What is a frozen shoulder (Adhesive Capsulitis)?

Frozen shoulder is a condition that can cause the shoulder to become very painful and stiff. Frequently there is no clear reason as to why frozen shoulder comes on. Sometimes people can remember a particular trigger like holding themselves steady on a bus when its suddenly breaks and the arm is jerked. Or tripping or  very rapidly moving the shoulder to break a fall etc.

At the time these incidents are often not thought to be that serious but sometimes it sets in motion the early stages of what eventually will become clear as the early stages of frozen shoulder or adhesive capsulitis. Frozen shoulder often affects people in the 40s to 60s. The highest incidence is seen in those in their 50s.

What are the early symptoms of frozen shoulder?

Pain symptoms: The pain is often described as a dull ache in the shoulder. Initially can be perceived as mild but over time it can become more intense. Usually the pain is worse at night. The pain usually is of a gradual onset. The pain often progresses from the initial ache to a more severe pain.

Stiffness: Initially people might find there are subtle restrictions in range of motion. It might be noticed that reaching higher up or putting on a coat feels like more of an effort.

Traditionally three different stages are described in literature.

The freezing stage. Where pain is gradually intensified as time goes by. The shoulder also become stiffer during that period.

The frozen stage when the stiffness is quite significant but pain levels are actually slightly less intense

The thawing stage which is the recovery phase when slowly movement is regained and pain subsides.

Who are most at risk of frozen shoulder?

People between 40 and 60 are more likely to be affected.

People who suffer from diabetes are more likely to be affected.

People who have thyroid disorders are also more likely to be affected.

How if frozen shoulder diagnosed?

Frozen shoulder is primarily a clinical diagnosis. A detailed history and detailed clinical examination is usually enough to make the diagnosis.

There are a number of other conditions that can have features consistent with frozen shoulder. Some of these conditions are listed below:

• Osteoarthritis of the glenohumeral joint
• Rotator cuff impingement syndrome
• Calcific tendinopathy
• Osteoarthritis of the acromioclavicular (AC) joint
• Long head of biceps tendinopathy

Imaging investigations to further investigate the painful shoulder

X-ray:

In order to evaluate the bony anatomy i.e. check it to see if there is any degenerative change or bony trauma such as fracture an x-ray is an excellent imaging option.

Diagnostic Ultrasound:

In order to evaluate the soft tissues such as musculature including tendon and ligaments as well as nerves as well as blood vessels real time investigation such as diagnostic ultrasound is fantastic. Ultrasound is however operator dependent and therefore requires a very skilled operator to carry out. The resolution of high-resolution ultrasound is higher then MRI.

MRI scan:

For most common shoulder condition MRI is not required as bone and soft tissue can be evaluated very well with ultrasound and as indicated perhaps at times x-ray. Of course there are some conditions where MRI might be required and at Sonoscope we always guide you in this direction when this is the case.

What injection options do we have for frozen shoulder?

For all frozen shoulders we would advise people to have a steroid injection. However especially in cases where the shoulder is very restricted it could be even more beneficial to have a hydrodistention injection. Which is a combination of steroid and a volume of (salty) water.

Steroid injection:

Steroid injection is very effective (Sun et al, 2017) in reducing inflammation and improving function . As inflammation drives frozen shoulder has steroid injection inside of the shoulder joint is therefore very good at very rapidly reducing high levels of inflammation and pain. Once pain levels have reduced these people can then with the help of further physiotherapy and or exercise focused management fully recover functionally.

Hydrodilatation/Hydrodistension:

The steroid is injected with a volume of local anaesthetic and then a further volume (possibly as much as 30 mL) of saline. The volume of the injection stretches the joint capsule which helps to restore flexibility of the shoulder joint. Evidence (Lin et al., 2018) does demonstrate that hydrodistention injections are more effective in improvement of external rotation of the shoulder than regular steroid injection.

https://www.youtube.com/watch?v=skvaSCCcfHI

Number of steroid injections required:

In most cases one injection is sufficient to make a good recovery. However in some cases after several months there is a degree of recurrence and then another injection might be required.

Please contact us on: 07999 923844 to book an appointment or email us at: info@sonoscope.co.uk

Lin, M.T., Hsiao, M.Y., Tu, Y.K. and Wang, T.G., 2018. Comparative efficacy of intra-articular steroid injection and distension in patients with frozen shoulder: a systematic review and network meta-analysis. Archives of physical medicine and rehabilitation, 99(7), pp.1383-1394.

Sun, Y., Zhang, P., Liu, S., Li, H., Jiang, J., Chen, S. and Chen, J., 2017. Intra-articular steroid injection for frozen shoulder: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. The American journal of sports medicine, 45(9), pp.2171-2179.