Frozen Shoulder

The hallmark presentation of frozen shoulder is progressive, painful stiffening of the shoulder joint resulting in the loss of movement both actively and passively (someone moving it for you). Sharp pain is typically felt with quick, forgetful movements of the shoulder. In the early stages this condition can be easily misdiagnosed as ‘rotator cuff-related shoulder’ pain due to the absence of joint stiffness. Only with time does the diagnosis become clear clinically as the joint becomes stiffer.

This condition classically progresses through three distinct phases.

• Freezing: During this phase the movements of the shoulder become painful and the joint starts to stiffen. This is due to the capsule or lining of the joint becoming thickened and inflamed, known as capsulitis. This phase can take anywhere from six weeks to nine months to progress through.
• Frozen: This is when the worst of the shoulder pain has subsided, but the joint is at its stiffest, making basic activities of daily living like getting dressed and combing your hair very difficult. This phase of stiffness can last up to 12 months.
• Thawing: The final stage of frozen shoulder is the ‘thawing stage’, where the movement slowly returns. This can take up to a total of 2 years before patients see resolution of their symptoms.

For the majority of patients with frozen shoulder, the prognosis is good, with patients typically having resolution of symptoms within 2 years without any treatment. Symptoms can linger in certain cohorts of patients, typically patients with poorly controlled metabolic and endocrinological diseases. It is important to understand the natural history of the disease, as this aids in decision-making for patients when considering their treatment options, especially invasive procedures that have associated risks.

With later presentations of frozen shoulder, the diagnosis is relatively straightforward, as patients present with global joint stiffness. A shoulder X-ray may be recommended to exclude any other shoulder pathology that can mimic this condition, such as arthrosis, but is often normal in patients with frozen shoulder.

Diagnosis is more difficult in the early stages where the range of movement is still globally maintained. Ultrasound and MRI can be sensitive at seeing early inflammatory features in the axillary capsule (in the armpit) and over the front of the shoulder in the rotator cuff interval, which is a hallmark of early developing frozen shoulder. They also allow confirmation of an intact rotator cuff, which is an important consideration when considering treatment options.

As mentioned, frozen shoulder will eventually resolve with time, and treatment depends on the severity of symptoms and functional restrictions it has on the patient. This will differ between individuals.

If a patient is managing well, then they may not need any specific intervention other than over-the-counter medication and the reassurance and education of the favourable outcome of this condition. If patients are struggling, then they have treatment options. These options include:

• Physiotherapy is often recommended to patients with frozen shoulder, but there remains much debate about the benefits of physiotherapy for this condition in isolation. Vigorous stretches of the shoulder can exacerbate the problem and should be avoided.
• A simple injection of steroid placed into the shoulder joint can be helpful at settling the painful capsulitis. It is typically most beneficial in the ‘freezing stage’. This allows better compliance with physiotherapy once the pain is less.
• A hydrodistension procedure is a further conservative treatment option for patients with frozen shoulder. This involves a combination of steroid, local anaesthetic and saline to stretch the shoulder capsule and help promote better movement. (Please see our hydrodistension procedure page.) Compliance with physiotherapy after the procedure is important in a combined approach for the best possible outcomes.

Finally, for completeness, an arthroscopic capsular release is the surgical treatment. This procedure removes the thickened, painful, contracted capsule that prevents shoulder movement. The surgery rapidly improves the range of movement in the shoulder and reduces pain but does have the potential risks of surgery. The overall results of surgery are not significantly different to conservative treatment options at 2–3 years, but clearly this is a lengthier process if managed conservatively.