Frozen Shoulder (Adhesive Capsulitis)

This is a condition in which the shoulder may become increasingly stiff and painful. There has been some argument regarding the appropriate term for this condition. Adhesive capsulitis, although in common use, is a misnomer as the process does not involve any sticking together or adhesion and it is not a capsulitis as it is not an inflammatory process.

Structures involved:

The capsule, or lining of the shoulder joint, is normally relatively loose, allowing the shoulder to have the greatest range of movement of any joint in the body. When a Frozen shoulder or Intrinsic Capsular Stiffness (ICS) develops the lining of the joint contracts and becomes thickened. As a consequence both the active and passive range of movement is reduced, that is shoulder movement is restricted when either the patient or examiner attempt to move the shoulder.

The muscles, which would normally move the shoulder, are typically unaffected but cannot move the joint normally because of the physical limitation of the capsule.

The other joints that make up the shoulder complex are unaffected.

Symptoms:

Pain.

Pain is normally the first issue that is noted. The pain may be severe and is typically felt over the upper arm or deltoid rather than necessarily the shoulder itself. The pain is often noted on movement such as reaching up to say a top shelf (abduction) or reaching back to reach the back seat of a car (external rotation) and reaching behind the back to tuck in a shirt or fasten a bra (internal rotation). The pain may be particularly troublesome at night and disturb sleep. Lying on either shoulder may be uncomfortable. Pain is often particularly marked on sudden unanticipated movements.

Secondary pain may develop over the back, shoulder blade and neck (Parascapular and Trapezial regions). This is often a consequence of the extra strain on the scapular stabilising muscles and neck as the Shoulder (Gleno-Humeral Joint) stiffens.

In the early stages when stiffness is not marked it may be very difficult to distinguish an ICS or frozen shoulder from an impingement syndrome as the pain on abduction may be similar and the impingement tests may appear positive.

The marked pain associated with the Gleno-Humeral joint typically subsides over a period of 6 months, although the neck and back pain may persist.

A small proportion of patients may continue to have some ongoing discomfort in the long term but this is uncommon.

Stiffness.

The stiffness or loss of active and passive movement, in the presence of normal structural imaging is the cardinal feature of ICS or a frozen shoulder. The stiffness is often progressive and may become increasingly disabling. The stiffness may reach a point where there is essentially no significant movement at the Gleno-Humeral joint and all apparent movement takes place as a consequence of scapula-thoracic movement (shoulder blade). This Scapluo-thoracic movement may compensate to a remarkable degree but may result in secondary pain around the scapula and neck.

The stiffness typically subsides over 12-24 months. Complete range of movement may not return but significant restriction or functional impairment is uncommon.

Causes:

A Frozen shoulder or ICS typically occurs for no clear reason. However, it may be associated with an injury, such as a trip and fall, or as a complication of surgery or possibly as a consequence of repeated activities at the extreme range of movement, such as painting the ceiling.

There are some conditions that appear related to a frozen shoulder or ICS, these include Diabetes, Dupytren’s Disease and Plantar Fibrosis. If you have had a frozen shoulder before you have an increased risk of developing a frozen shoulder in the other shoulder.

Diagnosis and investigations:

The diagnosis is likely to be made on the basis of the history and examination. However, investigations are important to exclude alternative causes of shoulder stiffness and identify co-existing issues.

X-Rays (plain radiographs).

These are particularly important to exclude alternative causes of stiffness including arthritis and rarely, a missed dislocation of the Gleno-Humeral Joint.

Magnetic Resonance Imaging scan (MRI).

Stiffness in the shoulder may make physical assessment of other structures such as the rotator cuff difficult. An MRI scan may be particularly useful for identifying associated structural damage, particularly if the stiffness has come on following a fall. It is not uncommon in this situation to have co-existing Rotator Cuff tears and a Frozen shoulder or ICS.

Ultrasound scan (USS).

An ultrasound scan can be a rapid way of assessing associated structural damage, particularly of the rotator cuff.

Treatment:

The majority of cases of Frozen shoulder or ICS will settle without any intervention. However, it is often an extremely painful and disabling condition. There are a number of treatments available that may relieve symptoms or potentially alter the course or rate of recovery. The evidence to support many treatments that are commonly offered is limited.

Analgesia (Painkillers).

Treatment with simple painkillers and anti-inflammatories may be particularly useful and all that is required to make the condition manageable.

Physiotherapy and rehabilitation.

Physiotherapy may be useful for symptomatic relief and to maintain as much range of movement as possible. Physiotherapy, including acupuncture and Tissue massage may be particularly useful for addressing secondary pain in the Parascapular and Trapezial regions.

Injections.

An injection of steroid and local anaesthetic may be provided into the Gleno-Humeral Joint itself. The injection may be useful from a diagnostic standpoint, confirming the articular nature of the pathology. The injection may also produce symptomatic relief in the short or long term as well as potentially modifying the course of the condition.

houlder steroid injections / Cortisone injections (Corticosteroid injections).

Corticosteroids are hormones that are produced naturally by the adrenal glands. They have many important functions in the body, including control of inflammatory responses. Corticosteroid medicines are man-made derivatives of the natural hormones and are often simply called steroids.

