Frozen Shoulder

Introduction

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.

Your risk of developing frozen shoulder increases if you're recovering from a medical condition or procedure that affects the mobility of your arm — such as a stroke or a mastectomy.

Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.

When is Frozen Shoulder Surgery recommended?

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.

  • Painful stage. During this stage, pain occurs with any movement of your shoulder, and your shoulder's range of motion starts to become limited.

  • Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.

  • Thawing stage. During the thawing stage, the range of motion in your shoulder begins to improve.

For some people, the pain worsens at night, sometimes disrupting normal sleep patterns.

What are the causes?

The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.

Doctors aren't sure why this happens to some people and not to others, although it's more likely to occur in people who have recently experienced prolonged immobilization of their shoulder, such as after surgery or an arm fracture.

How is Frozen Shoulder diagnosed?

During the physical exam, your doctor may ask you to perform certain actions, to check for pain and evaluate your range of motion. These may include:

  • Hands up. Raise both your hands straight up in the air, like a football referee calling a touchdown.

  • Opposite shoulder. Reach across your chest to touch your opposite shoulder.

  • Back scratch. Starting with the back of your hand against the small of your back, reach upward to touch your opposite shoulder blade.

Your doctor may also ask you to relax your muscles while he or she moves your arm for you. This test can help distinguish between frozen shoulder and a rotator cuff injury.

Frozen shoulder can usually be diagnosed from signs and symptoms alone. But your doctor may suggest imaging tests — such as X-rays or an MRI — to rule out other structural problems.

What are the treatment options for Frozen Shoulders?

Most frozen shoulder treatment involves controlling shoulder pain and preserving as much range of motion in the shoulder as possible.

Medications

Over-the-counter pain relievers, such as aspirin and ibuprofen (Advil, Motrin, others), can help reduce pain and inflammation associated with frozen shoulder. In some cases, your doctor may prescribe stronger pain-relieving and anti-inflammatory drugs.

Therapy

A physical therapist can teach you stretching exercises to help maintain as much mobility in your shoulder as possible.

Surgical and other procedures

Most frozen shoulders get better on their own within 12 to 18 months. For persistent symptoms, your doctor may suggest:

  • Steroid injections. Injecting corticosteroids into your shoulder joint may help decrease pain and improve shoulder mobility.

  • Joint distension. Injecting sterile water into the joint capsule can help stretch the tissue and make it easier to move the joint.

  • Shoulder manipulation. In this procedure, you receive a general anesthetic so you'll be unconscious and feel no pain. Then the doctor moves your shoulder joint in different directions, to help loosen the tightened tissue. Depending on the amount of force used, this procedure can cause bone fractures.

  • Surgery. If nothing else has helped, you may be a candidate for surgery to remove scar tissue and adhesions from inside your shoulder joint. Doctors usually perform this surgery arthroscopically, with lighted, tubular instruments inserted through small incisions around your joint.

What are the risk factors for Frozen Shoulder?

Although the exact cause is unknown, certain factors may increase your risk of developing frozen shoulder.

Age and sex

People 40 and older are more likely to experience frozen shoulder. Most of the people who develop the condition are women.

Immobility or reduced mobility

People who have experienced prolonged immobility or reduced mobility of their shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including:

  • Rotator cuff injury

  • Broken arm

  • Stroke

  • Recovery from surgery

Systemic diseases

People who have certain medical problems appear to be predisposed to develop frozen shoulder. Examples include:

  • Diabetes

  • Overactive thyroid (hyperthyroidism)

  • Underactive thyroid (hypothyroidism)

  • Cardiovascular disease

  • Tuberculosis

  • Parkinson's disease

Can Frozen Shoulder be prevented?

One of the most common causes of frozen shoulder is the immobility that may result during recovery from a shoulder injury, broken arm or a stroke. If you've had an injury that makes it difficult to move your shoulder, talk to your doctor about what exercises would be best to maintain the range of motion in your shoulder joint.

How fast can you recover?

After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to three months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.

Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion. In some cases, however, even after several years, the motion does not return completely and a small amount of stiffness remains.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.

