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Frozen Shoulder

(adhesive capsulitis) 

What is it?

Frozen shoulder is a common condition that causes thickening and inflammation of your shoulder joint’s lining (capsule).  This results in pain and stiffness.  

What are the Symptoms?

Patients often report a gradual onset of pain.  This is usually a deep ache, exacerbated by movement, felt deep within, or at the front of your shoulder. The pain can be very severe and it often causes difficulty sleeping. There is then a pattern of increasing stiffness in all shoulder movements.

Frozen shoulder usually has three phases, which generally progress over a two-year period:

  1. Painful freezing
  2. Frozen (not normally so painful, but stiff)
  3. Thawing – gradual resolution of most of range

Who gets it?

Normally 35-65 year olds, slightly more common in women. The incidence is more common in diabetics and those with thyroid disease. Some chemotherapy regimens carry a risk of developing frozen shoulder. While for most patients there is no identifiable cause, sometimes a frozen shoulder follows an injury or a surgery to the shoulder.  This is called a 'secondary frozen shoulder'.

What non-surgical treatments are there?

Rest, activity modification, painkillers and anti-inflammatories are obvious first-line treatments.  


Physiotherapy doesn’t work well on its ownin frozen shoulder and aggressive physiotherapy in early stages makes it worse.  Physio is however essential to maximise therapeutic gains AFTER treatment 

Steroid Injection (Cortisone)

Sometimes done by GP before referral to surgeon. However, it is very hard to get the needle into exactly the right place without image guidance in frozen shoulder as the capsular volume is so small. It is therefore normally done under X-ray or Ultrasound guidance. 

Hydrodistension (also called hydrodilation)

This is an awake, X-ray or Ultrasound-guided outpatient procedure (15 min). It is moderately uncomfortable, but generally well tolerated. A fine needle is guided into your shoulder. Cortisone and local anaesthetic are injected into your joint. Saline solution is then injected until your capsule ruptures, or no further distension is achieved (average 35ml total injected).  This stretches out the contracted capsule. Hydrodistension is effective in over 70% of patients and often avoids the need for surgery altogether. It improves pain and range of motion. Beneficial effects are often rapidly felt (sometimes immediately) and endure.    Risk of harm is very low, but up to 10% may find the procedure too uncomfortable to tolerate.


X-ray image of hydrodistension. The x-ray dye is providing a sillhouette of the joint space and dye can be seen escaping where the capsule has ruptured - blue arrow.

Surgery for Frozen Shoulder

Surgery is Indicated if less invasive measures have failed to improve your pain or stiffness to a degree that works for you. 

Arthroscopic Capsular Release is a keyhole operation performed under general anaesthesia and regional nerve block. Your thickened and inflamed capsule at the front of your shoulder is carefully excised before your shoulder is manipulated to restore range of motion. A steroid injection is normally performed at the same time. 

What is my Prognosis?

Overall very good; indeed fFrozen shoulder was initially thought to be a wholly self-limiting condition. However, about 40% of patients who receive no treatment will have on-going stiffness and/or pain even after 2 years, although they have normally got used to it.  Frozen shoulder often happens in opposite shoulder at a later date, but rarely recurs in same shoulder. Hydrodistension and, if necessary, arthroscopic capsular release are both effective at improving the pain and stiffness of frozen shoulder. Sometimes, the improved motion after treatment can unmask a separate shoulder problem, such as impingement or rotator cuff disease.