It should be noted that corticosteroids are very different from another group of steroids, called anabolic steroids, which have gained notoriety because of their abuse by some athletes and body builders.

Your surgeon or doctor may recommend an injection of steroid into or around the shoulder. The injection may be intra-articular (into the joint itself) or peri-articular (into the soft tissue around the joint).

The steroids function like a powerful local anti-inflammatory. The purpose of the injection is to provide relief of symptoms such as pain and swelling as well as to confirm the location of the shoulder pathology.

Types of injection:

There are a number of different preparations (Triamcinalone, Methylprednisolone, Hydrocortisone etc.). The steroid is often given with a local anaesthetic. There are a number of different types of local anaesthetic of which Bupivacaine (Trade names include; Marcaine, Marcain) and Lidocaine (also called; Xylocaine, Lignocaine) are the most commonly used. The local anaesthetic provides relief from discomfort associated with the injection but also serves a useful diagnostic function in confirming the source of the symptoms.

Location of injections:

A local steroid injection is location specific so it is important where the injection is provided. The 3 most common sites of a shoulder injection are the Subacromial space (under the tip of the shoulder blade), the Gleno-Humeral Joint (shoulder joint) and the Acromio-Clavicular Joint (the joint between collarbone and shoulder blade).

Following the injection:

The local anaesthetic typically provides pain relief within a few minutes. The effect of the local anaesthetic may last several hours. The steroid itself may start to take effect within a few hours or may take a few days to work.

There may be a short-term increase in discomfort between 24 and 72 hours of the steroid injection (a steroid flare). This may be associated with the absorption of the steroid but there is no correlation with the efficacy of the steroid injection.

Following the injection it is usually advisable to rest the joint or limb and avoid strenuous activities for the first few days.

The beneficial effects of the steroid injection may last for weeks or months or it may be associated with resolution of symptoms.

There may be no appreciable benefit following the injection or the benefit may be short lived. Short-lived benefit for even an hour can be important in establishing the diagnosis and location of the problem.

If an injection is helpful then a repeat injection can be considered. However, if symptoms return following an injection there may be significant underlying issues that may require further investigation or treatment.

Alternative treatments:

Alternative treatments include; physiotherapy, oral anti-inflammatories or analgesics.

Additional medication or treatment:

You may usually continue to take other tablets and medication when given a local steroid injection. You should inform your treating physician of any tablets you are taking especially blood thinning agents (eg: Warfarin and Dibigatran etc.) prior to an injection.

Pregnancy and Breast-feeding:

While it is usually best to avoid steroid injections during pregnancy and while breast-feeding they may be necessary or indicated.

A single local steroid injection should not effect fertility or pregnancy but you should inform your treating physician and any concerns can then be discussed.

During breast-feeding a small amount of steroid may pass into the breast-milk. However, the amount associated with a single local steroid injection is unlikely to be harmful to a baby but you should inform your treating physician and any concerns can then be discussed.

Alcohol:

There is no particular reason to avoid alcohol following a local steroid injection. Care should be taken if additional analgesia or anti-inflammatories are being used.

Complications of steroid injections:

The amount of steroid typically injected and the way it is absorbed makes systemic symptoms such as those frequently associated with oral steroid medication (tablets) rare.

Pain:

Discomfort between 24 and 72 hours following the injection is the most common complication. It is a reasonable precaution to take simple analgesics and anti-inflammatories, if tolerated, following the injection.

Infection:

There is a risk of infection developing either associated with the injection itself or the local reduction in immune response at the site of the injection. Care should be used be taken at the time of injection to minimise this risk.

You should inform your treating physician or General Practitioner should you develop a hot, swollen area any redness at the site of the injection or any systemic effects such as; fever, sweating or feel generally unwell following the injection. Infection following a steroid injection is extremely uncommon but the consequences can be significant and so it is best to seek advice promptly if there is any concern.

If an infection were to develop this can typically be treated with antibiotics. If the injection were into a joint then this joint may need to be washed out with an arthroscopic (keyhole) procedure.

Skin changes:

Rarely there may be skin depigmentation or discolouration at the site of the injection. The darker the skin colouration the more noticeable this may be. These changes are typically temporary but may take several months to settle. Rarely the depigmentation may persist in the long term.

Subcutaneous Lypodystrophy:

There may be dimpling or thinning of the skin as a consequence of changes in the underlying fatty tissue as a consequence of the action of the steroid.

Additional side effects:

Patients do occasionally note; facial flushing, menstrual cycle disturbance, mood changes and changes in diabetic control.

Please discuss any concerns with your treating physician.

Surgical intervention.

Occasionally the shoulder continues to cause pain and functional impairment despite initial treatment. In this situation surgical intervention may be considered.

Manipulation Under Anaesthetic (MUA).

The traditional surgical intervention is a Manipulation Under Anaesthetic (MUA). This involves a general anaesthetic (being fully asleep). The shoulder is then carefully stretched to release the capsule and break down the thickened contractures. The shoulder is then mobilised as soon as possible with focused physiotherapy to limit or prevent recurrence of stiffness.

