How Do We Treat Frozen Shoulder
Research has revealed that conservative management alone has limited value in the painful stage of frozen shoulder. Physiotherapy for the management of frozen shoulder will include a progressive stretching home exercise program, manual techniques to mobilise your shoulder joint, and potentially acupuncture and taping.
It is not uncommon that the pain is too severe for you to engage in a course of physiotherapy. This is when an injection is advised to get the pain under control. An ultrasound guided injection is a well-supported treatment modality for frozen shoulder and is recommended in the NICE guidelines.
Here are some top tips which may help:
Conservative Care Options Non
An April 2021 paper offered an updated set of clinical guidelines in the management of frozen shoulder. We would like to reiterate that many people do very well with the treatments that are described here below. These are the people we do not see at our center, we see the people for whom these treatments were not successful. Here are the updated guidelines presented:
NSAIDs
- NSAIDs and other analgesics: NSAIDs remain one of the most common medical interventions in treating frozen shoulder. A short course of NSAIDs for 23 weeks is very frequently used to minimize the intense pain of the freezing stage. However, the course of NSAIDs does not alter the course of the frozen shoulder but enables the patient to carry out their activities of daily living in a more relaxed fashion and perform PT with ease.
Cortisone disastrous complication of avascular necrosis of femoral head has to be feared of, even with a short course of oral steroid.
PT combined with NSAIDs and steroids
Is Surgery A Good Option For A Frozen Shoulder
Surgery also called a capsular release, is only helpful for persistent cases. You must remember that surgery has risks and is not always successful. A recent study suggests that surgery outcomes for frozen shoulder are equal to physiotherapy but have serious adverse effects of 4-5%. Overall, your decision regarding surgery should not be taken lightly.
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Frozen Shoulder Injection: Useful Or Not
Frozen Shoulder, also known as adhesive capsulitis, is an inflammatory condition affecting the shoulder joint capsule. It occurs in about 5% of the population and is more common in females between 40 and 60. Most cases occur without a cause. However, some cases start after a fall onto the shoulder. Other triggers include recent surgery and medical conditions such as diabetes and thyroid disease. Often, we perform a steroid injection for frozen Shoulder to reduce severe pain and improve movement. What is a frozen shoulder injection, and when should you use it?
Injections For Frozen Shoulder
Frozen shoulder, also called adhesive capsulitis is a condition characterized by pain and loss of motion in shoulder joint. It commonly affects the left shoulder than right and occurs more often in women than men. The exact cause of frozen shoulder is not known. It is most commonly associated with diabetes and a few other endocrine diseases. The main symptoms include pain, stiffness, and decreased motion of the shoulder.
Frozen shoulder is a self-limiting disease and symptoms usually subside after a year. Treatment is aimed at pain control and restoration of motion.
The treatment of frozen shoulder requires a combination of non-steroidal anti-inflammatory medications, steroid injections, and physical therapy.
Cortisone injections: Cortisone injections are given directly into, or near to the shoulder joint. It reduces the inflammation within the frozen shoulder joint. Cortisone is a type of corticosteroid released by the adrenal gland in response to stress.
Cortisone is a potent anti-inflammatory medicine that can reduce inflammation, but is not pain reliever. Cortisone injections typically result in pain relief within a few days, which is because the inflammation diminishes. The effects may last for several weeks.
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Adhesive Capsulitis Of The Shoulder
Adhesive capsulitis has been reported to be a self limiting disease, meaning that untreated, it will eventually spontaneously improve, however this may take up to 2 years.
In its early phase, the disease may result in vague shoulder pain which mimics other causes of shoulder pain. The diagnosis is often suggested at the time of ultrasound evaluation, when patients are unable to move their shoulder in the necessary positions required for the scan. An ultrasound also yields important information, as it may diagnose the underlying cause that resulted in the patient developing adhesive capsulitis in the first instance.
Are There Extra Risks Of Steroid Injections During The Covid
There is some evidence that steroids can increase the risk of viral infections by suppressing your immune system. There arent any research studies about the risk of steroid injections and COVID-19 but as this is a new virus we are advising caution. Patients who are over 70 or have medical conditions such as diabetes mellitus, ischemic heart disease, chronic respiratory disease, and hypertension may be at higher risk from COVID-19 so they need to take extra caution. Patients in the shielding group should avoid steroid injections due to their possible risk and the risk of a hospital visit to get the injection. Patients should try alternative treatments such as anti-inflammatory drugs, and icing to control inflammation and pain.
Before considering a steroid injection patients will need to read this blog, and sign a consent form stating that they understand the risks. The British Orthopaedic Association, British Elbow & Shoulder Society and British Society of Surgery of the Hand have created a useful patient information leaflet for upper limb steroid injections. View the patient information leaflet and consent form here.
