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Aug 21, 2020

Frozen Shoulder: Alternatives to Surgery

What is a frozen shoulder?

Frozen shoulder, or adhesive capsulitis, is a condition that causes pain and restricted movement in the shoulder. The joint of the shoulder is held together by a joint capsule, which becomes thickened and results in a global restriction of shoulder movement. This manifests with shoulder motion being stuck or frozen in all planes of motion, and loss of motion especially in external rotation is an early sign.

What causes frozen shoulder?

Frozen shoulder is a poorly understood disease. Genetic and environmental factors likely play an important role.

Who can get frozen shoulder?

Anyone can get a frozen shoulder. In the general population, the incidence of frozen shoulder is 5%. In diabetics the incident can be as high as 20% (Sharma, 2011), with frozen shoulder being twice as common in insulin-dependent diabetics compared with non-insulin dependent diabetics (Yian et al., 2012). Patients with Dupuytren’s disease are also at increased risk, and are 8 times more likely to develop a frozen shoulder (Smith et al., 2001).

Various other triggers have been associated with adhesive capsulitis, including trauma, surgery (not just limited to the shoulder), stroke, thyroid disorders, and other inflammatory diseases. Periods of immobilization are also a risk factor for adhesive capsulitis (Bruckner & Nye 1981).

What are the symptoms of frozen shoulder?

Frozen shoulder progresses in a predictable manner.

  • Freezing Stage In the early stages of the disease, patients report constant severe pain which can increase at night-time. This initial painful stage, is known as the ‘freezing’ or stiffening stage and typically lasts about 3 months.
  • Frozen Stage The disease then progresses to a ‘frozen’ stage, which can last up to 9-months. This phase is characterized by less pain and marked restriction of movement. This second phase is typically has less painful.
  • Thawing stage Finally, the disease enters a ‘thawing’ phase where the range of movement improves and can last up to 18 months.

How is frozen shoulder diagnosed?

The diagnosis of frozen shoulder is typically made clinically, and often by the diagnosis can be made by testing the range of motion in the shoulder.

X-rays and an MRI can differentiate frozen shoulder from alternative causes of shoulder pain such as osteoarthritis, posterior shoulder dislocation, rotator cuff calcification or tumors.

Will frozen shoulder resolve on its own?

Historically, patients were reassured that frozen shoulder will resolve with conservative treatment or observation. In some reports, frozen shoulder resolved in 94-96% of patients over a 2-year period or longer (Grey, 1978; Vastamaki et al. 2012).

In other reports, the rates of complete recovery were as low as 39-50% (Reeves, 1975; Shaffer et al., 1992). It is unusual for adhesive capsulitis to recur in the same shoulder, but in one report 14% of people develop it in the opposite shoulder (Simth et al. 2014).

What are common treatments for frozen shoulder?

The stage of the disease process influences treatment options. Often medications and early activity are the first-line treatments. Physical therapy is often prescribed and joint mobilization with a therapist has been shown to be better than stretching exercises alone (Celik & Mutlu, 2016). In the majority of patients, 60-95% respond to a combination of therapy or medications (Schoch et al. 2020).

  • Cortisone Injections & Physical Therapy
    • While the underlying process is one of scarring of the joint capsule (adhesions or fibroblastic proliferation), in the early stages there are feature of inflammation (Hand et al., 2007). Typically, a corticosteroid injection is preferred in the freezing phase. Cortisone injections had superior outcomes and faster relief of symptoms than physical therapy (van der Windt et al., 1998) or oral medications (Ranalletta et al. 2016). However, there is a statistically significant benefit to a course of physical therapy after the cortisone injection compared to an injection alone (Carette et al., 2003).
    • So a cortisone injection maybe more effective than therapy in the short term, but a combination of therapy and a cortisone injection may be more effective. Multiple intraarticular cortisone injections provide no added benefit to a single injection, so if you do not respond to a cortisone injection it may not be worth repeating the injection and additional treatment may be necessary.
  • Surgical management
    • Surgical treatment include manipulation under anesthesia (MUA) involves general anesthesia and forcibly tearing or rupturing the thickened and inflamed joint capsule and ligaments. Potential complications of MUA include fracture or brachial plexus injury (Birch, 1991). MUA can be performed alone or along with capsular release (arthroscopic arthrolysis) with improved results in the short term (Sivardeen, 1992). No studies support the superiority of surgical treatment for frozen shoulder over conservative management (Sharma, 2011).

Are there alternative treatments to cortisone injections or surgery for frozen shoulder?