Arthroscopic Capsular Release.

In this situation and arthroscopic (keyhole) examination of the shoulder is undertaken. This is typically undertaken under a General anaesthetic (fully asleep) with a nerve block above the clavicle (collarbone) to numb the arm and allow early pain free movement following the procedure. The diagnosis is confirmed by the visualisation of the abnormal capsule (lining) of the Gleno-Humeral Joint. Additional damage can be confirmed and or treated. The thickened contracted tissue can then be divided under direct vision. It is not normally necessary to circumferentially release the capsule. Once the capsule has been released sufficiently the shoulder is then carefully manipulated to release any residual limitation of movement. An injection of steroid and local anaesthetic is then typically provided to the Gleno-Humeral joint. The shoulder is then mobilised as soon as possible with focused physiotherapy.

Arthroscopic Capsular Release.

Frozen Shoulder, Adhesive Capsulitis or Intrinsic Capsular Stiffness:

This is a condition in which the shoulder may become increasingly stiff and painful. The capsule, or lining of the shoulder joint, is normally relatively loose, allowing the shoulder to have the greatest range of movement of any joint in the body. When a Frozen shoulder or Intrinsic Capsular Stiffness (ICS) develops the lining of the joint contracts and becomes thickened. As a consequence, both the active and passive range of movement is reduced, that is shoulder movement is restricted when either the patient or examiner attempt to move the shoulder.

Indication:

Pain and functional impairment as a consequence of a frozen shoulder or ICS that has not responded to non-operative treatment.

Anaesthetic:

The surgery is typically undertaken with the patient asleep with a nerve block to provide additional pain relief and allow early pain free movement immediately following the surgery.

Structures involved:

It is the capsule or lining of the joint that is thickened and contracted resulting in the restriction of movement. The capsule is typically red with leashes of prominent new blood vessels visible when viewed with the arthroscope from inside the Gleno-Humeral Joint.

Procedure:

The surgery is undertaken as an arthroscopic or keyhole operation. The Gleno-Humeral Joint is inspected to confirm the diagnosis and identify any additional pathology. The interval between the Subscapularis and Supraspinatus Tendons is typically thickened and contracted. This is cleared with an arthroscopic tissue shaver. The lining of the joint is then divided to release the joint. The release does not have to be completely circumferential and it is normal practice to avoid the lower portion of the joint where the Axillary Nerve lies close to the capsule and could be damaged. Once a satisfactory release has been obtained the arm is then Manipulated where it is put though a range of movement to stretch out any residual stiffness. By the end of the procedure the range of movement should be the same as normal. An injection of Steroid and Local Anaesthetic is then typically placed in the joint under direct vision.

Incision:

The procedure is usually carried out through 2 or 3 small (5mm) incisions. These incisions do not normally require sutures or stitches. Steri-StripsTM are normally used to close the wounds and these are covered by an OpsiteTM dressing. These dressings may in turn be covered by a large padded dressing immediately following the operation. This padded dressing is removed prior to being discharged home.

Admission and Discharge:

You will normally be admitted the day of surgery and go home the same day. It may be necessary for you to stay in overnight particularly if you do not have a responsible adult to keep an eye on you overnight or if your operation is late on in the day.

Rehabilitation:

The arm will usually be numb after the operation because of the nerve block. As a consequence range of movement exercises can be commenced soon after the operation typically without discomfort. The physiotherapist will typically go through the rehabilitation exercises before and after the procedure. A PolyslingTM may be provided to protect the arm while it remains numb but should be discarded as soon as possible. Follow up with the physiotherapists is typically made soon after discharge. It will be necessary to be diligent and continue with the rehabilitation to optimise the outcome of the surgery.

Please see the link to post capsular release rehabilitation guidelines.

Risks associated with the operation:

All operations are associated with a degree of risk but significant complications associated with an arthroscopic capsular release are uncommon. The following risks are those that are serious or most commonly reported in the literature.

Infection (<1%):

Infection in shoulder surgery is very uncommon, particularly in keyhole (arthroscopic) surgery. Antibiotics are often given pre-operatively to reduce the risk of an infection further. If an infection were to develop it is typically a superficial infection, which can be treated with oral antibiotics. Rarely does an infection develop that requires re-admission to hospital and surgery to wash the infection out.

Anaesthetic Risks:

Anaestheic complications are rare but include Heart Attack (Myocardial Infarction, MI), Stroke (Cerbero-Vascular Accident, CVA) and a clot in the leg (Deep Vein Thrombosis, DVT) or lungs (Pulmonary Embolus, PE).

Neuro-Vascular Damage (<1%):

Damage to nerves or blood vessels is rare. Damage to the axillary nerve may occur as it passes close to the joint. Damage to this nerve may result in weakness and difficulty bringing the arm out to the side (abduction).

Stiffness (1-10%):

At the end of the procedure the range of movement in the Gleno-Humeral Joint should be restored. However, some recurrence of the stiffness may occur. Rarely the recurrence of stiffness is such that a repeat procedure is indicated. It is rare for there to be long term persistent stiffness.

