‘Frozen Shoulder – Adhesive Capsulitis.’
Ms Ruth Delaney

I am a shoulder surgeon and certainly not an expert on menopause but there is a shoulder condition that we tend to see more commonly in women and often around the time of the menopause and that’s Frozen Shoulder. The other name for it being Adhesive Capsulitis. So, in terms of shoulder pain around the time of the menopause there is good evidence to show that the most common diagnosis both premenopausal and perimenopausal by far is adhesive capsulitis or frozen shoulder. So almost a third in both cases whether its before the menopause or around the time during the menopause, the diagnosis behind shoulder pain is frozen shoulder.

The second most common diagnosis is shoulder synovitis which often goes hand in hand with frozen shoulders inflammation of the lining of the joint more common that was found in the actual perimenopausal group rather than the premenopausal, but the point is shoulder pain around menopause is far more commonly due to frozen shoulder than in the general population where there is a lifetime prevalence of frozen shoulder of 2-5% yet In the perimenopausal or premenopausal population you are looking at 35% and 32% of all shoulder pain is due to frozen shoulder.

So, what is Frozen Shoulder? Who tends to get it? What is not frozen shoulder? How do we go about figuring it out and diagnosing it? And then how do we treat frozen shoulder once we have arrived at that diagnosis? These are the things that I will go through this evening.

So, the terminology that is often used medically is Adhesive Capsulitis, the capsule of the shoulder joint is the lining around the ball and socket, so the shoulder joint is a ball and socket, the capsule is around the joint and the capsule gets inflamed and that’s the capsulitis. The adhesive part is I suppose reflective of the fact that it tends to be almost like adhesions where the capsule gets really tight and thick and scarred as that’s how its become to be known as adhesive capsulitis.

We don’t really know why this happens, there are some theories out there, but there is often no real cause for it. Its important when somebody has a painful and stiff shoulder that we don’t just call all of those things frozen shoulder, there are other things that can present like that and those need to be ruled out before we make a diagnosis of frozen shoulder.

One of the other things that can present with a painful/stiff shoulder is Arthritis of the shoulder joint, the very simple way to make that diagnosis is with a x-ray and you will see as on the x-ray here in the picture where instead of there being a nice ball and socket and some space between the ball and socket, that space on the x-ray is no longer really visible, the space reflects the cartilage being worn away and there is in that picture what you would call bone on bone arthritis. Whereas in frozen shoulder the capsule is inflamed and x-ray should look pretty normal.

There are other situations where it is difficult to move the shoulder for example, with sever weakness it can be difficult to raise the arm and that can happen with a massive tear of the rotator cuff and sometimes people will make the mistake of calling that frozen shoulder because it seems as though the patient can’t move the shoulder at all but in fact if you take the other hand and move the arm up or if I move the persons arm, there is movement there they just don’t have the strength and so we are just differentiating the passive from the active movement and frozen shoulder both will be very stiff whereas in a case of severe weakness the passive motion will often still be there.

Sometimes a shoulder is just simply too painful to move but again if we move it passively its possible to move through the pain, whereas with frozen shoulder its not actually possible to move beyond a certain limited range or what we call a capsular end field, physiotherapists will often refer to that and so basically with frozen shoulder the shoulder must be stiff actively and passively but have a normal x-ray.

People find it quite frustrating when we cant explain why they got a frozen shoulder, what caused it, did they do anything, usually no. There is no real consensus on what causes it, it is inflammation of the capsule, so usually its idiopathic for no good reason. It can happen after trauma so sometimes you will see somebody who falls or has some trauma to the shoulder doesn’t actually do any structural damage to the shoulder but the shoulder responds by getting really inflamed and that can result in a frozen shoulder.

One theory is that if there is a minor injury to the shoulder, then the first response is inflammation which is normal, the first stage of any healing is inflammation and if the shoulder somehow gets stuck in that inflammatory phase or overdo the inflammation that can result in frozen shoulder.