Patients are advised to continue to use hand washing, social distancing and face coverings where appropriate to reduce their risk of contracting COVID-19.
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More About Frozen Shoulder Injection
Generally, injections for frozen shoulder are effective in the early stages to reduce pain. A recent high-level study found that frozen shoulder injections improve pain for up to 4 months. A frozen shoulder hydrodistension injection, a procedure using a high volume of water combined with cortisone, is sometimes effective. However, we are unsure whether a frozen shoulder hydrodilatation injection is better than a simple cortisone injection. In general, we suggest a simple steroid injection for frozen shoulder for the early stages and hydrodilatation for the latter stages. Moreover, we think a steroid injection for frozen shoulder should always be done with ultrasound to improve accuracy.
Platelet-rich plasma or PRP injections are used for various musculoskeletal conditions. In a study comparing PRP to cortisone injections in frozen shoulder, PRP showed a more significant reduction in pain and improved movement. We need more investigations to determine whether PRP is more effective than cortisone in frozen shoulder. However, the early results are promising and suggest that we could use PRP as a replacement for cortisone.
Will Frozen Shoulder Resolve On Its Own
Historically, patients were reassured that frozen shoulder will resolve with conservative treatment or observation. In some reports, frozen shoulder resolved in 94-96% of patients over a 2-year period or longer .
In other reports, the rates of complete recovery were as low as 39-50% . In one study, 40% of patients had persistent symptoms at the 3 year follow up .It is unusual for adhesive capsulitis to recur in the same shoulder, but in one report 14% of people develop it in the opposite shoulder .
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Request An Appointment At The Orthopedic Clinic Today
At The Orthopedic Clinic, we want you to live your life in full motion. If youre experiencing pain that can be relieved by cortisone injections, let us help you. Well tailor a treatment plan thats best for your lifestyle and get you back to doing the things you love.
Call us at to schedule an appointment.
How Do I Book A Cortisone Injection For Frozen Shoulder
To book for a steroid injection you can call our normal reception line, 0142084487 or email direct to requesting an appointment for an injection. Please include your name, date of birth, your address and GP contact details. You will be sent a form to complete and forward back to us or bring along on the day which gives information about the injection.
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Getting A Cortisone Injection
Once youre ready to get the shot, the doctor will position you in a way to easily administer the injection. Then, the injection site will be cleaned, and an anesthetic spray may be used to numb the area where the needle is inserted. In some cases, your doctor may also use digital imaging like fluoroscopy to watch the needles progress and place it in the right spot.
Once the medication has been released into the injection site, you will receive corticosteroid medication to help relieve pain and inflammation. You may also receive an anesthetic to provide immediate pain relief. Once thats been completed, the doctor will send you home to recover.
Clinical Features And Clinicopathological Stages
Patients with FS complain of insidious onset of pain and stiffness without any preceding traumatic, infective, or inflammatory event. Pain is usually poorly localized, around the shoulder and is almost always troublesome in the night while the patient lies on the affected side. The index shoulder examination reveals global restriction of both active and passive range of movements at least in two planes, and that is one of the critical findings. The loss of external rotation with arm by the side of the chest is one of the earliest signs. According to ISAKOS guidelines if the range of movement is less than 100° in forward flexion, less than 10° in external rotation, and less than L5 vertebral level in internal rotation, it is defined as a global restriction of ROM . In a recently published FROST trial, investigators defined FS as a condition characterised by the restriction of passive external rotation in the affected shoulder to less than 50% of the opposite shoulder with normal radiographs . The strength of the rotator cuff is relatively unaffected.
Traditionally, FS is described in three clinico-pathological stages , which we find practical to understand and explain to the patients and decide the treatment plan . Another classification suggested by Hanchard et al. as pain predominant and stiffness predominant is also useful in clinical practice .
The principal clinical characteristics of three stages are pain, pain and stiffness, and stiffness, respectively.
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Cortisone Shot In Shoulder Side Effects: Are They Common
Generally, a cortisone shot is well tolerated. However, you need to be aware of side effects.
Cortisone flare is the most common side effect. This flare usually starts within 24 hours of injection and lasts up to a week. Other side effects include infection , allergy to cortisone, bleeding into joints, and a short-term increase in sugar levels if you have diabetes.
Also, we should avoid repeated cortisone injections into one area as recent evidence suggests that cortisone can weaken the tendon structure.
