Frozen Shoulder

In this episode of PodMD, shoulder and elbow orthopaedic surgeon Dr Owen Mattern will be discussing the topic of the frozen shoulder, including what a frozen shoulder is, the causes of it, treatment and more.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMd studio Dr Owen Mattern is a shoulder and elbow orthopaedic surgeon. He specialises in arthroscopy, joint replacement surgery and traumatic conditions affecting these joint.

    Today, we’ll be discussing the topic of frozen shoulder.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Owen, thanks for talking with us on Pod MD today.

    Owen: Thank you for having me

    Question 1
    The topic of today’s discussion is on frozen shoulders. Owen, can you describe for our listeners what a frozen shoulder is?

    Owen: A frozen shoulder, otherwise known as he, as adhesive capsulitis is a condition that causes both stiffness and pain in the shoulder. Patients will have a loss of both active and passive range of motion with associated pain, which can often be quite severe, particularly at nighttime it’s caused by an inflammatory based thickening and scarring of all the connective tissue around the shoulder joint. And the scarring generally affects the glenohumeral capsule, the ligaments around the shoulder joint, as well as the rotator interval. It can be quite a disabling condition for patients with pain, often being very severe and the stiffness significantly affecting patient’s activities of daily living frozen shoulder can have a prolonged course, usually lasting for 18 to 24 months from the onset of symptoms.

    Question 2
    How would a patient initially present with a shoulder that is beginning to freeze?

    Owen: So, pain is often the first symptom that patients complain of. They can start as a gradual onset, but often by the time they present for medical attention, it can be quite severe often at night as well. The pain will often affect sleep and can usually be out of proportion 20 x-ray findings or any other imaging findings. You see the loss of range of motion may not become apparent for some months after the onset of the pain. Therefore the frozen a diagnosis of frozen shoulder should always be considered in a patient whose pain. Who’s got a painful shoulder out of proportion to their clinical, their radiological findings.

    Question 3
    How does it develop to a fully frozen shoulder?

    Owen: So, a frozen shoulder progresses through three stages. The initial stage is the freezing or inflammatory stage. And that usually lasts for somewhere between three to six months. This is the painful stage we’ve just described. The shoulder is usually very sore affecting the patient’s sleep and any movement of the shoulder irritates it and also causes pain. The shoulder then progresses to the frozen or the stiff phase. And this often lasts for somewhere between six to 12 months. Often the pain will settle and alone become present at the extremes of movement. But the range of motion of the shoulder is often really markedly decreased, especially in the rotation. And this can have a severe limitation on patients’ abilities to perform their activities of daily living. Finally, the third stage and final stage of the frozen shoulder is the storing or resolution stage. The pain is usually well controlled by this. And the range of motion is slowly improving, allowing patients to perform more of their activities of daily living. Most patients will enter the resolution stage somewhere between nine to 15 months after the onset of symptoms. And the resolution stage will usually last for about six months

    Question 4
    What causes a frozen shoulder?

    Owen: Uh, so we know there’s two main types of frozen shoulder. The most common type is the primary or idiopathic frozen shoulder. And this is characterized by a deposition of all the scar tissue cell types, such as fibroblasts and myofibroblasts in the capsule, the glenohumeral ligaments and the rotator interval. We don’t actually know why this occurs, but some patients do report having a minor preceding injury. We know that there are some patient factors that increase the risk of developing this type of frozen shoulder. And they can also be a strong family history. But as I said, the etiology of what causes it, we’re unclear. Um, we also know post-traumatic, or post-surgical changes can cause a frozen shoulder. And this often occurs after a fracture injury of the shoulder girdle, such as a clavicle fracture of proximal humeral fracture, or following surgery of the shoulder, such as a rotator cuff for pain. This usually isn’t as painful as an idiopathic shoulder, uh, idiopathic frozen shoulder. And the recovery can be much quicker from this time.

    Question 5
    Who is predisposed to getting a frozen shoulder?

    Owen: Yeah, so a frozen shoulder usually presents in the 40 to 60 year old age group. It is more common in women and has a really strong association with diabetes, both type one and type two, one of the first things that we should always check in a patient who presents with idiopathic frozen shoulders, whether they have an undiagnosed type two diabetes, as we know, frozen shoulder only occurs in about 3% of the general population, but up to about 20% in diabetics are the conditions associated with frozen shoulder include thyroid conditions, a history of Jupiter Crohn’s disease and Jupiter ons, contractures Parkinson’s disease and any Atlas, atherosclerotic diseases as well.

    Question 6
    How can you manage or treat a frozen shoulder?

    Owen: So, we know most frozen shoulders improve with time, but it is a really long and difficult and painful period for patients. The primary goal in the first line of treatment is to improve a patient’s pain relief. And this is done by simple analgesics, such as paracetamol and antiinflammatories and a gentle exercise program. Cause something too aggressive with too much stretching can certainly flare up their pain. The next stage to improve their pain is to consider getting a glenohumeral joint injection subacromial injections that don’t address where the pathology is and often are unsuccessful. The two types of injections we can perform are a local anesthetic and steroid injection or a hydrodilatation local anesthetic and steroid injections can help alleviate the pain, but often won’t help the stiffness. Whereas hydrodilatation aims to improve the pain as well as improve the range of motion by stretching out the capsule.

    And they can be very effective in some patients and early glenohumeral injection, either a straight corticosteroid and local anesthetic or a hydrodilatation can both be really effective early forms of analgesic agents for the patients, especially those who are struggling with pain. Finally, those surgeries are a very good solution. Um, and arthroscopic capsular release can be performed. And this has been shown to be extremely successful, gives patients excellent pain relief and returns a range of motion really quickly. Um, and they get significant improvements in their functional, functional activities. After surgery, a recent study in the UK, you found that movement and pain relief with surgery was better than after a hydrodilatation and it is shown to be especially useful in those patients. Who’ve had an unsuccessful hydrodilatation.

    Question 7
    When should a GP refer?

    Owen: So, patients can be referred at any time as some patients may choose and non-operative management pathway and injection, or a surgical release. Generally, if a patient has ongoing pain and symptoms following injection or a hydrodilatation, then a referral should be made as should patients who’ve had any prolonged symptoms. The key, like with most conditions around, um, like most conditions around the shoulder is education, patient education and ability for them to make an informed decision over their prognosis timeframe and treatment is really the key to a good outcome. And so that’s the key, um, when the referral needs to be made.

    Question 8
    Is there often recurrence or is it something that you can pretty much get rid of?

    Owen: So, recurrence doesn’t really occur in a frozen shoulder. Once, once a shoulder has been managed and treated, it usually will not freeze again, but we know up to about a quarter of people will develop frozen shoulders and their contralateral arm. And so whilst it won’t come back in that same shoulder, the chance of them getting it in their other shoulder is quite high

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on a frozen shoulder?

    Owen: Yeah, so the first one really is frozen shoulder can be quite a hard diagnosis to make. And for me, it’s one of the diagnoses I consider in any patient who has severe shoulder pain at night out of proportion to what I’d expect on that x-ray or ultrasound or MRI findings. The second point is for pain relief injections, either glenohumeral or hydro dilatations have a really good result in alleviating pain and stiffness, and this should be done early in the disease process. Surgery can provide a quick and reliable improvement in pain and in range of motion. Um, and so that’s really the last take home message that don’t be afraid of an operation here. It’s a really good solution for these patients.

    Thanks for your time and the insights you’ve provided.

    Owen: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.