Management of frozen shoulder remains controversial. Codman, when he coined the term ‘frozen shoulder’, claimed that this disorder is ‘difficult to define, difficult to treat, and difficult to explain from the point of view of pathology’;1 almost 80 years later, we are still not much farther.
Both conservative and surgical treatment may result in equal outcome two to three years from the onset. However, this is at the expense of pain, stiffness and disability for this length of time. Surgical treatment with manipulation under anaesthetic or arthroscopic release shortens this to several weeks.
The authors of these two excellent papers acknowledge the differences in approach in different stages of the disorder. In early stage there is a place for conservative treatment and one may try intra-articular steroid injections.
One should bear in mind that manipulation should be performed in a particular way using a short lever arm, stabilising the scapula and utilising ‘Codman's paradox’ to avoid torque on the arm bone and avoid complications. Physiotherapy is a crucial part of success.
1. Codman EA. The Shoulder. Boston, USA: Thomas Todd; 1934.
PROFESSOR OFER LEVY
Consultant Orthopaedic Surgeon
Reading Shoulder Unit – Royal Berkshire Hospital
Orthopaedic Surgery Research and Learning Centre – Brunel University
Frozen shoulder is a painful and debilitating condition with an incidence of 3% to 5% in the general population and up to 20% in those with diabetes.1,2 The term ‘frozen shoulder’ was first introduced by Codman in 1934 to describe a condition that has been of interest to clinicians since the late 1800s.3 Clinically it is characterised by considerable pain and insidious shoulder stiffness, which results in loss of passive and active forward flexion and external rotation.
Some studies have described frozen shoulder as a self-limiting condition that resolves in 1 to 3 years.1,4 Yet others report that between 20% and 50% of patients can be symptomatic for up to 10 years.5 A number of treatments have been advocated. These include rest, analgesia, active and passive mobilisation, acupuncture, physiotherapy, oral and injected corticosteroids, capsular distension, manipulation under anaesthesia and surgical capsular release. It is surprising that for such a common condition there is no consensus on the most effective treatment.
Frozen shoulder involves 3 phases. These include the ‘freezing phase’ or the ‘painful phase’ lasting 3 to 8 months, the ‘frozen phase’ or the ‘adhesive phase’ lasting 4 to 12 months and the ‘thawing phase’ or ‘resolution phase’, which lasts anywhere from 12 months to 42 months and is characterised by a steady return of shoulder mobility and function.6
Surgical treatment for frozen shoulder is usually considered after a concerted effort at conservative management has failed. There is no discrete timeline to proceed to surgery. As a general rule patients should have participated in some form of physiotherapy for a minimum of 4 to 6 months and shown little or no progress. A more conservative approach is largely recommended for patients in the ‘freezing phase’, which is the painful phase of the disease process. Patients have to feel that they are not making progress and have limitations of occupation, recreation or sleep, for them to proceed with surgical intervention.
In a recent survey of healthcare professionals only
3% of the respondents recommended surgical treatment for the ‘freezing phase’ of the disease process. In comparison, 47% of respondents recommended surgical treatment for the second and third phases of frozen shoulder.7 The surgical treatment options in this survey were manipulation under anaesthesia, arthroscopic capsular release and open capsular release.
As operative techniques continue to shift from open to arthroscopic procedures, the open surgical release is less common, although still effective.8 Manipulation under anaesthesia is another technique commonly used to improve the range of shoulder movement. However, manipulation under anaesthesia is not without its disadvantages. There is a small risk of humeral fracture, dislocation, rotator cuff injuries, labral tears and brachial plexus injury. Arthroscopic arthrolysis has become well accepted in treating this process.
A tightened coracohumeral ligament and rotator interval with the contracted capsule are the ‘essential lesions’ noted in frozen shoulder. These contracted structures can be treated by release with arthroscopic instruments. The arthroscope is inserted through the posterior portal and the rotator interval is released with an electrocautery wand inserted through the anterior portal. All rotator interval tissue between the upper subscapularis and the superior glenohumeral ligament is released. Care is taken to preserve the medial sling of the biceps. The middle glenohumeral ligament is then released followed by an anterior capsular release and inferior capsular release. The arthroscope is then placed in the anterior portal and a posterior capsular release performed with the electrocautery wand inserted through the posterior portal. The arthroscope is then placed in the subacromial space. Subacromial adhesions, if present, are released through the lateral portal. This provides a more controlled release than manipulation alone.9,10
Operative treatment of frozen shoulder has been shown to decrease the disease duration and return shoulder motion with success.11,12 Total recovery of pain-free range of movement averages 2.8 months (range 1 month to 6 months). As a result of the added diagnostic ability of arthroscopy and the favourable return of range of movement, this is my preferred method of operative treatment. Immediate postoperative physiotherapy is initiated after surgical treatment. Exercises are progressed in accordance with the conservative protocol. In general 1 week to 2 weeks post surgery light sub-maximal isometrics for the glenohumeral joint, rotator cuff and scapular muscles can begin, with isotonic exercises starting around the 2-week to 3-week time frame. Full unrestricted use of the shoulder should be attained by the 12-week to 16-week time frame in most cases.
Although I have made a case for surgical treatment for frozen shoulder, demonstrating superiority of surgical treatment intervention over non-operative treatment requires an adequate sample size with a controlled study population and random allocation of treatment. Systematic reviews to date have been largely inconclusive as a result of insufficient numbers in small trials. One would anticipate that the limitations of previously published studies on frozen shoulder could be overcome by conducting a large multicentre randomised trial in the future.