder is based on a presentation of shoulder pain and stiffness. It's important to exclude other causes of pain and restriction, and this is where other investigations such as X-ray, ultrasound or MRI could be useful. Most cases of frozen shoulder resolve after 18-24 months, but treatments are aimed at accelerating this process.

Unfortunately, there is a lack of agreement on the best management of frozen shoulder. There is no evidence for the use of analgesic medications such as steroids and anti-inflammatories. Cortisone injections into the shoulder seem to be effective in the short term and are probably suited for patients with a painful frozen shoulder to assist with physiotherapy. Hydrodilatation or shoulder joint distension with water and cortisone has also been shown to be effective particularly in the stiff or restrictive stage. A few studies have used hyaluronic acid injections (brand names include Synvisc, Durolane or Ostenil) with some success. Injections should be performed under ultrasound or X-ray-guidance as it improves accuracy. Physiotherapy is an important part of rehabilitation and includes shoulder joint mobilisation, stretches and a home exercise program. However, there is a lack of agreement on the best type of physiotherapy. Surgery should be reserved for cases that fail a conservative program (like many other conditions in musculoskeletal medicine).

Injection under Ultrasound

Hydrodilatation or Distension of Shoulder

I use a combination of treatments for frozen shoulder depending on the stage. In early cases of frozen shoulder presenting with severe pain, I suggest a shoulder injection with cortisone (under ultrasound-guidance) followed by gentle stretching and mobilization of the shoulder joint. In latter stages of frozen shoulder presenting with significant stiffness or restriction, I prefer a shoulder distension procedure under ultrasound-guidance followed by more aggressive stretches and strengthening exercises. Most cases of frozen shoulder settle without the need to refer for surgery. In my opinion, the most important part of the management of frozen shoulder is to make sure that the diagnosis is in fact frozen shoulder and not another cause of pain and stiffness of the shoulder such as osteoarthritis, avascular necrosis or bone tumours.

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