This is an inflammatory condition which affects the shoulder joint. However in the lay press the term has been very loosely applied to any painful condition of the shoulder - this may cause some confusion among patients as the course of the condition, the treatment and the expected outcome are very different, depending on the actual condition.

The true Frozen Shoulder or Adhesive Capsulitis has been considered in most patients to be a self limiting process which eventually will recover, but it may take an incredibly and frustratingly long time! Help can be provided during this period if desired.

Frozen Shoulder has the following characteristics:

1. Usually affects people between 40 - 70 years of age.
2. Patients with Diabetes are not only more commonly involved, but they are also more difficult to treat, take longer to subside and may be left with some residual trouble even with treatment.
3. There are 3 phases to this condition
   1. painful phase - usually no precipitating cause, gradual onset, mainly at night especially if patient lies on it. Lasts 2 - 4 months.
   2. stiffening phase - movement at the shoulder is gradually lost while the shoulder remains painful. There is usually a loss of movement in all planes rather than one specific direction. The pain becomes a dull ache and severe pain occurs with sudden movements such as reaching when the capsule is stretched at the end of its restricted range. Lasts 4 - 12 months.
   3. thawing phase - motion gradually returns over an unpredictable period often over 6 - 9 months
4. May occur after periods of immobilisation or episodes of shoulder surgery for other conditions. It has also been related to other episodes of trauma or injury to the upper limb, neck degeneration and thyroid over activity

Treatment options:

• Wait. Allow nature to take its course, confident that good function will return eventually ....(in the majority of cases)
• Medication. Pain killing (analgesic) and antiinflammatory tablets are useful in the early stages.
• Exercises. Gentle motion exercises by the patient are beneficial. Stretching by another person eg. physiotherapist may infact aggravate the condition and should be avoided. Local heat such as hot shower or warm wheat bag will help to relax the muscles, allow gentle movements and feel more comfortable.
• Manipulation under anaesthetic.
• Hydrodilatation.
• Arthroscopic capsular release (with Laser).

Manipulation under Anaesthetic

Stretching of the inflamed capsule with the patient awake may cause the surrounding muscles to go into spasm trying to protect the underlying capsule - thus producing further pain. By performing the stretch of the contracted capsule while the patient is anaesthetised, the muscles are paralysed and so cannot go into spasm and therefore allow the capsule to be stretched (torn) without tearing the muscles.

The tearing of the capsule is haphazard and of course bleeding into the joint occurs.

Hydrodilatation

Fluid can be injected underpressure into the joint space till the capsule bursts (tears). Again haphazard tearing of the capsular tissue and will create bleeding into the joint.

Arthroscopic Capsular Release

The contracted capsule and adhesions can be precisely divided inside the joint while watching through the arthroscope. The muscles are of course not damaged with this procedure and a complete release observed without stretching or tearing other adjacent structures.

This was at first performed using scissors, basket forceps, or mechanised cutting machines (debriders) but the lining of the joint is very inflamed and bleeds with gentle touch let alone cutting thus resulting in blood clouding the fluid in the joint and reducing visibility.

Using Laser or radiofrequency to perform the release does not cause the same bleeding as they seal the blood vessels as they cut the tissue, simultaneously. Therefore there is less blood in the joint, less irritating, less swelling as the joint does not need to be over distended to stop the bleeding and hence less pain.

before		after

Postoperatively:

1. You stay overnight to be helped with the exercises by the nurses. (You are not going there for a holiday !). Very little is needed for pain relief as this is not a very painful procedure when using the Laser.
2. Discharge (with full range of motion) from hospital next day usually about 10 am with oral analgesic if required & antiinflammatory tablets if tolerated. If there is any muscle tightness or spasm while doing the stretches, an antispasmotic tablet (Valium) may be prescribed by the doctor.
3. Physiotherapy supervision starts in hospital and best continued for 3 visits a week for 3 weeks only. Hydrotherapy is often of great value as it helps relax your muscles while you keep the joint fully stretched.
4. Consult with the doctor occurs at 3 weeks and usually no further visits are necessary.

N.B. Patients with Diabetes are often more difficult to manage and the chance of a recurrence is much higher if the Frozen Shoulder is still in its painful inflammatory phase.

Complications:

Complications such as anaesthetic, medical and surgical can occur after any surgery but fortunately are uncommon. The anaesthetist will the discuss risks of anaesthesia with you prior to the operation and advise on the safest form (you may contact him/her before the day of surgery if you wish, or your doctor is concerned).

Possible complications with shoulder surgery include:

• infection - we take all steps to minimise this, including covering the operation with an antibiotic
• bleeding, swelling, stiffness and possible nerve injury
• recurrence of frozen shoulder - more common in Diabetics and minimised by starting movement early. Muscle tension and spasm tend to make patients more prone to this so must be controlled. Recurrence is less likely if waited till aching pain at rest subsided before undertaking the procedure.
• scar formation is usually minimal because of the arthroscopic technique.