There are some theories about it maybe being autoimmune and then sometimes we see it if somebody has sort of had less movement of their arm for an unrelated reason, for example if they have been put in a sling for something else, so that’s often why we don’t put say hand and wrist injuries or elbow injuries into a sling very much because the shoulder ends up getting stiff. Sometimes we see it after something like a pacemaker insertion, so on the left side and maybe there is a bit of soreness there for a little while afterwards as the person doesn’t move their shoulder as much and they can develop a frozen shoulder or after breast surgery or IR radiation to that area, but there is no definitive cause known for frozen shoulder.

It was interesting during Covid we saw there was an increase the presentation of frozen shoulder to us at the clinic and we wondered were we imagining it or was there actually a pattern to it, so we analysed that time period to an equal time period before hand and we found that yes there were a lot more frozen shoulders, it had increased by more than a third.

In terms of presentations it wasn’t any different in terms of the severity or how responsive to treatment or what proportion needed surgery and other centres have found similar phenomenon as well, we don’t have an explanation but the theories were perhaps its related to a low grade pro-inflammatory state so either if people had subclinical or even clinical Covid  was that somehow related to frozen shoulder or perhaps stress, everybody was some mental distress at the time during the pandemic for various reasons and that is a pro-inflammatory state and whether that has translated into an increased risk of frozen shoulder is unclear. However, we were able to see that there was a spike of frozen shoulder during Covid for whatever reason.

There are classic associations with frozen shoulder, diabetic is probably the most well known one, Thyroid disorder is usually underactive but can be overactive thyroid as well and the one that we are discussing tonight around the time of the menopause, so those are all hormonal disorders, so there does seem to be some interplay between the endocrine or hormone system and frozen shoulder, its yet to be explained fully.  The associations are not causes, they are sort of seen as patterns. Typically frozen shoulder effects females in their 40s or 50s but we do see men with it and we do see people outside of those age groups.

The way we go about making a diagnosis, the history can give us a clue, so many people with frozen shoulder will have those typical associated factors that we have just mentioned not always. The classic pattern is that there has been this gradual onset of pain which is worsening over time and it can be very severe pain especially with any sudden movements which is a sign of capsular irritation or having to reach or overstretch beyond the range that’s available as the shoulder starts to get a bit stiff and irritable, a lot of people will find getting dressed or undressed or reaching out to get a ticket out of a machine in a car park can be really painful.

Usually the pain starts first and then the stiffness comes in a little bit later, the capsule is becoming thicker and tight as it becomes more inflamed and that’s making it physically impossible to move the shoulder and that’s why its limited both passively and actively. In fact if we were to put someone asleep who has frozen shoulder, we give them a general anaesthetic muscles are completely relaxed they are not feeling any pain and fully asleep the range of motion is still the same because its physical block that this thickened tight capsule is creating, physical block in movement.  Typically, frozen shoulder will get better on its own if nothing is done but the reason to think about doing something is that can take a long time.

It can take up to 2-3 years with some people and It tends to go through phases where its painful and intensely painful, then it becomes stiff and painful. The pain gradually fades away and your just left with stiffness and then eventually the range of motion comes back and the shoulder does tend to go back to normal, there is nothing wrong with the shoulder joint, the underlying joint itself, its this inflammatory process involving the joint capsule that does burn itself out eventually. As it is so miserable when people have it its not entirely reasonable to just wait two or three years to get better.

The other way we diagnose it is by doing clinical examination and unfortunately for whatever reason this part is often skipped and everyone with shoulder pain is just sent for an MRI and that’s where things can get confusing, what we are looking at in the clinical exam is the shoulder being irritable with range of motion and that obviously is non-specific a lot of other shoulder problems can show that as well. Often we find pain towards the end range of motion and then if its very early in frozen shoulder that might be the only thing that we find, if it is a little bit later then stiffness will have developed and the stiffness should be both the active and the passive range of motion.

All we usually need is an x-ray and many people will already come having a MRI but if we examine the shoulder and there is no weakness we can establish that the rotator cuff muscles and tendons are all working well and we have a stiff painful shoulder. We take an x-ray to make sure it is not arthritic and if the x-ray shows a normal joint then we know it’s the capsule and that’s our diagnosis. It’s a combination of history in a typical patient, the clinical exam and an x-ray being normal.