Change in symptoms:

Continued pain (5%) The probability of symptom improvement is high it remains possible but rare that symptoms may remain unchanged or deteriorate.

Fracture (<1%)

This is a rare but recognised complication. In order to stretch out the capsular contraction considerable force may be necessary. The arthroscopic capsular release should result in a more controlled and less forceful release reducing the risk of fracture further.

Arthritis:

It is unlikely that the surgery itself would predispose the shoulder to arthritis. The presence of shoulder pathology generally may increase the probability of later arthritis.

Further surgery (Re-operation)

Preventing further stiffness:

Continuing rehabilitation is important to limit or prevent recurrence of stiffness. Despite this a small number of patients will have a relapse in the degree of stiffness. Very rarely repeat arthroscopic release is indicated. Those with associated conditions such as Diabetes or Dupytren’s Disease may be most at risk.

Often called a stiff or “frozen shoulder,” adhesive capsulitis occurs in about 2% to 5% of the general population. It affects women more than men and typically occurs in people who are over the age of 45. Of the people who have had adhesive capsulitis in one shoulder, 20% to 30% will get it in the other shoulder.

What is Frozen Shoulder (Adhesive Capsulitis)?

Adhesive capsulitis is the stiffening of the shoulder due to scar tissue, which results in painful movement and loss of motion. The actual cause of adhesive capsulitis is a matter for debate. Some believe it is caused by inflammation, such as when the lining of a joint becomes inflamed (synovitis), or by autoimmune reactions, where the body launches an "attack" against its own substances and tissues. Other possible causes include:

•  Reactions after an injury or surgery

•  Pain from other conditions—such as arthritis, a rotator cuff tear, bursitis, or tendinitis—that has caused you to stop moving your shoulder

•  Immobilization of your arm, such as in a sling, after surgery or fracture

Often, however, there is no known reason why adhesive capsulitis starts.

How Does it Feel?

Most people with adhesive capsulitis have worsening pain and then a loss of range of movement. Adhesive capsulitis can be broken down into 4 stages, and your physical therapist can help determine what stage you are in:

Stage 1 - "Pre-Freezing"

During this stage, it may be difficult to identify your problem as adhesive capsulitis. You've had symptoms for 1 to 3 months, and they're getting worse. There is pain with active movement and passive motion (movements that a physical therapist does for you). The shoulder usually aches when you're not using it, but pain increases and becomes "sharp" with movement. You'll have a mild reduction in motion during this period, and you'll protect the shoulder by using it less. The movement loss is most noticeable in "external rotation" (this is when you rotate your arm away from your body), but you might start to lose motion when you raise your arm (called "flexion and abduction")or reach behind your back (called "internal rotation"). You'll have pain during the day and at night.

Stage 2 – "Freezing"

By this stage, you've had symptoms for 3 to 9 months, most likely with a progressive loss of shoulder movement and an increase in pain (especially at night). The shoulder still has some range of movement, but this is limited by both pain and stiffness.

Stage 3 – "Frozen"

Your symptoms have persisted for 9 to 14 months, and you have greatly decreased range of shoulder movement. During the early part of this stage, there is still a substantial amount of pain. Toward the end of this stage, however, pain decreases, with the pain usually occurring only when you move your shoulder as far you can move it.

Stage 4 – "Thawing"

You've had symptoms for 12 to 15 months, and there is a big decrease in pain, especially at night. You still have a limited range of movement, but your ability to complete your daily activities involving overhead motion is improving at a rapid rate.

Overall goal is to restore your movement so that you can perform your activities and life roles. Once the evaluation process has identified the stage of your condition, your therapist will create an exercise program tailored to your needs. Exercise has been found to be most effective for those who are in stage 2 or higher.

Stages 1 and 2

Your physical therapist will help you maintain as much range of motion as possible and will help reduce the pain. Your therapist may use a combination of stretching and manual therapy techniques to increase your range of motion. The therapist also may decide to use treatments such as heat and ice to help relax the muscles prior to other forms of treatment. The therapist will give you a home exercise program designed to help reduce the loss of motion.

Stage 3

The focus of treatment will be on the return of motion, with your therapist using more aggressive stretching and manual therapy techniques. You may begin some strengthening exercises as well, and your home exercise program will change to include these exercises.

Stage 4

In the final stage, your therapist will focus on the return of "normal" shoulder body mechanics and your return to normal, everyday, pain-free activities. The therapist will continue to use stretching, strength training, and a variety of manual therapy techniques.

Sometimes, conservative care cannot reduce the pain. If this happens to you, your physical therapist may refer you for an injection of anti-inflammatory and pain-relieving medication into the joint space. Research has shown that although these injections don’t provide longer-term benefit for range of motion and don’t shorten the duration of the condition, they do offer short-term benefit in reducing pain.

Can this Injury or Condition be Prevented?

The cause of adhesive capsulitis is debatable, with no definitive cause, so there is no known method of prevention. The onset is usually gradual, with the disease process needing to "run its course."

