Frozen Shoulder I m now going to talk about rare but really big deal problem with the shoulder. It is called adhesive capsulitis or its common name - frozen shoulder syndrome. The frozen shoulder is not the same as rotator cuff tears, impingement, it s completely different. Rotator cuff tears are common, impingement is common, frozen shoulders are not. A lot of people who say when they ve got impingement, they say, Ah ah ah because they tell me I ve got a frozen shoulder and it s the same way of saying I ve got the flu when you ve got a cold. When you ve got a cold, you cough and your nose runs a bit and you don t feel that well and you are sniffing but when you ve got the flu, the flu is this illness, which puts you in bed for a week and your fever s going up and down, and you re convinced you re going to die. It s a big deal thing. Frozen shoulder is a big deal thing. It affects the glenohumeral joint and its medical name is adhesive capsulitis. So I ll talk a little bit about this joint. You have a little cup with cartilage over that. You have a big head with cartilage over that, and you have a rim which is the labrum. You then have a capsule, and the capsule is the vital part of all joints. The capsule is literally a skin around the joint, and it holds the little bit of fluid that s in the joint, which allows lovely gliding movements. In the shoulder, which has vast array of movement, the capsule is very big and floppy and redundant, because it s not a structural element and the capsule just locks around it if you bring your arm this way; it stretches if you bring you arm this way, that part stretches. With a frozen shoulder, the capsule starts becoming inflamed and it becomes hot and it starts shrinking. It s inflamed and then you get fibrosis, scarring, and the whole thing shrink wraps around the head of the humerus. Inside the joint you ve got fibrous tissue floating around and basically you start feeling pain and the pain is here because that s within the joint so you feel it here and in the front and in the back of your shoulder. It s a diffuse pain. It s deep inside and as the inflammation in the fibrosis process continues, the shoulder is not only incredibly sore but you can t move it.
You find that the normal movements of putting food in your mouth becomes the last movement that you can still do. All other movements start becoming very restricted and in particular for those examining shoulders, the movement of external rotation is very difficult. If you ve got a rotator cuff problem this is a movement you can do quite freely. But in a frozen shoulder, you lose this movement. You can t put your hand behind your back, wiping your bottom becomes impossible. You end up with a shoulder that just can t do things. The only thing you can do is feed yourself. Many other functions like things like washing your hair, with a bad frozen shoulder you literally can t get up there to do it. So this is totally different process from what I described before with impingement and rotator cuff tears. The cause is essentially unknown. The process is called fibromatosis. So that s fibrous scar tissue, everything crunching down. When it starts, often people will remember some kind of trivial incidence like they lifted or they did something and then they think it started hurting becuase of that. But that s not really where it s at. Most of the time it occurs for no reason, and you think back Why is my shoulder so sore? Ah! Yes, I did that little thing and now three months down the line, and I can t move my shoulder. The cause is not known. The inflammatory process turns on, and it progresses over many months getting worse and worse. The pain is often intense, the disability or ability to do stuff is significant. It interferes with your sleep. You are given anti-inflammatory medication, it doesn t touch it at all. Normal pain medications do not touch it. The process runs a course. As I said, it s a mysterious thing. It runs a course of eighteen months to two years and then as mysteriously as it started, it starts to turn off and by the end of two years, most people will have gone through the process of a frozen shoulder. Now in the literature earlier, there were statements made like, Ah yes, after two years you ll be fine and your shoulder will be fine, but the truth is actually that this is not correct. 70% of people will recover but 30% of people will have a long ongoing pain and restriction of movement and disability. So this is a big deal condition. There is one important thing, if you present with a frozen shoulder and you ve got these symptoms, your doctor should check you for diabetes. For an unknown reason, people with diabetes are more likely to get a frozen shoulder. If you ve had a frozen shoulder on one side, you also have an increased risk of having it on the other side unfortunately. If a frozen shoulder occurs, what treatments are going to make a difference
The first thing that s important is that because it s right inside the joint, you may have trigger points associated with it, but treating those do not make much difference to the underlying process. So massage, mobilization, physiotherapy, acupunture unfortunately do not do very much to this process. What a lot of doctors do do is they inject cortisone, and cortisone is usually injected into that subacromial space that I described before. Injecting cortisone into the subacromial space does very little. Now this is important, because lot of people say, Well, I ve had one or two shots of cortisone and it hasn t helped me or it s helped me just a little bit. Remember that at some stage the process is going to burn itself out. So then that leaves painkillers. Anti-inflammatories don t work particularly well. For painkillers to make a difference you need to get up to very strong ones like tramadol or morphine. They will make the difference to the pain, but they will also knock you out. So you re left really with three treatments that have been shown to make a difference. I will mention the first one to dismiss it. It s something called mobilization under anesthesia. This is something that s been done by a number of orthopedic surgeons over time. What happens is you re put to sleep and then the surgeon goes crunch, crunch, crunch, crunch, crunch, crunch, crunch, crunch, and breaks all the fibrous bands that are around and then basically frees up your shoulder. This is a kill or cure treatment. You wake up and you think, Ah! This surgeon is wonderful or you re thinking about the name of your lawyer. It can make things much, much worse. So it s something that s just not worth looking at. The second treatment is something that I ve had actually really a lot of success with. It s very specific. The treatment is call hydrodilation. With hydrodilation, the doctor needs to inject into the joint itself, not under the acromion, but into the joint; it s a different injection because the joint has the capsule over it. You inject into the glenohumeral joint and then you put a lot of local and that would be 8ml of local, lots and lots of local into the joint. Then I inject some cortisone, long-acting cortisone that will reduce the inflammation and then I inject saline which is salt water, and I push in 40 ml or 50 ml of saline. So what I m doing is I m dilating up that capsule, which has got all gummed down. I m dilating it up once the local anesthetic is working.
