Give Shoulder Pain The Cold Shoulder!

Source:

Akshay Date & Luthfur Rahman (2020) Frozen Shoulder: Overview of Clinical Presentation and Review of the Current Evidence Base for Management Strategies, Future Science OA, 6:10, FSO647, DOI: 10.2144/fsoa-2020-0145

Frozen shoulder is a common condition which occurs in approximately 2-5% of the population with a peak incidence between 40-70 years of age. It is characterised by varying levels of pain and limitation in range which is more common in women and can occur in both shoulders in roughly 20-30% of cases.

While frozen shoulders are normally self limiting, symptoms can continue for a number of years with varying levels of pain and functional limitation and in some instances may never fully resolve.

There are 2 reasons why people can go on to develop frozen shoulder:

· Primary : The most common presentation where pain and limitation are noted however without an underlying cause

· Secondary : Frozen shoulder can occur following trauma, shoulder surgery, prolonged immobilisation, diabetes, thyroid disease or other autoimmune disorders

Pathophysiology and presentation

The reason as to why people develop primary frozen shoulder is still not full understood, however research has shown that the joint capsule that surround the shoulder becomes thickened and tight with evidence of inflammatory cell within the capsule with some suggestion of an autoimmune cause for primary shoulder pain.

It is proposed that there are 4 stages of frozen shoulder that is demonstrated in the table below. Ther onset of symptoms however can be gradual over a period of months with symptoms being poorly locaused and reported as a deep ache, with night pain being an common feature. On examination people usually demonstrate good rotator cuff strength and no specific tenderness on palpation however a marked loss of range of movement, partiucuarly into rotation. As frozen shoulder affects the joint capsule, any form imaging such as an x-ray is normal but can helpful to rull out any other types of pathology.

Management

The main aim of management is to manage symptoms and restore function as a consequence of the freezing portion of the condition. Conservative management is the preferred chocice of treatment with more patients usually improving within 6-18 months and usually comprises of physiotherapy and medication. Surgery is usually considered when shoulder symptoms persistent despite physiotherapy

Physiotherapy: Is the preferred initial treatment of choice, focussing on both stretching and strength maintence. Previous studies evaluating a supervised stretching programme results in a satisfactory outcome for 90% of patients and that mobilisation within tolerable pain was more beneficial than working within pain limits. However, further high quality research is required to assess the benefit of physiotherapy compared to medical therapy alone.

Pharmaceutical Treatments: Paracetamol and NSAID’s are the usual go to treatments for the management of frozen shoulder and has been shown to have more of an effect when combined with physiotherapy. In some steroids, oral steroids have been shown to have a positive benefit however a study examining this did not idtenifyt any additional benefit beyong 6 weeks, concluding that they may be beneficial in the short term however to remain mindful about the long term use of steroids medication

Intra-articular shoulder injections: Studies have shown that steroid injections appear to have greater benefit in the short term for pain relief when compared to steroids. In some studies, a cortisone injection has been shown to reduce pain for up to 8 weeks and himprove passive range of movement in both the short and long term when compared to placebo. Furher studies have identified significant iprovements in pain when an injection is provided between 6 weeks and 4 months compared to placebo and physiotherapy alone, but even higher-level evidence of the combination of cortisone injections and physiotherapy together which the authors of this paper advocate.

Intra-articular sodium hyaluronate injections: Usually performed as an alterative to or in conjuction with steroid injections with some studies highlighting similar benefits to a cortisone injection with less side effects. However, evidence in the literature appears low and further studies are required.

Hydrodilatation: This technique involves dilation of the joint capsule with either saline or steroid and local anathesic in view of stretching the joint capsule and breaking down adhesions. Some stuids have showed improvement in range of movement following such a procedure but pain and functional scores were compareable. The authors conclude that there is insufficient evidence in the literature to suggestion hydrodilation as superior to other froms of treatment for frozen shoulder

Suprascapular nerve block: The aim of this treatment is to target the nerve that innervates the shoulder, in particular the supraspinatus and infraspinatus. Some studies have shown this may provide some short term relief however the author recommends that more trials are needed.

Surgical Treatment

Manipulation Under Anaestheic (MUA): During this procedure the patient is anthesatised and the shoulder is manioulated to breakdown the scar tissue within the shoulder. It has been shown to have a good benefit in both the short and long term, particularly when combined with physiotherapy. However, care is required that other structures around the shoulder are not affected as a result of the shoulder being manipulated.

Arthroscopic Release: Has been shown to have both good short and long term outcomes in terms of both pain and function. While allowing a controlled released of the capsule, it also allows the surgeon direct visualtion of the shoulder and any other pathology that may need addressing. It also allows physiotherapy to commence early due to patients often having minimal pain. Open surgery is a far less common procedure due to the potential complication as a result

My Conclusion

Frozen shoulder is a common shoulder condition which specifically targets the joint capsule leading to inflammation and thickening of the tissue. This initially results in significant pain and subsequent loss of range of movement and while the prognosis is good it can take a number of months to settle. In the initial stages anti inflammatories and in particular a cortisone injection alongside physiotherapy appears to good evidence behind it while for more chronic conditions that haven’t responded to treatment, surgical treatment by way of a manipulation under anaesthetic or arthroscopic release and physiotherapy following also appears to be favourable.