Adhesive Capsulitis

Adhesive capsulitis (or Frozen Shoulder) is a condition where inflammation and scarring of the shoulder joint capsule causes pain and stiffness.

The exact mechanism is not completely understood. It may occur after an injury but often there is no clearly identifiable cause. Inflammation of the nerves that supply the shoulder capsule is thought to be an important factor in frozen shoulder. It occurs more frequently in Diabetes and Hypothyroidism. It is characterised by an early painful phase with slowly increasing stiffness. The natural history is of slow resolution, however, the time for recovery is variable and unpredictable, ranging from 6 months to 3 years. Up to 30% may have ongoing pain and restriction in movement. It affects both shoulders in 15%.

Treatment is aimed at alleviating pain and restoring range of movement and function. A holistic, multidisciplinary approach is used.

  • Symptom control (pain relief)

    • Tablets (Paracetamol, Anti-inflammatories)

    • Amitriptyline (Endep)- for nerve sensitisation

    • Injections

      • Cortisone/ Hydrodilatation

  • Avoidance of provocative activity

  • Controlled active assisted range of motion exercises

  • Avoid aggressive stretching into pain as this can flare the condition

  • Treatment of associated shoulder tightness (trigger points in the upper back and neck muscles)

  • Correction of scapular (shoulder blade) movement patterns

  • Optimising range of movement of the thoracic and cervical spine (upper back and neck)

Hydrodilatation

This procedure involves injecting the shoulder joint with a mixture of steroid, local anaesthetic and sterile water with sufficient volume to gently stretch the tightened capsule. The steroid has an anti-inflammatory and pain-relieving effect. Around 30-40mls is usually required. The aim is to decrease pain and improve the range of movement. This procedure can be done by your sports physician in a sterile manner using ultrasound guidance. Your doctor can then have the benefit of assessing your shoulder immediately afterwards. The procedure is done with the patient lying on their side. It can also be done by a radiologist using xray or CT guidance, which involves a small amount of radiation. This procedure may influence the course of the condition, with some reports that it can decrease the severity of pain and stiffness, as well as shortening the duration of disability.

Ultrasound-guided Corticosteroid injection without hydrodilatation

 This involves the same technique as above but without the aim of stretching the capsule. It can provide pain relief.

Ultrasound-guided suprascapular nerve injection.

The suprascapular nerve is responsible for supplying sensation to up to 70% of the joint capsule. An injection of cortisone can be very useful in treating pain and improving function, especially in the early phase. The procedure is performed using ultrasound guidance with the patient sitting on a chair. Your doctor may recommend this prior to a hydrodilatation as it can decrease the pain associated with the procedure.

Adverse effects

  • Pain

  • Infection 1:20,000

  • Injury to nerves/ vessels – using ultrasound guidance decreases this risk.

  • Incomplete resolution

  • Recurrence of stiffness

 

After the Procedure

  • You will be observed until you feel well enough to leave (usually this only a few minutes)

  • Advised not to drive that day

  • If you have pain, take paracetamol as directed

  • Recommence your rehabilitation exercises when the shoulder feels comfortable

  • Review as planned with your doctor

Active Assisted Range of Movement Exercises – to a comfortable level.
Do not push into pain.

Sports MedicineDoctor Krishant NaiduAdhesive capsulitis, Pain Management, First Section