Anatomy

The capsule is a sack which surrounds the bones of the main glenohumeral (shoulder) joint. 
The capsule is thin (about the thickness of a lycra gym top) and stretchy, allowing the shoulder to move through its full range.

Shoulder Anatomy

What happens in frozen shoulder?

Initially the capsule becomes inflamed (irritable).
Over time it becomes thicker (up to 5mm or more) and it shrinks, as it does this the range of motion decreases

What are the causes of frozen shoulder?

In the vast majority of cases no cause is found -this is often called “Idiopathic Frozen Shoulder”
Other causes are:
Inflammation- if the shoulder has been sore for another reason such as “impingement” or “calcific tendinitis”
Injury
Diabetes

What are the signs and symptoms?

Initially the shoulder is uncomfortable but it is often not very specific, just “sore”
The should then becomes more sore and often movement is painful as is dressing and sleeping
After a few weeks or months the range of motion decreases in all directions

Typically the range becomes:
Rising the arm forwards: To the horizontal 
Raising the arm to the slide: Slightly less than Horizontal
Rotating out to the side (with the elbow tucked in): Almost nothing
Internal rotation (hand behind back): tot the buttock

What is the progress of frozen shoulder?

In the first 2-3 months the shoulder is uncomfortable but it is often not very specific, just “sore”
3-6 months the shoulder is more painful and the range of motion steadily decreases
By about 6 months the range has plateaued and the pain decreases. Typically the resting pain subsides and it is only of the shoulder is moved too far, too fast that there is any pain.
Typically the shoulder loosens up again by 2-3 years after the symptoms started and becomes normal

How is the diagnosis made?

The clinician will listen to the description of events and examine the shoulder. X-Rays will also be taken to exclude the shoulder joint as a cause of the problem.
Usually it is not necessary to do any more investigations but occasionally an MRI may be helpful

What is the initial treatment?

The initial treatment depends on the symptoms.
In the early stages simple anti-inflammatories and physiotherapy can help

What if the initial treatment fails?

If the symptoms do not improve then there are several options
Do nothing: The condition is self limiting and will eventually get better
Hydrodilatation:
Manipulation under anaesthetic:
Arthroscopic Capsular release:

Hydrodilatation

This is a procedure performed by the radiologists in the x-ray department.
Using ultrasound the shoulder joint is localised and an mix of steroid, saline and local anaesthetic is injected.
The radiologist will try to get as much fluid as possible into the joint. 
It does not matter how much it is actually possible to inject – the result is usually the same.
You can go home about 30 mins after the injection and resume normal activities.
Physiotherapy needs to start within the first 48 hours and will typically need to be continued for about 2 months

The procedure is successful in about 85% of patients and can be repeated if necessary

If the procedure is not successful then it is possible to proceed to a manipulation under anaesthetic or capsular release 

Manipulation Under Anaesthetic

Anaesthetic

General Anaesthetic with an interscalene block (Fully asleep with a local anaesthetic injection into the side of the neck will numb the nerves to the shoulder for post-operative pain relief)

Procedure

The shoulder will be stretched through the full range of motion to stretch out the tight tissues.
You can go home the same day
Physiotherapy needs to start within the first 48 hours and will typically need to be continued for about 2 months

The procedure is successful in about 80% of cases
If the range obtained is not adequate then, typically, the surgeon will proceed to a capsular release under the same anaesthetic

Arthroscopic Capsular Release

Anaesthetic

General Anaesthetic with an interscalene block (Fully asleep with a local anaesthetic injection into the side of the neck will numb the nerves to the shoulder for post-operative pain relief)

Operation type

Arthroscopic – 2 0.5cm incisions, one at the back and one at the front of the shoulder

Procedure

The gleno-humeral (shoulder) joint will be inspected first followed. A soft tissue shaving device will be used to clear any scar tissue away. 