The thing about the MRI’s and we have I suppose learned this and gotten this message out there that not every back pain gets an MRI but for some reason in Ireland every shoulder pain seems to get an MRI and the reality is, that nobody of the age around the time of menopause in fact nobody over above 30 is going to have a normal shoulder MRI, there is age related changes that happen within the tendons, little bits of wear they are not necessarily significant but the radiologist has to describe everything they see, so when you get an MRI of your shoulder you will have a big long report and what we often see that things get inappropriately emphasized on that report and people get sent down the wrong road. The reality is often if you had a MRI on the asymptomatic shoulder it would generate a report very similar.

We don’t encourage getting MRI’s without a good clinical exam and often we don’t need it in cases of frozen shoulder where we have a good exam, we don’t need the MRI to make the diagnosis, it can be quiet uncomfortable to lie inside a scanner for 20-30 minutes if you have capsulitis of the shoulder, a lot of patients with frozen shoulder find that there pain is quite bad at night time and its quite uncomfortable when they lie down and the same thing inside a scanner.

The times when we will ask for an MRI is if we cant establish in the clinical exam whether the strength of the rotator cuff is normal because sometimes the shoulder is so sore when you have a frozen shoulder that it’s really hard to cooperate with the exam and do all the tests, sort of push and pull against the examiners hand because its just too painful, so a lot of times we will check an MRI for that reason, but the vast majority of people we can exam and understand what’s going on without necessarily having to put them through having a scan. Sometimes you can have a rotator cuffed hair that gets secondarily stiff and that’s kind of a secondary frozen shoulder which is a bit of a different scenario.

Then if you have a frozen shoulder what to do with it? How to treat it? The first thing is pain management, if you are still in that painful phase we need to decrease the pain to give back quality of life, to get back sleep, and to then allow you to start doing some gentle stretching of the shoulder. As it is an inflammatory problem we use anti-inflammatory as the first line, usually start with the non-steroidal anti-inflammatories’ simple things like ibuprofen or maybe some of the prescription non-steroidal anti-inflammatories. Its also reasonable to do a short course of oral steroids, yes that’s giving steroid to the whole system but in a very short burst for maybe a week to 10 days of a decreasing dose. Many times GP’s will be happy to give that and that can give a really intense burst of anti-inflammatory treatment which helps the frozen shoulder.

Other simple things like using heat to try and loosen it out, using ice to settle it down before you go to bed at night, those are kind of the basic pain management strategies. We also then suggest very gentle stretching, maximum five out of ten discomfort when stretching. Getting into a pool can be very helpful people often say well I like to swim in the sea, well its not quite the same, I think you need the warm temperature of the water to help you stretch. O

ften people with frozen shoulder have been sent to physiotherapy and they have found that it has aggravated it and they actually feel that physio made them feel worse and I think that is probably because the instinct on the part of the physiotherapist is to try and push and get the range of motion back and not let the shoulder get stiff but when there is a capsulitis that often just actually makes it worse and it tends to get more painful, more inflamed and then stiffer. So usually we have people just stretch by themselves and do some self-directed stretching rather than have anyone else go at the shoulder particularly when its in that irritated phase.

Sometimes if the shoulder is really sore you might want to give it a rest and put it in a sling but that’s probably the worst thing to do because it will just get more and more stiff with that, so no slings for frozen shoulder try to gently keep it moving. With the pain management sometimes we will add an injection of steroids so usually if somebody has come to me they have normally tried some of the simple things already and we will be thinking about injecting cortisone.

The diagnosis needs to obviously be made first, we need to make sure the injection is going to the right place that it needs to be and I wouldn’t advise having anymore than three steroid injections because if you keep having indefinite amounts of steroid it can have a negative effect on other structures in the shoulder such as the tendons. The vast majority of cases of frozen shoulder absolute vast majority will resolve with anti-inflammatory treatment, injections and gentle stretching most don’t end up needing further treatment.

