Your Body

Understanding the Shoulder

Frozen Shoulder

Frozen shoulder is a painful condition that affects movement of the shoulder.

Frozen shoulder is also known as adhesive capsulitis or shoulder contracture.  A frozen shoulder will limit your range of movement and may cause you significant pain.

This pain may make it difficult to carry out Activities of Daily Living (ADLs) due to this loss of range of shoulder motion. People with frozen shoulder report difficulties with;

  • bathing
  • dressing
  • driving
  • reaching
  • rapid movement of affected arm
  • sleeping comfortably

Symptoms may vary from mild to severe, where it may not be possible to move your shoulder at all.

Stages of frozen shoulder

The symptoms of a frozen shoulder usually progress gradually over a number of months/years.  There are three stages to the condition, which can sometimes be difficult to identify. The symptoms also vary from person to person.

Stage one

Stage one, often referred to as the ‘freezing’ phase, your shoulder will start to ache and become very painful when reaching.  The pain is often worse at night and when you lie on the affected side. This stage may last 2-9 months.

Stage two

Stage two is often known as the ‘frozen’ phase. Your shoulder may become increasingly stiff, but the pain does not usually get worse and may decrease.  Your shoulder muscles may start to waste away slightly because they are not being used. This stage lasts 4-12 months.

Stage three

Stage three is the ‘thawing’ phase. During this period, you will gradually regain some movement in your shoulder. The pain will begin to fade, although it may recur from time to time as the stiffness eases.  Although you may not regain full movement of your shoulder, you will be able to carry out many more tasks. Stage three can last from five months to many years.

 

What causes frozen shoulder?

Frozen shoulder is caused when the sleeve that surrounds the shoulder joint, known as the capsule, becomes swollen and thickened.

The shoulder capsule is fully stretched when you raise your arm above your head, and hangs down as a small pouch when your arm is lowered.  In frozen shoulder, bands of scar tissue form inside the shoulder capsule, causing it to thicken, swell and tighten. This means there is less space for your upper arm bone in the joint, which limits movements.

 

Risk factors

It is not fully understood why frozen shoulder occurs and, in some cases, it is not possible to identify a cause. However, a number of factors have been highlighted as increasing your risk of developing it (see below)

1)    Shoulder injury or surgery

Frozen shoulder can sometimes develop after a shoulder or arm injury, such as a fracture, or after having surgery to your shoulder area.  This may partly be a result of keeping your arm and shoulder immobile (still) for long periods of time during your recovery.

2)    Diabetes

If you have diabetes, your risk of developing a frozen shoulder is increased. The exact reason for this is unknown.  It is estimated that people with diabetes are twice as likely to develop a frozen shoulder compared with those who do not have diabetes.  If you have diabetes, your frozen shoulder symptoms are likely to be more severe. You are also more likely to develop the condition in both shoulders.

3)    Other health conditions

Your risk of developing a frozen shoulder may also be increased if you have health conditions including:

Other shoulder conditions

Frozen shoulder can also sometimes develop in association with other shoulder conditions such as:

  • calcific tendonitis – where small amounts of calcium are deposited in the tendons of the shoulder
  • rotator cuff tear – the rotator cuff is a group of muscles that control shoulder movements

 

Diagnosing frozen shoulder

You should see your GP or Physiotherapist if you think you have a frozen shoulder, or if you have shoulder pain that limits your range of movement.

Early diagnosis and treatment can help prevent long-term stiffness and pain.  Your clinician will examine your shoulder and ask about your symptoms.

 

Physical examination

During the physical examination, your GP/Physiotherapist will test your range of movement by asking you to move your arm and shoulder as far as you can in each direction.  Your GP/Physiotherapist will also assist you in moving your arm and shoulder. You may find this painful but it will help them to determine whether your symptoms are indicative of frozen shoulder.  Your GP/Physiotherapist may apply pressure to parts of your shoulder to determine where your pain is most severe and what is causing it.

Further tests

You may need to have further tests to rule out other possible health conditions.  For example, a blood test may be recommended if your GP thinks that you may have diabetes.

Your GP/Physiotherapist will also want to rule out other possible causes, such as an infection or a tumour (an abnormal growth of cells)

 

Imaging

An image of your shoulder joint may be taken to help confirm or rule out other possible damage. However, it is rarely necessary to confirm your diagnosis.

If an image is required, you may have:

  • an X-ray – where high-energy radiation is used to highlight bone abnormalities; an X-ray helps distinguish a frozen shoulder from other causes of a painful, stiff shoulder such as arthritis
  • special imaging, such as a magnetic resonance imaging (MRI) scan – where a strong magnetic field and radio waves are used to produce a detailed image of the inside of your body

MRI scans are rarely needed for the initial diagnosis of a frozen shoulder.

 

Treating frozen shoulder

Some people with frozen shoulder may get better over a period of 18-24 months. In other cases, symptoms can persist for several years.

Studies suggest that about 50% of people with frozen shoulder continue to experience symptoms up to seven years after the condition starts. However, with appropriate treatment it is possible to shorten the period of disability.

The aim of treatment is to keep your joint as mobile and pain free as possible while your shoulder heals. The type of treatment you receive will depend on how severe your frozen shoulder is and how far it has progressed.