Introduction

Adhesive capsulitis, also called frozen shoulder, is a painful condition. It results in a severe loss of motion in the shoulder. It may follow an injury, or it may arise gradually with no injury or warning.

This guide will help you understand

•  what causes frozen shoulder

•  what tests your doctor will do to diagnose it

•  how you can regain use of your shoulder.

Anatomy

What part of the shoulder is affected?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). The joint capsule is a watertight sac that encloses the joint and the fluids that bathe and lubricate it. The walls of the joint capsule are made up of ligaments. Ligaments are soft connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so the shoulder is unrestricted as it moves through its large range of motion.

In frozen shoulder, inflammation in the joint makes the normally loose parts of the joint capsule stick together. This seriously limits the shoulder's ability to move, and causes the shoulder to freeze.

Related Document: A Patient's Guide to Shoulder Anatomy

Causes

Why did my shoulder freeze up?

The cause of frozen shoulder is largely a mystery. One theory is that it may be caused by an autoimmune reaction. In an autoimmune reaction, the body's defense system, which normally protects it from infection, mistakenly begins to attack the tissues of the body. This causes an intense inflammatory reaction in the tissue that is under attack.

No one knows why this occurs so suddenly. Frozen shoulder may begin after a shoulder injury, fracture, or surgery. It can also start if the shoulder is not being used normally. This can happen after a wrist fracture, when the arm is kept in a sling for several weeks. For some reason, immobilizing a joint after an injury seems to trigger the autoimmune response in some people.

Frozen shoulder has also been known to occur after surgery unrelated to the shoulder, even after recovering from a heart attack. Other shoulder problems like bursitis, rotator cuff tears, or impingement syndrome can end up causing a frozen shoulder. Doctors theorize that the underlying condition may cause chronic inflammation and pain that make you use that shoulder less. This sets up a situation that can create frozen shoulder. Usually, the frozen shoulder must be treated first to regain its ability to move before the underlying problem can be addressed.

Related Document: A Patient's Guide to Impingement Syndrome

Related Document: A Patient's Guide to Rotator Cuff Tears

Symptoms

What are the symptoms of frozen shoulder?

The symptoms of frozen shoulder are primarily shoulder pain and a very reduced range of motion in the joint. The range of motion is the same whether you are trying to move the shoulder yourself or someone else is trying to move the arm for you. There comes a point in each direction of movement where the motion simply stops, as if something is blocking it. At this point, the shoulder usually hurts. The shoulder can also be quite painful at night. The tightness in the shoulder can make it difficult to do regular activities like getting dressed, combing your hair, or reaching across a table.

Diagnosis

What tests will my doctor run?

The diagnosis of frozen shoulder is usually made on the basis of your medical history and physical examination. One key finding that helps differentiate a frozen shoulder from a rotator cuff tear is how the shoulder moves. With frozen shoulder, the shoulder motion is the same whether the patient or the doctor tries to move the arm. With a rotator cuff tear, the patient cannot move the arm. But when someone else lifts the arm it can be moved in a nearly normal range of motion.

Simple X-rays are usually not helpful. An arthrogram may show that the shoulder capsule is scarred and tightened. The arthrogram involves injecting dye into the shoulder joint and taking several X-rays. In frozen shoulder, very little dye can be injected into the shoulder joint because the joint capsule is stuck together, making it smaller than normal. The X-rays taken after injecting the dye will show very little dye in the joint.

As your ability to move your shoulder increases, your doctor may suggest tests to rule out an underlying condition, such as impingement or a rotator cuff tear. Probably the most common test used is magnetic resonance imaging (MRI). An MRI scan is a special imaging test that uses magnetic waves to create pictures that show the tissues of the shoulder in slices.

The MRI scan shows tendons and other soft tissues as well as the bones.

Colorized to illustrate soft tissues revealed in MRI

Treatment

What treatment options are available?

Nonsurgical Treatment

Treatment of frozen shoulder can be frustrating and slow. Most cases eventually improve, but the process may take months. The goal of your initial treatment is to decrease inflammation and increase the range of motion of the shoulder. Your doctor will probably recommend anti-inflammatory medications, such as aspirin and ibuprofen.

Physical or occupational therapy treatments are a critical part of helping you regain the motion and function of your shoulder. Treatments are directed at getting the muscles to relax. Therapists use heat and hands-on treatments to stretch the joint capsule and muscle tissues of the shoulder. You will also be given exercises and stretches to do as part of a home program. You may need therapy treatments for three to four months before you get full shoulder motion and function back.

Your doctor may also recommend an injection of cortisone and a long-acting anesthetic, similar to lidocaine, to get the inflammation under control. Cortisone is a steroid that is very effective at reducing inflammation. Controlling the inflammation relieves some pain and allows the stretching program to be more effective. In some cases, it helps to inject a long-acting anesthetic with the cortisone right before a stretching session. This allows your therapist to manually break up the adhesions while the shoulder is numb from the anesthetic.

Surgery

Manipulation under Anesthesia

If progress in rehabilitation is slow, your doctor may recommend manipulation under anesthesia. This means you are put to sleep with general anesthesia. Then the surgeon aggressively stretches your shoulder joint. The heavy action of the manipulation stretches the shoulder joint capsule and breaks up the scar tissue. In most cases, the manipulation improves motion in the joint faster than allowing nature to take its course. You may need this procedure more than once.