So I put the local anesthetic, I put as much possibel in, I wait a bit, I put a little more cortisone in and then I dilate up the joint. I go till the joint is dilated as much as it can hold. Some people, somewhere in the literature you keep dilating until the capsule pops. Don t do this. You want the capsule intact. You inject until there s a back pressure and you feel like you can t get any further, and then I pull the needle out. At this point, the feeling people describe as, Wow, that s weird. My arm feels kind of weird. It is not truly painful. I then mobilize up with all the local in place. I gently mobilse the shoulder of a patient who is awake. The capsule is dilated up and I mobilize this joint and what you usually find is at the end of the first treatment, you go from this amount of movement to this amount of movement. So you increase hugely. It s not back to where it was but it increases hugely. From the first treatment, your pain is usually significantly improved. For a majority of people pain stops being an issue. After that, we focus on mobility. Now sometimes you get about 50% improvement when I see them back. I see them back about six to eight weeks later and then I often will repeat the hydrodilation and the second time, we ll be for aiming for getting more mobility. Then people go home with specific stretching exercises. Once the joint is dilated up and people have regained some of their movement, I give them specific exercises to do, which they do at home, and I ll go through these exercises now. These are the exercises that I give. The first is an exercise that works for any shoulder problem. You drop you arm forward, drop your whole body forward, so your arm is just hanging. What s happening now is that there s space created in the joint. You re allowing gravity to work, and the head of the humerus is just hanging in the joint. When you ve had a painful shoulder, a lot of your movements have become tense, abnormal, and guarded. So doing this, dropping your arm forward you just allow it just to wobble very gently. You make movements feeling the comfort in the shoulder or the relative comfort and then you make little circular movements and swing it around. So that s the first thing to do. The second is that you start in this position to swing your arm in the plane that s going to put food in your mouth. So you start and you gradually increase that movement. You re staying out of pain and you re using your shoulder mostly comfortably with your arm forward like this with your shoulder forward so that you are allowing the shoulder to hang and glide as best as it can, just swinging and getting back the feeling that your shoulder can move freely.
Once you ve done that, you now want to explore. You now need to push the envelope of movement. So I m going to turn around as you take your hand in this comfortable position, you put it up against the wall and you walk it up as far as it will go. If that s as far as it will go, you don t force it, you walk it up like that, try and not to pull your body back as we learn to do a lot of weird movements when the shoulder is painful. You just walk it up as far as it will go. Once you re there you breathe in, you breathe out, you wait two or three seconds and then you lean into the wall. So if I m here, you lean into the wall just to stretch the shoulder a little bit. Having done that, you then experiment by turning your body one way, so now you are rotating the head of the humerus. You turn your body as far as it will go here, breathe out, and then you turn you body the other way as far as it ll go. Each time you when reach your limits, you breathe in, you breathe out, and you just lean into it. Then you come back, walk down. So what you ve done is that this movement above your head is a very important movement; we use it for so many things and that s your first movement that you can get back from a frozen shoulder. Other movements you can then start to explore and another important movement is behind you back. With a frozen shoulder, most people can t get their hand behind their back. Once you can, once you have the hydrodilation, you use your other hand to help you. So you take one hand with the other, you just slip this hand back, just behind you. You take it with your other hand and lift the hand up, gliding it firmly up against your body and again till you reach your limit, you breathe in, you breathe out, and you shift it up a little bit more. You re not trying to force anything. So you re working on this movement which is extension and internal rotation, you re working on flexion, internal and external rotation. The last movement you work on is raising your elbow up above your shoulder. You put your hand here, you allow the feeling of dropping and then lifting you arm. So, those are the movements you work on which are all the natural movements of the shoulder, concentrating on the one that you re going to get the most bang for your bucks. Right, so in summary what we ve done is we have looked at the unique functional anatomy of the shoulder, a fascinating mobile joint, which often runs into trouble and then we ve looked at really two major areas in which the shoulder becomes a problem.
The first is the impingement together with rotator cuff tears. They are the most common problems with the shoulder. The second is the frozen shoulder, adhesive capsulitis.