HC Chang Orthopaedic Surgery | Singapore

What is frozen shoulder?

It is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms begin gradually, worsen over time and then resolve, usually within a two-year period.

Why is it called frozen shoulder?

Frozen shoulder refers to a shoulder that has become “frozen stiff” due to inflammation inside the shoulder joint resulting in capsular contracture.

The inflamed capsule of the shoulder joint becomes thickened and contracted.  This reduces the actual space inside the shoulder joint.

This condition is typically described as having three stages:

• Stage one: The “freezing” or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.
• Stage two: The “frozen” or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to nine months.
• Stage three: The “thawing” or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months.

Adhesive Capsulitis

Adhesive Capsulitis and Pericapsulitis are common terms used to refer to the condition of frozen shoulder.

Adhesive capsulitis denotes the inflammation of the shoulder capsule leading to the tightening and sticking together of the shoulder capsule.

This results in a smaller shoulder volume hence leading to stiffness and pain.

The following picture shows a the inside of a frozen shoulder.  The shoulder joint capsule appears red and inflamed.

Arthroscopic Picture of Frozen Shoulder

Pericapsulitis refers to the inflammation that occurs around the shoulder.  Commonly, we have pain all around the shoulder during frozen shoulder.

This is due to inflammation of the tissues, muscles and tendons around the shoulder joint which contributes to the pathology.

There is a space above the shoulder joint and below the acromion bone (which is an extension of the shoulder blade/scapula).  This space is called the “subacromial space” and it contains a fluid-filled sac called a bursa.  This fluid filled sac acts as a lubricant during movement of the shoulder joint under the acromion bone.   Extensive scar tissues can form in this space in patients with frozen shoulder and this contributes to the stiffness of the affected shoulder.

This picture shows the scar tissues in the subacromial space before and after surgical removal.

Scar Tissues in Subacromial Space

What Causes Frozen Shoulder?

The cause of frozen shoulder is often unknown.

We like to differentiate two types of frozen shoulder.  They are:

a)  Primary frozen shoulder – whereby there is no real known cause and the condition just happens.  It is associated with diabetic patients.

b)  Secondary frozen shoulder – whereby there is a cause for the onset of the frozen shoulder.

For example, a tear of the rotator cuff tendon in the shoulder joint causes pain which makes the sufferer moves the painful shoulder less and this gradually develops into a full-blown frozen shoulder.

It can also occasionally result from trauma to the shoulder.

Who is most affected by frozen shoulder?

Frozen shoulder most commonly affects patients between the ages of 40 to 60 years old, and it is two times more common in women than in men.

Patients with diabetes are at particular risk for developing a frozen shoulder.  Their risk of developing frozen shoulder is five times  as common compared to non-diabetics. Other endocrine abnormalities, such as thyroid problems, can also lead to this condition.

Patients who sustain a shoulder injury, or undergo surgery on the shoulder can develop a frozen shoulder joint. When injury or surgery is followed by prolonged joint immobilisation, the risk of developing a frozen shoulder is the highest.

Several systemic conditions such as heart disease and Parkinson’s disease have also been associated with an increased risk for developing a frozen shoulder.

What are some of the symptoms?

Symptoms include:

• Shoulder pain; usually a dull, aching pain
• Limited movement of the shoulder
• Difficulty with activities such as brushing hair, putting on shirts or bras
• Pain when trying to sleep on the affected shoulder

I was told that frozen shoulder can clear up on its own, but only over a very long period of time. What are some medical steps that can be taken to facilitate this? Does it necessarily involve surgery?

Treatments generally involve the following:

1.  Stretching exercises to improve range of motions as well as prevent atrophy of surrounding shoulder muscles.

2.  Use of oral anti-inflammatory medications.

3.  Physiotherapy modalities – trigger point massage, ultrasound and heat therapy.

4.  Injection of corticosteroids into the shoulder – this allows the inflammation to reduce and hence decrease the pain to allow physiotherapy to proceed.

5.  Hydrodilatation – injection of saline into the contracted shoulder joint to break the adhesions and increase shoulder volume.

6.  Manipulation under anaesthesia – this allows the surgeon to break the adhesions in the frozen shoulder with the patient under anaesthesia.

7.  Arthroscopic release of frozen shoulder capsule and scar tissues.

Can I avoid getting frozen shoulder at all?

It is estimated that three percent of the population may be affected by frozen shoulder.

The only practical advice I can give is:

–  seek medical treatment for shoulder pain before it progresses to become a frozen shoulder.

–  keep the shoulder joint mobile and active when one has certain medical conditions that tends to reduce the mobility of that shoulder.  For instance after breast surgery and after a heart attack.

For more information on frozen shoulder and the treatment, please contact Dr HC Chang at 683 666 36 or email hcchang@ortho.com.sg.

Visit us at www.ortho.com.sg