What is a frozen shoulder?
Frozen shoulder (sometimes referred to as adhesive capsulitis) is a condition characterised by inflammation and stiffness of the shoulder joint capsule resulting in shoulder pain, stiffness and restriction of movement. To learn more about frozen shoulder, its causes and other FAQs, please see our article about frozen shoulder.
What are the available treatment options for frozen shoulder?
Conservative management
This usually consists of physiotherapy, using anti-inflammatory tablets and activity modification. The treatment usually starts by doing a targeted physiotherapy exercise program. This includes stretching exercises that you can do at home to improve shoulder movement and function. It also includes manual techniques that need to be done by the physiotherapist in the clinic. The physiotherapist will mobilise your shoulder joint in certain ways to help reduce the pain and increase the range of movement.
Management also includes patient education and modification of daily activities (for example, using supportive pillows under the shoulder when sleeping and taking regular breaks to rest your shoulder). Anti-inflammatory tablets like Ibuprofen or anti-inflammatory gels (like Voltarol) can also be used to help reduce the inflammation in the joint.
These measures are particularly useful for the “stiff stage” of a frozen shoulder. Evidence shows that conservative management has limited effect during the first “painful stage” of a frozen shoulder.
Joint injections
If the symptoms of a frozen shoulder are severe and not responding adequately to conservative management, particularly if the pain is severe, affecting your sleep, daily activities and sports, then a shoulder injection can be helpful. In a frozen shoulder, joint pain and stiffness may impede efficient rehabilitation. A shoulder injection is indicated in such cases to help reduce the pain and enable you to undertake an effective physiotherapy program. There is strong evidence that having a shoulder injection followed by a dedicated physiotherapy program (within a couple of weeks) is very effective. Injection therapy is particularly useful during the “painful stage” of a frozen shoulder, as the pain can be severe and restrictive with very little response to conservative management. Ultrasound-guided shoulder injection for managing a frozen shoulder is a well-recognised treatment option recommended by NICE guidelines.
We recommend doing any shoulder injection under imaging guidance (ultrasound or x-ray). Ultrasound is our preferred choice as it does not involve radiation and is very accurate when performed by an experienced doctor. We always recommend performing shoulder injections under ultrasound guidance to ensure accurate placement of the needle into the shoulder joint at the exact site of inflammation. Ultrasound guidance results in more accurate, less painful and faster procedures, with better outcomes than these injections without guidance.
Mainly, two types of injections can be used to treat frozen shoulder
Steroids are strong anti-inflammatory medicines that act by reducing the inflammation within the shoulder joint/capsule and thus reducing pain and stiffness, as well as improving the range of movement. It aims to give you an opportunity to undertake an effective physiotherapy program and achieve good recovery. A long-acting cortisone (Kenalog or triamcinolone acetonide) is usually injected into the shoulder under ultrasound guidance. The steroid is usually mixed with local anaesthetic (numbing medication) in this procedure. Evidence shows that Intra-articular steroid injection results in short-term pain relief and improvement in the range of movement that may continue into the medium and long term (ladermann et al 2021).
Ultrasound-guided hydrodistension (hydrodilatation)
Hydrodistension is a special procedure used to treat frozen shoulder/adhesive capsulitis. In addition to injecting cortisone and numbing medicine, a high volume of sterile (clean) water (approx. 20-30 mls) will be injected into the shoulder joint under ultrasound guidance. In addition to reducing the inflammation via the steroid's anti-inflammatory effect, the procedure aims to distend the inflamed, stiff and thickened joint capsule. To find out more, please see our article about shoulder hydrodistension. Evidence shows that hydrodilatation provides short-term pain relief and improvement in the range of movement that continues into the medium and long term (ladermann et al 2021). Therefore, hydrodistension/hydrodilatation with corticosteroid injection provides better medium-term and long-term improvements when compared to steroid injection and physiotherapy.
Ultrasound-guided hydrodistension is increasingly used to treat frozen shoulder, particularly during the “stiff stage”, as the procedure will help to stretch the thick and stiff joint capsule, in addition to reducing the inflammation.
Surgical treatment
The symptoms of a frozen shoulder usually respond well to a combination of the treatments described above, and surgical treatment is rarely needed nowadays.
There are two surgical treatment options available for frozen shoulders.
Manipulation under anaesthesia (MUA): You will be put to sleep (general anaesthesia), and the shoulder surgeon will move your shoulder joint aiming to stretch the tight joint capsular and release any inflamed scar tissue.
Arthroscopic capsular release (ACR). Using a keyhole surgery and under general anaesthesia, the tight and inflamed tissue within the shoulder joint capsule will be released. Surgical treatments are rarely needed nowadays as the response from hydrodistension followed by physiotherapy is usually very good. Some patients get a partial response from the procedure, so they may undergo a repeat hydrodilatation procedure. Please see our article to find out more about how hydrodilatation is done.
Shoulder conditions and treatments