After Discharge?

Your doctor will normally discharge you the day after surgery if your pain is well controlled, and the physiotherapists are happy with your progress.

Your exercises will be supervised by outpatient physiotherapy appointments, which will be arranged for you before you leave hospital.

Discharge Information

Pain relief & medication

The nursing staff will advise you about painkillers before you leave the hospital. Please tell the nurses what painkilling tablets you have at home.

Your wound

Your wounds must remain covered with dressings until your outpatient appointment, where your sutures will be removed.

Getting back to normal

Remember that you have just had an operation. It is normal to feel more tired than usual for a few days after having an operation.

Your shoulder is likely to be uncomfortable in the first few days post-surgery. This is normal but can be helped by;

  • Using ice on your shoulder for 15 minutes, 2 times per day or after exercise and therapy. Gel packs, frozen peas or a plastic pack of ice can be used. These must be wrapped in a moist towel as direct contact with the skin can cause burns (cover your dressings with cling film or a plastic bag to prevent them getting wet).   

  • Sleeping can be uncomfortable if you try and lie on your operated arm. We would recommend that initially you lie on your back or on the opposite side. If you lie on your back support the operated arm with a folded pillow under your lower arm. Make sure that your elbow is above your shoulder. If you are on your side then a folded pillow supports your operated arm from your elbow to your wrist.

  • Your sling is for comfort only and should be discarded as soon as possible -usually within the first 2-4 days. You may find it useful to continue to wear the sling at night for a little longer if the shoulder feels uncomfortable. In the first few days post-op it is generally recommended to wear the sling if you are going out to protect your arm.

  • Posture can make a significant difference to your pain post surgery. Avoid 'hitching' your shoulder or holding it in an elevated position. Also try to avoid slumping or standing/sitting with round shoulders.

  • In the first few days after surgery you will find it helps to support your arm on pillows with your elbow in front of your shoulder and slightly out to the side when you are sitting down

Exercises

It is essential that you carry out the exercises regularly following your procedure, ideally four to five times per day increasing as able. It is quite normal for you to experience aching, discomfort and stretching when doing the exercises but you can decrease the exercises if you experience intense or lasting pain

Returning to work

  • You can self-certify for the first seven days of sickness. Before you are discharged, a medical certificate (sick note) may be issued by your hospital doctor to cover the expected time off you will need. The time that you can return to work will depend on the nature of your work. If you are in a relatively sedentary job you may be able to return as early as 1 week after surgery. If your job involves heavy lifting or sustained overhead positions it may take 6 to12 weeks before you can return. Your doctor and physiotherapist will discuss this with you and advise you accordingly.

  • Driving - If you feel comfortable and have good range of movement you can begin driving 1 week after your operation. It is advisable to check this with your Doctor or Physiotherapist if you are unsure. It is important to advise your Insurance Company that you have had Shoulder Surgery.

Further Appointments

You will be seen in outpatient's clinic approximately 1- 2 weeks after your surgery. This appointment will be made and given to you before you are discharged from hospital.

Physiotherapy Appointments

  • It is important that physiotherapy is commenced immediately after surgery. An appointment will be arranged within two days of your surgery.

  • The amount of physiotherapy you require will depend on your individual progress.

What are the results of the surgery?

To be provided by the doctor.

What are the complications?

  • Stiffness and pain continue even with therapy

  • The arm can break if the shoulder is moved forcefully during surgery

Cost of Surgery?

The cost of surgery for Frozen Shoulder depends on many factors. They include the cost of being in the hospital for several days. Unexpected events that result in an extended hospital stay will also increase the overall cost.

Costs also vary depending on the type of insurance coverage you have. Many insurance companies cover the cost of the surgery, the hospital stay, and the instruments to straighten the spine. You may owe a co-payment or you may be billed the balance of what your insurance does not cover.

Be sure to contact your insurance provider prior to surgery to discuss the extent of your coverage. Discuss with your surgeon, as well as the hospital billing department to make sure you understand all the costs involved.

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