This procedure has risks. There is a very slight chance the stretching can injure the nerves of the brachial plexus, the network of nerves running to your arm. And there is a risk of fracturing the humerus (the bone of the upper arm), especially in people who have osteoporosis (fragile bones).

Arthroscopic Release

When it becomes clear that physical therapy and manipulation under anesthesia have not improved shoulder motion, arthroscopic release may be needed. This procedure is usually done using an anesthesia block to deaden the arm. The surgeon uses an arthroscope to see inside the shoulder. An arthroscope is a slender tube with a camera attached. It allows the surgeon to see inside the joint.

During the athroscopic procedure, the surgeon cuts (releases) scar tissue, the ligament on top of the shoulder (coracohumeral ligament), and a small portion of the joint capsule. If shoulder movement is not regained or if the surgeon is unable to complete the surgery using the arthroscope, an open procedure may be needed. An open procedure requires a larger incision so the surgeon can work in the joint more easily.

At the end of the release procedure, the surgeon gently manipulates the shoulder to gain additional motion. A steroid medicine may be injected into the shoulder joint at the completion of the procedure.

Rehabilitation

What can I expect after treatment?

Nonsurgical Rehabilitation

The primary goal of physical therapy is to help you regain full range of motion in the shoulder. If your pain is too strong at first to begin working on shoulder movement, your therapist may need to start with treatments to help control pain. Treatments to ease pain include ice, heat, ultrasound, and electrical stimulation. Therapists also use massage or other types of hands-on treatment to ease muscle spasm and pain.

When your shoulder is ready, therapy will focus on regaining your shoulder's movement. Sessions may begin with treatments like moist hot packs or ultrasound. These treatments relax the muscles and get the shoulder tissues ready to be stretched. Therapists then begin working to loosen up the shoulder joint, especially the joint capsule. You can also get a good stretch using an overhead shoulder pulley in the clinic or as part of a home program.

If your doctor recommends an injection for your shoulder, you should plan on seeing your therapist right after the injection. The extra fluid from the injection stretches out the tissues of the joint capsule. An aggressive session of stretching right afterward can help maximize the stretch to the joint capsule.

After Surgery

After arthroscopic release, you'll likely begin using a shoulder pulley on a daily basis. You'll probably be encouraged to use the treated arm in everyday activities. Strengthening exercises are not begun for four to six weeks after the procedure. You might participate in physical or occupational therapy for up to two months after arthroscopic release.

After manipulation under anesthesia, your surgeon may place your shoulder in a continuous passive motion (CPM) machine. CPM is used after many different types of joint surgeries. You begin using CPM immediately after surgery. It keeps the shoulder moving and alleviates joint stiffness. The machine simply straps to the arm and continuously moves the joint. This continuous motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint.

Some surgeons apply a dynamic splint to the shoulder after manipulation surgery. A dynamic splint puts the shoulder into a full stretch and holds it there. Keeping the shoulder stretched gradually loosens up the joint capsule.

You'll resume therapy within one to two days of the shoulder manipulation. Some surgeons have their patients in therapy every day for one to two weeks. Your therapist will treat you with aggressive stretching to help maximize the benefits of the shoulder manipulation. The stretching also keeps scar tissue from forming and binding the capsule again. Your shoulder movement should improve continually after the manipulation and therapy. If not, you may require more than one manipulation.

Once your shoulder is moving better, treatment is directed toward shoulder strengthening and function. These exercises focus on the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to help keep the ball of the humerus centered in the socket. This lets your shoulder move smoothly during all your activities.

The therapist's goal is to help you regain shoulder motion, strength, and function. When you are well under way, regular visits to the therapist's office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Frozen Shoulder or Intrinsic Capsular Stiffness (ICS) or Adhesive Capsulitis.

This is a condition in which the shoulder may become increasingly stiff and painful. There has been some argument regarding the appropriate term for this condition. Adhesive capsulitis, although in common use, is a misnomer as the process does not involve any sticking together or adhesion and it is not a capsulitis as it is not an inflammatory process.

Structures involved:

The capsule, or lining of the shoulder joint, is normally relatively loose, allowing the shoulder to have the greatest range of movement of any joint in the body. When a Frozen shoulder or Intrinsic Capsular Stiffness (ICS) develops the lining of the joint contracts and becomes thickened. As a consequence both the active and passive range of movement is reduced, that is shoulder movement is restricted when either the patient or examiner attempt to move the shoulder.

The muscles, which would normally move the shoulder, are typically unaffected but cannot move the joint normally because of the physical limitation of the capsule.

The other joints that make up the shoulder complex are unaffected.

Symptoms:

Pain.

Pain is normally the first issue that is noted. The pain may be severe and is typically felt over the upper arm or deltoid rather than necessarily the shoulder itself. The pain is often noted on movement such as reaching up to say a top shelf (abduction) or reaching back to reach the back seat of a car (external rotation) and reaching behind the back to tuck in a shirt or fasten a bra (internal rotation). The pain may be particularly troublesome at night and disturb sleep. Lying on either shoulder may be uncomfortable. Pain is often particularly marked on sudden unanticipated movements.