Shoulder hydrodilation or high-volume shoulder distension is a non-surgical treatment for frozen shoulder. The treatment involves injecting a high volume of saline and local anesthetic into the glenohumeral joint under ultrasound guidance. The objective of the treatment is to physically expand or distend the joint capsule, but the exact mechanism of the procedure is debated.

One study has shown that a high-volume distention of the joint capsule combined with mobilization and a corticosteroid injection was the most effective treatment for adhesive capsulitis (Park et al. 2014). Other studies have now shown clear superiority, but technique, volume of injectate and post-procedure manipulation may account for some of the variability in the outcome of these studies (Tveita et al, 2008; Sharma et al 2016). In one study, high-volume dilation without manipulation is less effective than intensive manipulation alone suggesting that the technique and protocol used by your physician matters (Park et al. 2014).

In one study comparing surgery to high-volume distention both groups of patients had significant improvement in range of motion and there was no significant difference in pain scores (EQ-5D VAS) at any time point (Gallacher et al. 2018). While surgery did have a significant improvement in the Oxford Shoulder Score, the results were otherwise comparable between non-operative management with high-volule shoulder dilation and surgery. High-volume dilation should be considered before surgery.

References
Birch R, Jessop J, Scott G. Brachial plexus palsy after manipulation of the shoulder. J Bone Joint Surg Br. 1991 Jan; 73(1):172.
Bruckner FE, Nye CJ. A prospective study of adhesive capsulitis of the shoulder ("frozen shoulder') in a high risk population. Q J Med. 1981;50(198):191-204.
Carette S, Moffet H, Tardif J, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum. 2003 Mar; 48(3):829-38.
Celik D, Kaya Mutlu E; Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial. Clin Rehabil. 2016;30(8):786-94.
Erickson BJ, Shishani Y, Bishop ME, Romeo AA, Gobezie R. Adhesive Capsulitis: Demographics and Predictive Factors for Success Following Steroid Injections and Surgical Intervention. Arthrosc Sports Med Rehabil. 2019;1(1):e35-e40.
Gallacher S, Beazley JC, Evans J, et al. A randomized controlled trial of arthroscopic capsular release versus hydrodilatation in the treatment of primary frozen shoulder. J Shoulder Elbow Surg. 2018;27(8):1401-1406.
Grey RG. The natural history of idopathic frozen shoulder. J Bone Joint Surg [Am] 1978;60-A:564.
Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br. 2007 Jul; 89(7):928-32.
Park SW, Lee HS, Kim JH; The effectiveness of intensive mobilization techniques combined with capsular distension for adhesive capsulitis of the shoulder. J Phys Ther Sci. 2014;26(11):1767-70.
Ranalletta M, Rossi LA, Bongiovanni SL, et al. Corticosteroid Injections Accelerate Pain Relief and Recovery of Function Compared With Oral NSAIDs in Patients With Adhesive Capsulitis: A Randomized Controlled Trial. Am J Sports Med. 2016;44(2):474-81.
Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975;4:193-196.
Schoch B, Huttman D, Syed UA, Patel MS, Lazarus MD, Abboud JA. Surgical Treatment of Adhesive Capsulitis: A Retrospective Comparative Study of Manipulation Under Anesthesia and/or Capsular Release. Cureus. 2020;12(7):e9032.
Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long term follow up. J Bone Joint Surg [Am] 1992;74-A:738-746.
Sharma S. Management of frozen shoulder – conservative vs surgical? Ann R Coll Surg Engl. 2011 Jul; 93(5):343-4; discussion 345-6.
Sivardeen KAZ, Paniker J, Drew S, et al. Frozen shoulder: Manipulation under anaesthesia or manipulation under anaesthesia and arthroscopic capsular release – which is the better treatment modality? J Bone Joint Surg [Br] 2012. 94-B:35.
Smith CD, Hamer P, Bunker TD; Arthroscopic capsular release for idiopathic frozen shoulder with intra-articular injection and a controlled manipulation. Ann R Coll Surg Engl. 2014;96(1):55-60.
Smith SP, Devaraj VS, Bunker TD. The association between frozen shoulder and Dupuytren’s disease. J Shoulder Elbow Surg 2001;10:149-151.
van der Windt DA, Koes BW, Devillé W, Boeke AJ, de Jong BA, Bouter LM. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ. 1998 Nov 7; 317(7168):1292-6
Vastamäki H, Kettunen J, Vastamäki M. The natural history of idiopathic frozen shoulder: a 2- to 27-year follow up study. Clin Orthop Relat Res 2012;470:1133-1143.
Yian EH, Contreras R, Sodl JF. Effects of glycemic control on prevalence of diabetic frozen shoulder. J Bone Joint Surg [Am] 2012;94-A:919-923.

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