Wound Closure

Small butterfly paper stitches will be used to close the wounds. 
Tegaderm waterproof dressings will be placed over the top of the paper stitches.

Pain relief

The anaesthetist will discuss a nerve block which will be administered after you are asleep, this means that you will wake up with no pain in the shoulder but the arm will feel numb for up to 12 hours. You will be prescribed painkillers to start taking when you get home and we encourage you to take these regularly for at least the first few days. There will be some discomfort but this settles quite rapidly and ice packs can be used in addition if you wish.

Wound care

The dressings will be changed before you go home and these can be left alone until they are removed. Typically they can be removed 10 days after surgery just by peeling them off and you do not need to visit the doctor for this.

The dressings are showerproof and you will be given some spares in case they start to peel off.

Rehabilitation after surgery

You will wake up with a sling on your arm. This can be removed as soon as you are comfortable, typically the next day.
Physiotherapy needs to start as soon as possible to work on regaining the range of motion.
The movement is often not quite as good over the first week but then recovers to the range obtained during surgery.

Surgical Risks

Every operation has a degree of risk. It is important that you are aware of these risks before you agree to proceed with your operation.
If you decide not to proceed with surgery there is a possibility that the symptoms will settle on their own but they may continue and they may get worse. You will not damage the shoulder if you decide not to proceed with surgery. 

The most common or significant risks are outlined below. A risk of 0.1% means that 1 in 1000 people will suffer the complication 

  • Failure of the procedure to relieve symptoms: 5% 
  • Superficial Infection (requiring antibiotics): 0.16% 
  • Deep Infection (requiring further surgery): 0.02% 
  • PE (Pulmonary Embolus) (Blood clot in the lung): 0.13% – Blood thinning medication is required for several months. Can rarely result in death. 
  • DVT (Deep Vein Thrombosis) (Blood clot in the leg): 0.14% – Blood thinning medication is required for several months. Can lead to PE 
  • Nerve Injury: 0.01% – Usually temporary. Can cause weakness around the shoulder with loss of function and rarely can be permanent. 
  • Heart attack: 0.02%
  • To put these numbers in perspective
    The chance of:
    • Getting three balls in the UK national lottery: 0.9%
    • Needing emergency treatment in the next year after being injured by a can, bottle, or jar: 0.1% 
    • Death by an accident at home: 0.01%
    • For a 50 year old man in good health the 5 year risk of dying is 0.8%

Frequently asked questions

Return to work after surgery

This is very much dependent on the type of work that you do, whether you need to drive to get to work and the type of surgery that you have had done.

You, as the patient, have the best idea of the specific demands that are required of you to do your work safely and effectively.

Having an operation with an anaesthetic often takes more out of people than they would expect. Generally it is probably worth taking at least a week off from your regular work after having had any procedure.

You should discuss expected post-operative recovery and work with the surgeon before your operation.

Driving after surgery

To be able to drive safely you should be capable of actively moving your shoulder without assistance and without damaging the surgical repair. You should be able to react normally to avoid causing injury to yourself or others due to a lack of control.

Typically this is a no more than 2 weeks after surgery.

It is a UK requirement that, unless specific dispensation has been granted by the DVLA, a driver uses both arms to control the steering wheel.

It is the responsibility of the driver to ensure that they are in control of the vehicle at all times. They should be able to demonstrate this if stopped by the police.

It is not a requirement to notify the DVLA unless the medical conditions likely to affect safe driving persist for longer than three months after the date of the surgery.

Drivers must not drive under the influence of narcotic medications or within a minimum of 24 hours after an anaesthetic.

Although it is not essential, it may be wise to discuss your return to driving with your car insurance company.

Sports after surgery

You can start simple cardio such as walking or using a static bicycle immediately following surgery. Exercises which involve the shoulder can start as soon as you feel comfortable. Typically this is a few weeks but it may take 5 months or more for high demand overhead sports (swimming, tennis etc to return to normal)