Frozen Shoulder (Adhesive Capsulitis)

What are the symptoms of frozen shoulder?

The typical symptoms are pain, stiffness, and limitation in the range of movement of a shoulder. The symptoms typically have three phases.

• Phase one - the 'freezing', painful phase. This typically lasts 2-9 months. The first symptom is usually pain. Stiffness and limitation in movement then also gradually build up. The pain is typically worse at night, and when lying on the affected side.
• Phase two - the 'frozen', stiff phase. This typically lasts 4-12 months. Pain gradually eases but stiffness and limitation in movement remain and can get worse. All movements of the shoulder are affected but the movement most severely affected is usually rotation of the arm outwards. The muscles around the shoulder may waste a bit as they are not used.
• Phase three - the 'thawing', recovery phase. This typically lasts 5-24 months. The stiffness gradually goes and movement gradually returns to normal, or near normal.

Symptoms often interfere with everyday tasks such as driving, dressing, or sleeping. Even scratching your back, or putting your hand in a rear pocket may become impossible. Work may be affected in some cases.

There is great variation in the severity and length of symptoms. Untreated, on average the symptoms last 2-3 years in total before going. In some cases it is much less than this. In a minority of cases, symptoms last for several years.

Who gets frozen shoulder?

Frozen shoulder affects about 1 in 50 adults at some stage in their life. It most commonly occurs in people aged between 40 and 60. It is more common in people who have diabetes. Either shoulder can be affected but most commonly it is the non-dominant shoulder. That is, the left shoulder in a right handed person. In about 1 in 5 cases the condition also develops in the other shoulder at some stage. Frozen shoulder is not a form of arthritis, and other joints are not affected.

What causes frozen shoulder?

The cause is not clear. It is thought that some scar tissue forms in the shoulder capsule. The capsule is a thin tissue that covers and protects the shoulder joint. The scar tissue may cause the capsule to thicken, contract, and limit the movement of the shoulder. The reason why the scar tissue forms is not known.

A frozen shoulder occasionally follows a shoulder injury, but this is not usual and most cases occur for no apparent reason.

What are the treatment options for frozen shoulder?

The aim of treatment is to ease pain and stiffness, and to keep the range of shoulder movement as good as possible whilst waiting for the condition to clear. One or more of the following may be advised to help ease and prevent symptoms.

Anti-inflammatory painkillers
For example, ibuprofen, diclofenac, naproxen, etc. One of these drugs is commonly prescribed to ease pain. There are many different brands. Therefore, if one does not suit, another may be fine. Side-effects sometimes occur with anti-inflammatory painkillers. Always read the leaflet that comes with the drug packet for a full list of cautions and possible side-effects.

Ordinary painkillers
Paracetamol or codeine may be an option if anti-inflammatory painkillers do not suit. These do not have any anti-inflammatory action, but are good painkillers. Constipation is a common side-effect from codeine. You can take painkillers in addition to other treatments.

Shoulder exercises
These are commonly advised. The aim is to keep the shoulder from 'stiffening up', and to keep movement as full as possible. For most benefit, it is important to do the exercises regularly, as instructed by a doctor or physiotherapist.

Physiotherapy
Many people are referred to a physiotherapist who can give expert advice on the best exercises to use. Also, they may try other pain relieving techniques such as heat, cold, TENS machines, etc.

A steroid injection
An injection into, or near to, the shoulder joint brings good relief of symptoms for several weeks in some cases. Steroids reduce inflammation. It is not a 'cure' as symptoms tend to gradually return, but many people welcome the relief that a steroid injection can bring.

Nerve block
This is a technique that a specialist may try. This is an injection to block the nerves that send pain messages from the shoulder. Like a steroid injection, it often eases symptoms for a while, but it is not usually a cure.

Hydrodistension
Again, this is a technique that a specialist may try. This is a procedure where the joint space is expanded (distended) by injecting a liquid. In one study, saline (salt water) mixed with a steroid injected into the painful shoulder improved symptoms in a number of cases.

Surgery
An operation is sometimes considered if other treatments do not help. Techniques that are used include:

• Manipulation. This is a procedure where the shoulder is moved around by the surgeon while you are under under anaesthetic.
• Arthroscopic capsular release. This is a relatively small operation done as 'keyhole' surgery. It is often done as a day-case procedure. In this procedure the tight capsule of the joint is released with a special probe. One recent research study showed that this procedure gave about an 8 in 10 chance of greatly improving symptoms. Because of the encouraging results of this research study, it may become a more popular treatment.

© EMIS and PIP 2006   Updated: May 2006