We use just very simple stretches for frozen shoulder which anybody can find on our website, under services and then stiff shoulder stretches and you will see some videos on how to do the stretches for different directions of movement and with frozen shoulder again we do not advise pushing the stretches really hard as to not aggravate that inflamed capsule. Getting in the pool and do some very simple things can be helpful as well, just walking in the water and some stretches in addition to dry land stretches and that’s what we prescribe our patients.

In terms of cortisone injections, a lot of times people will come to us and may have had an injection already but found that it didn’t help a lot and I think a lot of the time that’s probably because it was in a different space of where the frozen shoulder is. The subacromial space is the space above the rotator cuff tendons underneath the point of the shoulder, its not actually in the main joint but a lot of time people who are not shoulder specialists will inject there because that’s kind of the easiest space to inject in the shoulder and it is where a lot of shoulder pain comes from.

So often if you go to a non-shoulder specialist and have an injection, the injection will be put into that space, that can be done from the side or from the back, so if somebody tells me they had an injection done from the side I know it was into the subacromial space. If it was done from the back it could be into the main joint or it could be into this subacromial space. With frozen shoulder the capsule and the main joint is actually what we call the glenohumeral space, the humorous being the arm bone and the glenoid being the socket, and that’s where the frozen shoulder is happening.

There is often some secondary inflammation in the subacromial space or what we call bronchitis, so you might find you get a bit of relief from a subacromial injection, but unless injection is into the main glenohumeral joint its not treating the capsulitis directly. A lot of times when people have come they have had an injection and that hasn’t helped, I still like to inject them myself so I know the location is exactly where it needs to be. It depends on the exam whether we inject both spaces or whether we only inject the glenohumeral space.

Then further treatments, a small minority of patients with frozen shoulder end up having surgery, usually that is if it is not resolving with those conservative measures, or if it dragging on a really long time, 6/7 months. The best candidates for surgery are the ones that are no longer so painful but may have gotten stuck in that stiff phase, it’s a small minority of people but they find they can’t really get any range of motion back. If we do any surgical intervention on a shoulder that’s still painful it can take a little bit longer to settle down afterwards compared to a shoulder that is no longer so painful but is stiff and problematic in terms of stiffness.

What we do is a keyhole surgery called an arthroscopic capsule release, so we have a thick inflamed tight capsule and we release it all the way around front and back, using a radio frequency wand as you can see in the picture. Its done under general anaesthesia but we also like to have the anises do a regional nerve block, so we put a long acting local anaesthetic around the nerves that come from the neck, the roots which cross over in the network called the brachial plexus and we block that brachial plexus with local anaesthetic, so that when the patient wakes up after the capsule release they don’t have any feeling from the shoulder and the muscles are also asleep, so the arm is basically floppy and that allows us to get stretching straight away because after surgery to release the capsule the thing we want to avoid is the capsule scaring back in and that’s what tissue will tend to do when you operate on it or when you cut it.

So unlike the non-operative treatment if we operate we are really aggressive with physiotherapy straight away. The nerve block will typically last 18-24 hours, so we keep the patient in the hospital, not because it’s a big surgery but because we want physiotherapy to start immediately and take advantage of that nerve block and actually get some stretching done passively while the arm is still asleep. The key and the challenging part is to maintain that stretching once the nerve block wears off the next day and that’s why we have people start their physiotherapy straight away after a capsular release.

This is what it looks like on the inside if we have a camera inside the shoulder and the humorous is on the picture that you see on the left, on the right-hand picture the humorous is on the right, so the camera is looking from the front and this is all the same shoulder. We have got in he back at the beginning, were releasing the front then we switch the camera to the front and release the back, but you can see just how thick that tissue is and how red and angry and inflamed it is.

This is one of the most painful conditions in the shoulder and people are often frustrated because they have been told there is often nothing much on their MRI or they have been told something completely inappropriate based on an MRI and nobody’s actually put the picture together of the typical history and the exam.