Secondary pain may develop over the back, shoulder blade and neck (Parascapular and Trapezial regions). This is often a consequence of the extra strain on the scapular stabilising muscles and neck as the Shoulder (Gleno-Humeral Joint) stiffens.

In the early stages when stiffness is not marked it may be very difficult to distinguish an ICS or frozen shoulder from an impingement syndrome as the pain on abduction may be similar and the impingement tests may appear positive.

The marked pain associated with the Gleno-Humeral joint typically subsides over a period of 6 months, although the neck and back pain may persist.

A small proportion of patients may continue to have some ongoing discomfort in the long term but this is uncommon.

Stiffness.

The stiffness or loss of active and passive movement, in the presence of normal structural imaging is the cardinal feature of ICS or a frozen shoulder. The stiffness is often progressive and may become increasingly disabling. The stiffness may reach a point where there is essentially no significant movement at the Gleno-Humeral joint and all apparent movement takes place as a consequence of scapula-thoracic movement (shoulder blade). This Scapluo-thoracic movement may compensate to a remarkable degree but may result in secondary pain around the scapula and neck.

The stiffness typically subsides over 12-24 months. Complete range of movement may not return but significant restriction or functional impairment is uncommon.

Causes:

A Frozen shoulder or ICS typically occurs for no clear reason. However, it may be associated with an injury, such as a trip and fall, or as a complication of surgery or possibly as a consequence of repeated activities at the extreme range of movement, such as painting the ceiling.

There are some conditions that appear related to a frozen shoulder or ICS, these include Diabetes, Dupytren’s Disease and Plantar Fibrosis. If you have had a frozen shoulder before you have an increased risk of developing a frozen shoulder in the other shoulder.

Diagnosis and investigations:

The diagnosis is likely to be made on the basis of the history and examination. However, investigations are important to exclude alternative causes of shoulder stiffness and identify co-existing issues.

X-Rays (plain radiographs).

These are particularly important to exclude alternative causes of stiffness including arthritis and rarely, a missed dislocation of the Gleno-Humeral Joint.

Magnetic Resonance Imaging scan (MRI).

Stiffness in the shoulder may make physical assessment of other structures such as the rotator cuff difficult. An MRI scan may be particularly useful for identifying associated structural damage, particularly if the stiffness has come on following a fall. It is not uncommon in this situation to have co-existing Rotator Cuff tears and a Frozen shoulder or ICS.

Ultrasound scan (USS).

An ultrasound scan can be a rapid way of assessing associated structural damage, particularly of the rotator cuff.

Treatment:

The majority of cases of Frozen shoulder or ICS will settle without any intervention. However, it is often an extremely painful and disabling condition. There are a number of treatments available that may relieve symptoms or potentially alter the course or rate of recovery. The evidence to support many treatments that are commonly offered is limited.

Analgesia (Painkillers).

Treatment with simple painkillers and anti-inflammatories may be particularly useful and all that is required to make the condition manageable.

Physiotherapy and rehabilitation.

Physiotherapy may be useful for symptomatic relief and to maintain as much range of movement as possible. Physiotherapy, including acupuncture and Tissue massage may be particularly useful for addressing secondary pain in the Parascapular and Trapezial regions.

Injections.

An injection of steroid and local anaesthetic may be provided into the Gleno-Humeral Joint itself. The injection may be useful from a diagnostic standpoint, confirming the articular nature of the pathology. The injection may also produce symptomatic relief in the short or long term as well as potentially modifying the course of the condition.

Link to additional information on steroid injections.

Surgical intervention.

Occasionally the shoulder continues to cause pain and functional impairment despite initial treatment. In this situation surgical intervention may be considered.

Manipulation Under Anaesthetic (MUA).

The traditional surgical intervention is a Manipulation Under Anaesthetic (MUA). This involves a general anaesthetic (being fully asleep). The shoulder is then carefully stretched to release the capsule and break down the thickened contractures. The shoulder is then mobilised as soon as possible with focused physiotherapy to limit or prevent recurrence of stiffness.

Arthroscopic Capsular Release.

In this situation and arthroscopic (keyhole) examination of the shoulder is undertaken. This is typically undertaken under a General anaesthetic (fully asleep) with a nerve block above the clavicle (collarbone) to numb the arm and allow early pain free movement following the procedure. The diagnosis is confirmed by the visualisation of the abnormal capsule (lining) of the Gleno-Humeral Joint. Additional damage can be confirmed and or treated. The thickened contracted tissue can then be divided under direct vision. It is not normally necessary to circumferentially release the capsule. Once the capsule has been released sufficiently the shoulder is then carefully manipulated to release any residual limitation of movement. An injection of steroid and local anaesthetic is then typically provided to the Gleno-Humeral joint. The shoulder is then mobilised as soon as possible with focused physiotherapy.

Link to additional information on Arthroscopic Capsular Release.

