Frozen shoulder

Q    I’ve had a frozen shoulder for quite a while now, and noth-ing seems to be work-ing. I had an initial injection, and that relieved the pain for four months, but a second one has had no effect. I don’t want to rely on paracetamol for the
rest of my life. What else can I do?—G.C., via e-mail

A    Frozen shoulder (adhesive capsulitis) is a chronic debilitating condition that can make even the most simple of tasks, such as putting your hand in your pocket or scratching your back, almost impossible. It affects around 2 per cent of the population, and is more common in women aged 40 to 70 years, and in up to 20 per cent of diabetics. Usually, the non-dominant shoulder is affected, so a right-handed person is more likely to suffer from a left shoulder freezing.

But no one knows why it happens or what the outcome will be. There’s usually no apparent reason; in only a few cases is it due to trauma, breast reconstruction or shoulder surgery. In some cases, scar tissue forms in the thin tissue that covers and protects the shoulder joint, causing this ‘cap-sule’ to thicken and, thus, restrict the shoulder’s ability to move normally.

There may be a genetic association. In one study involving twins, one twin is up to three times more likely to suffer a frozen shoulder or tennis elbow if the other twin has been a victim (Rheuma-tology, 2005; 42: 739–42).

A frozen shoulder is characterized by a dull ache in the shoulder or upper-arm area, with stiffness or restriction of movement. There are three phases:

  • In the first, ‘freezing’ stage, the patient experiences a slow onset of pain and, as the pain worsens, any movement becomes more difficult. This phase can last from six weeks to nine months.
  • The ‘frozen’ phase is marked by a slow improvement in pain, although stiffness remains unchanged. This stage lasts four to nine months.
  • The final, ‘thawing’ phase lasts from five to 26 months, during which time, mobility slowly returns.

By this reckoning, a frozen shoulder can persist for three years or more if it’s not treated, but it can often be resolved within a year with professional help.

There is a range of options open to the sufferer. Pain reduction and relief is the primary concern and for this, a GP will prescribe either an NSAID (a non-steroidal, anti-inflammatory drug) such as aspirin, or ibuprofen, or a stan-dard painkiller such as paracetamol or codeine. While these can be effective, you should be aware of their side-effects, which include stomach ache, heartburn and stomach ulcers.

You may also be referred to a physiotherapist, who will recommend a regular regime of exercises to stop the shoulder from stiffening. One study found that exercise was partic-ularly beneficial if it was combined with acupuncture. Those who underwent exercise and acupuncture fared better than those who only had exercise as therapy (Hong Kong Med J, 2001; 7: 381–9).

The physiotherapist may also try some pain-relieving methods, such as heat or cold therapies, or TENS (transcutaneous electrical nerve stimulation). Although TENS is regularly used for pain relief, a review of 20 studies on low back pain found that it worked in just 12 of the trials (Cochrane Library, 1997; issue 1).

Short-term pain relief can also be achieved with a steroid or nerve-block injection. The steroid injection can reduce inflammation around the shoulder area, although it is usually effective for only a few weeks before the pain returns. However, in one meta-analysis, a corticosteroid injection provided pain relief for up to nine months, and was more effective than an NSAID (Br J Gen Pract, 2005; 55: 224–8).

In more serious and protracted cases, the specialist may recommend surgery. The most common is manip-ulation under anesthesia (MUA). This is a procedure that can be fraught with difficulty; instances of dislocation, fracture, nerve palsy and rotator-cuff tears have all been reported.

However, in one study of 38 pro-cedures, most patients reported pain relief after surgery, although 8 per cent required a second manipulation before they felt any positive effects. Overall, most patients reported continuing improvement over time, and there were no serious injuries other than one case of a torn rotator cuff (Md Med J, 1999; 48: 7–11).

Another possible surgical procedure is arthroscopic capsular release, a ‘keyhole’ operation where the tight capsule of the joint is released with a special probe. In a study involving 30 patients, the procedure was found to be generally helpful, especially if complemented by manipulation.  However, the researchers recommend that patients wishing to undergo this surgery be carefully assessed and screened beforehand (Knee Surg Sports Traumatol Arthrosc, 2006; e-publication Oct 10).

Of the manipulative therapies, the Bowen technique has been found to be effective, even for long-term sufferers. In one small study of 20 patients, the technique helped to relieve pain and improved mobility in every case (Complement Ther Med, 2001; 9: 208–15). A similar result was achieved in a double-blind placebo-controlled study carried out by the European College of Bowen Studies with 100 sufferers, half of whom were given placebo therapy. After six weeks, the Bowen-treated group reported improvement in mobility and reduction in pain (http://www.thebowentechnique.com/content/frozen.htm).

Another treatment, a variation of standard osteopathy known as the ‘Neil–Asher technique’—specially designed to treat frozen shoulder—was also very effective when compared with standard physiotherapy and a placebo treatment. After six sessions, those in the Neil–Asher group reported significant improvement in movement and flexibility, and a general reduction in pain (Br J Rheumatol, 2003; 42: 146).