There are some other things you may hear about in terms of treating frozen shoulder, Hydrodilatation is something that is sometimes done. The idea is to dilate the joint capsule by injecting fluid, by injecting saline and then a steroid injection is done at the end. Its probably the steroid injection that actually helps as because the capsule is so thick as you just saw in those surgical pictures that to actually distend it or to actually stretch it you would need a really high volume of pressure under quite a bit of pressure. If that is done awake as it often is in a radiology department there is no way your going to be able to do that to somebody because it would be so painful, the volumes that tend to be put in are pretty small, so I think probably what’s helping there is the steroid that’s been put in.

The other thing you may here of is an old-fashioned technique called manipulation under anaesthesia and I would strongly advise against that, what that involves is simply putting someone under general anaesthetic and then manipulating the shoulder very forcefully to rip the capsule and there is a few reasons why this could be problematic. Its what used to be done before we had arthroscopy and keyhole surgery and it would work in a lot of cases but there are some potential problems. One is your basically tearing the capsule instead of cutting it in a controlled fashion so it is more likely to scar back in but the bigger issues are that the amount of force it takes to actually rip that capsule and regain movement in the shoulder can also damage things around the shoulder including brachial plexus, that network of nerves going along just under the shoulder joint.

I have seen patients with damage to the nerves from manipulation under anaesthesia and I have actually seen cases where the humorous actually broke so they got a fracture from being manipulated, so I would strongly advise against blind manipulation under anaesthesia. If you have done a controlled capsular release sometimes you will stretch the shoulder gently at the end to make sure there is no last little adhesions but that doesn’t take much force whereas the amount of force involved in blindly manipulating is quite significant and I think in this day and age its probably not reasonable as its not very safe.

So the take home messages about frozen shoulder which we do see more commonly around the time of the menopause. The underlying joint itself is normal and even though it feels really terrible and its hard to believe at the time when you are going through it, most cases it will go back to normal in the end without needing any surgery. You need to have a normal x-ray otherwise you cant call it frozen shoulder, and most of the time you don’t actually have to go to the bother of an MRI.

The treatment is basically aimed at decreasing that time to recovery, the natural history is that it should recover anyway but if we can shorten the amount of time that it is miserable, then I think that makes a big difference to peoples quality of life. So pain control, gently restoring range of motion and in a very small number of cases maybe a arthroscopic capsular release.

I suppose if you can stop the process early on then you may not develop the full blown frozen shoulder, if you have shoulder pain and its keeping you awake at night or making you struggle with you normal day to day activities that’s something that you should go and get evaluated and so the key is having someone examine it and decide what the diagnosis is and that’s the tricky part with frozen shoulder it gets missed or misunderstood a lot of the time.

There are no hard and fast rules about it the reason why we say it that way round is typically that the heat will kind of loosen any muscular stiffness and help people do stretches better. The ice will tend to help with pain relief particularly at night and help with sleep. How it does that well you could argue well its probably not going to get as deep as the capsule to reduce the capsular inflammation directly, is it sort of providing a different stimulus kind of like the gate theory of pain control or is it actually having an anti-inflammatory effect, hard to know as the capsule is quite deep the muscle and tendon between the skin and the capsule so the ice may not get all the way into the capsule but I think it tends to decrease the pain sensation that people are having from their shoulder.

Its very successful in the long term now you could argue well its frozen shoulder its going to get better anyway overtime, the people who would tend to run into trouble again which is very rare tend to be the diabetics. The diabetic frozen shoulder tends to be a bit more difficult to shift, I have only very rarely seen it where they have gotten stiff again after capsular release, I have never seen it in a non-diabetic. So a peri menopausal frozen shoulder I have never seen after frozen shoulder.

You don’t jump then with the surgery straight away and you would rather not jump in when the shoulder is still in the painful phase, so typically most patients before considering surgery would be at least 6 or 7 months in and if they are caught early enough and started the anti-inflammatory therapy and had injections early enough they may be better by 6 or 7 months so certainly the non-invasive and less invasive treatments are first line.