Frozen Shoulder

• Freezing stage (red) - The patient develops a slow onset of pain. As the pain worsens, the shoulder loses motion. 
  

• Frozen stage (blue) - The patient experiences a slow improvement in pain, but the stiffness remains. 

• Thawing stage (green)- the patient slowly regains full mobilisation of their shoulder as it returns to normal. 

Causes of Frozen Shoulder

We aren’t entirely sure why Frozen Shoulder occurs; however, it is more likely to occur in patients who recently had to immobilize their shoulder for a long period or trauma (after surgery or an arm fracture).

There is an association with auto-immune conditions such as Hashimoto’s and Graves Thyroiditis, Type 1 diabetes, Celiac disease and Pernicious anemia (the so-called thyro-gastric cluster). 2 The strongest association is with Type 2 Diabetes (and Insulin Resistance or "Pre-Diabetes") 3–5 

Frozen shoulder is also associated with Heart Disease and cardiac surgery, Parkinson’s Disease, Breast Cancer (post-surgery).

Frozen Shoulder Symptoms

Frozen Shoulder tends to cause a background of Dull, Aching Pain With sharper shoots of Pain occurring with sudden movements and shoots down the front and side of the arm.

Lack of mobility- especially loss of rotation and elevation (patients often notice inability to reach behind their back first).

Diagnosis of Frozen Shoulder

Often, Frozen Shoulder can be identified during a physical exam, but further testing may pick up on important contributors and overlapping conditions such as diabetes, osteoarthritis, rotator cuff tears and impingement syndromes.

This process starts with Consultation including a comprehensive history, examination and possibly a point of care ultrasound

• Further testing can include
• X-rays – Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in the shoulder, such as osteoarthritis.
• MRI – provides high resolution, panoramic, detailed images of the soft tissues. An MRI can produce cross-sectional images of internal structures required if the diagnosis is unclear. 7
• Ultrasound is a dynamic test that can allow us to examine the shoulder during movement at the time of consultation. One key finding in a frozen shoulder is increased blood flow and tissue thickening around the top of the biceps tendon (this is called the “Rotator Interval”). 8
  

While not all these approaches or tests are required to confirm the diagnosis, this diagnostic process will us to review any possible risks or existing conditions that could affect treatment and recovery.

Treatment for Frozen Shoulder 

Nonsurgical treatments

Frozen shoulder generally improves over time without any intervention, however, it can take an average of 2-3 years.9 If symptoms are severe, affecting sleep quality and not controlled by physiotherapy and judiciously prescribed medication, escalation to corticosteroid injections is reasonable. 10,11

• Steroid injections have been shown to be effective for pain in the early phases of a frozen shoulder for reduction of pain. The location of injection is important as bursal cortisone injections do not enter the joint and settle joint related pain
• These injections are delivered to the shoulder joint, often via the rotator interval as well as the bursa and sometimes from the posterior approach as well
• Hydro-dilatation or High-Volume injections have no strong evidence of being superior to cortisone injections but may assist in return of range of motion in the later phases 12–15
• Physical therapy- especially after the painful phase has settled is useful to maintain and restore strength and range of motion 16
  

Frozen Shoulder Surgery

Surgery for a frozen shoulder is a last resort but has been shown to improve range of motion significantly. 17,18

However, most surgeons do not like to operate in the early stages before the condition has stabilized as surgery is known to cause frozen shoulder. It is thought that the trauma of surgery can stir up further immunological stimulus to make pain and stiffness worse. Therefore, patients tend not to be offered surgery while they are in the freezing phase.