Painkillers, corticosteroid injections, Hydrodilation injected into the joint , shoulder exercises and physiotherapy are all possible treatment options. Surgery may be recommended if your symptoms have not improved with treatment.

 

Rotator Cuff Tear

As sown in the video link the rotator cuff is a group of tendons that connects the four muscles of the upper shoulder to the bones. The strength of the cuff allows the muscles to lift and rotate the humerus (the bone of the upper arm), If these tendons tear this can result in pain and weakness.

A tear may result suddenly from a single traumatic event or develop gradually. When the tendons or muscles of the rotator cuff tear, the patient may complain of no longer being able to lift or rotate the arm with the same range of motion as before the injury and they may describe significant pain during movement. The rotator cuff can also become weak and prone to rupture or tear as people age due to degenerative changes.

rotaor cuff tear

CAUSES:

  1. Injury, especially while trying to lift or catch a heavy object
  2. Overuse, especially after a period of inactivity
  3. Poor blood supply to an area of the cuff (which occurs with increasing age)
  4. A fall on an outstretched arm
  5. A gradual weakening of the tendons of the shoulder, often associated with impingement

DIAGNOSIS:

  1. Physical Examination – your clinician will perform a series of test looking for weakness and to rule out other causes of shoulder pain.
  2. Ultrasound Scan – in some cases this can be done immediately in the clinic and is accurate, dynamic and cost effective.
  3. MRI Scan – This is more costly and less accessible, but can provide information on the quality of the muscles and other underlying structures of the shoulder.

TREATMENT: (Your clinician will discuss and recommend the best treatment option)

  1. Painkillers and anti-inflammatory medications
  2. Physiotherapy – keeps your shoulder strong and flexible and reduce the pain and weakness
  3. Cortisone steroid injections – reduces inflammation and control the pain. It is advisable to avoid repeated steroid injections in the presence of a tendon tear, as this may weaken the tendon further.
  4. Surgery may be required:
    • If the tear follows an injury
    • When pain and weakness is not improved with injections and physiotherapy
  • The goal of any surgery is to relieve the pain and improve the shoulder strength. This requires a long period of physiotherapy in addition to the surgery.
  • Surgery may be done Arthroscopically (keyhole) or Open, or a combination of the two, know as a Mini-repair.
  • Some tears are too large to repair and are known as ‘Massive Cuff Tears’

 

Shoulder Dislocation

The shoulder has a great degree of free movement in multiple directions allowing us to use our arms in a very dynamic way. This free movement however makes the shoulder one of the most unstable joints in the body and therefore the joint that most frequently dislocates. The joints integrity is maintained by the glenohumeral joint capsule, the cartilaginous labrum and the rotator cuff muscles (see the anatomy video)

Anterior (forward) dislocation occurs in approximately 98% of all cases of dislocations. Anterior displacement of the humeral head is the most common dislocation seen by emergency physicians and is usually confirmed by plain film x-ray at Accident and Emergency A+E.

Posterior (backward) displacement is the next most frequently occurring dislocation. Inferior, superior, and intrathoracic dislocations are rare and are usually associated with complications (e.g. fractures).

Common Causes

Anterior shoulder dislocations usually result from abduction, extension, and external rotation, such as when preparing to throw a ball above head. Falls on an outstretched hand are also common causes.

Posterior dislocations are caused by severe internal rotation and adduction. This type of dislocation usually occurs during a seizure, a fall on an outstretched arm, or electrocution. Occasionally, a severe direct blow may cause a posterior dislocation. Bilateral (both sides) posterior dislocation is rare and almost always results from seizure activity.

Rare, but serious, inferior dislocations may be due to axial force (downward) applied to an arm raised overhead, such as when a motorcycle collision victim tumbles to the ground. More commonly, the shoulder is dislocated inferiorly by indirect forces hyper abducting the arm.

 

Treatment/investigations

Most shoulder dislocations will be treated in hospital A+ E departments.  If you have dislocated your shoulder you should go to your nearest A+E immediately. If your shoulder has dislocated without any major accident and you have managed to gently manipulate the arm back into place, there may be no need to go to A+E however, it is still a good idea to seek advice from your GP who can check your shoulder post event.

If the dislocation has happened after a traumatic event then A+E will firstly X-Ray your shoulder to ensure you have not also broken any bones.

An ultrasound scan of the shoulder will be needed to reveal if the rotator cuff tendons have been torn. It is common to tear tendons in a traumatic dislocation

Once you have had investigations you will be provided with a sling, with your elbow bent at a right angle, and a pillow placed between your chest and your arm to provide comfort and support.

Your arm will be gently manipulated into its joint using a procedure known as reduction. You will normally be given some medication to help sedate you during this procedure.

In some cases surgery is indicated if the tissues surrounding the joint are badly torn or the joint is unstable. If the tissues are not torn and the joint is stable, Surgery can be avoided by doing the appropriate physiotherapeutic exercises.

 

Pain relief

You should consult your GP if you are unsure about pain medication.

Recovery time

It can take 12 to 16 weeks to completely recover from a dislocated shoulder with a personalised rehab programmes.