Arthroscopic Capsular Release.

Frozen Shoulder, Adhesive Capsulitis or Intrinsic Capsular Stiffness:

This is a condition in which the shoulder may become increasingly stiff and painful. The capsule, or lining of the shoulder joint, is normally relatively loose, allowing the shoulder to have the greatest range of movement of any joint in the body. When a Frozen shoulder or Intrinsic Capsular Stiffness (ICS) develops the lining of the joint contracts and becomes thickened. As a consequence, both the active and passive range of movement is reduced, that is shoulder movement is restricted when either the patient or examiner attempt to move the shoulder.

Indication:

Pain and functional impairment as a consequence of a frozen shoulder or ICS that has not responded to non-operative treatment.

Anaesthetic:

The surgery is typically undertaken with the patient asleep with a nerve block to provide additional pain relief and allow early pain free movement immediately following the surgery.

Structures involved:

It is the capsule or lining of the joint that is thickened and contracted resulting in the restriction of movement. The capsule is typically red with leashes of prominent new blood vessels visible when viewed with the arthroscope from inside the Gleno-Humeral Joint.

Procedure:

The surgery is undertaken as an arthroscopic or keyhole operation. The Gleno-Humeral Joint is inspected to confirm the diagnosis and identify any additional pathology. The interval between the Subscapularis and Supraspinatus Tendons is typically thickened and contracted. This is cleared with an arthroscopic tissue shaver. The lining of the joint is then divided to release the joint. The release does not have to be completely circumferential and it is normal practice to avoid the lower portion of the joint where the Axillary Nerve lies close to the capsule and could be damaged. Once a satisfactory release has been obtained the arm is then Manipulated where it is put though a range of movement to stretch out any residual stiffness. By the end of the procedure the range of movement should be the same as normal. An injection of Steroid and Local Anaesthetic is then typically placed in the joint under direct vision.

Incision:

The procedure is usually carried out through 2 or 3 small (5mm) incisions. These incisions do not normally require sutures or stitches. Steri-StripsTM are normally used to close the wounds and these are covered by an OpsiteTM dressing. These dressings may in turn be covered by a large padded dressing immediately following the operation. This padded dressing is removed prior to being discharged home.

Admission and Discharge:

You will normally be admitted the day of surgery and go home the same day. It may be necessary for you to stay in overnight particularly if you do not have a responsible adult to keep an eye on you overnight or if your operation is late on in the day.

Rehabilitation:

The arm will usually be numb after the operation because of the nerve block. As a consequence range of movement exercises can be commenced soon after the operation typically without discomfort. The physiotherapist will typically go through the rehabilitation exercises before and after the procedure. A PolyslingTM may be provided to protect the arm while it remains numb but should be discarded as soon as possible. Follow up with the physiotherapists is typically made soon after discharge. It will be necessary to be diligent and continue with the rehabilitation to optimise the outcome of the surgery.

Please see the link to post capsular release rehabilitation guidelines.

Risks associated with the operation:

All operations are associated with a degree of risk but significant complications associated with an arthroscopic capsular release are uncommon. The following risks are those that are serious or most commonly reported in the literature.

Infection (<1%):

Infection in shoulder surgery is very uncommon, particularly in keyhole (arthroscopic) surgery. Antibiotics are often given pre-operatively to reduce the risk of an infection further. If an infection were to develop it is typically a superficial infection, which can be treated with oral antibiotics. Rarely does an infection develop that requires re-admission to hospital and surgery to wash the infection out.

Anaesthetic Risks:

Anaestheic complications are rare but include Heart Attack (Myocardial Infarction, MI), Stroke (Cerbero-Vascular Accident, CVA) and a clot in the leg (Deep Vein Thrombosis, DVT) or lungs (Pulmonary Embolus, PE).

Neuro-Vascular Damage (<1%):

Damage to nerves or blood vessels is rare. Damage to the axillary nerve may occur as it passes close to the joint. Damage to this nerve may result in weakness and difficulty bringing the arm out to the side (abduction).

Stiffness (1-10%):

At the end of the procedure the range of movement in the Gleno-Humeral Joint should be restored. However, some recurrence of the stiffness may occur. Rarely the recurrence of stiffness is such that a repeat procedure is indicated. It is rare for there to be long term persistent stiffness.

Change in symptoms:

Continued pain (5%) The probability of symptom improvement is high it remains possible but rare that symptoms may remain unchanged or deteriorate.

Fracture (<1%)

This is a rare but recognised complication. In order to stretch out the capsular contraction considerable force may be necessary. The arthroscopic capsular release should result in a more controlled and less forceful release reducing the risk of fracture further.

Arthritis:

It is unlikely that the surgery itself would predispose the shoulder to arthritis. The presence of shoulder pathology generally may increase the probability of later arthritis.

Further surgery (Re-operation)

Preventing further stiffness:

Continuing rehabilitation is important to limit or prevent recurrence of stiffness. Despite this a small number of patients will have a relapse in the degree of stiffness. Very rarely repeat arthroscopic release is indicated. Those with associated conditions such as Diabetes or Dupytren’s Disease may be most at risk.