Final Word From Sportdoctorlondon
A combination of treatments for Frozen Shoulder exists, depending on the stage. In the early phases, we prefer an ultrasound-guided Frozen Shoulder injection followed by gentle stretching and strengthening of the shoulder. For later stages, frozen shoulder hydrodistension injection is helpful. Most cases settle without the need for surgery. The most important part of the treatment is to ensure that the diagnosis is correct. Therefore, you should always see a doctor with expertise in shoulders and performs injections under ultrasound.
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Common Misconceptions & Faqs
Cortisone injections are painful: The majority of patients expect the injection to be very painful, an most are pleasantly surprised that it isnt the case. At the time of injection it should hurt no more than a common immunization needle. Around 1:20 patients may have pain that is worse after the injection. This generally occurs for no more than 2-3 days and is related to irritation of the tissue injected from the cortisone itself. This injection flare is much less common now as the modern cortisone injections are more water soluble. It is best treated with local ice packs and simple analgesics.
You should only have 3 injections: There is no scientific evidence to support this statement, but it seems to have been set in concrete somewhere along the line. Common sense would suggest if 3 injections given at 4-6 week intervals have been unhelpful then further injections are less likely to be beneficial, but having one further injection if progress is being made is not inappropriate, or indeed dangerous.
Cortisone injections will make me fat and give me weak bones: Taking oral cortisone for long periods of time can certainly have side-effects, which do limit the use of this very effective drug. These would include weight gain, osteoporosis, diabetes and high blood pressure. A small amount of cortisone is absorbed after an injection, but quickly cleared within 2-3 days. There are no long term side-effects from repeat local injections of cortisone.
These would include:
How Quickly Do Cortisone Shots Work
Most patients find that their pain significantly improves about 1-3 days after an injection.
After receiving a shot, you may feel numbness for about a day if your doctor used an anesthetic on your shoulder. You may also notice a flare-up of swelling or redness after the numbness fades, which can be uncomfortable. This flare-up typically fades within 48 hours. After the discomfort fades, you should feel little to no pain.
Get your swing back.
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How Much Frozen Shoulder Release Is Too Much Release When Less Cutting Is Better
Here is an interesting study published in Orthopaedics and Traumatology, Surgery and Research . Here, doctors took three groups of patients who had a frozen shoulder release procedure. They divided the patients by the type of procedure.
Explanatory note: Arthroscopic capsular release is considered a minimally-invasive shoulder surgery. In treating frozen shoulders, radiofrequency is used to cut through tissue that may be causing the frozen shoulder condition.
- Anterior-inferior capsular release Smaller cutting area.
- Anterior-inferior-posterior capsular release Larger tissue cutting area or releasing.
- and 360-degree capsular release at follow-up points 3,6 and 12 months.
Then they compared the patient outcomes:
- Group 1 Anterior-inferior capsular release -had greater early abduction, early and overall external rotation than Group 2 , as well as greater early flexion, early abduction, early and overall internal rotation than Group 3.
- Group 2 had greater early and overall flexion than Group 1, as well as greater early and overall flexion, early abduction, and early internal rotation than Group 3. Group 3 had greater overall flexion than Group 1 and greater overall external rotation than Group 2.
- Comparing VAS , the less extensive releases saw the greatest significant postoperative reduction.
What If Conservative Management Does Not Work
Injection therapy
If your pain remains significant and is affecting your daily life, then injection therapy may be appropriate. Injection therapy is particularly effective in the following circumstances:
- If you are in significant pain, particularly pain that is waking you several times a night, then an ultrasound guided steroid injection is the treatment of choice. This is well supported in the medical literature.
- Pain that is stopping you from completing normal tasks such as washing and dressing, cooking or leisure activities.
- Pain that is limiting your ability to undertake physiotherapy rehabilitation.
A recent systematic review by revealed steroid injections to be the most effective treatment for frozen shoulder in stage one, the painful stage. During this stage patients find it very difficult to gain any pain relief and even small movements aggravate the pain. Often once pain is aggravated it takes several hours even days for the pain to settle again. Injections are used to reduce the pain and inflammation associated with frozen shoulder. This allows a window of opportunity for you to stretch your shoulder effectively. Research has recommended that, for best results, a course of physiotherapy should be started within two weeks after receiving a shoulder joint injection.
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How Long Do Steroid Injections Last
The local anaesthetic effect of the injection wears off after a few hours and pain will recur. Steroids themselves take about 2-3 days to kick in so there is usually a gradual reduction in symptoms in the early days following a steroid injection. The duration of the effect of steroids is difficult to predict. Some injections may last weeks or months while others only last days. It is a common observation that the more steroid injections you have the less effective and shorter their duration is.
What Are The Typical Findings Of Frozen Shoulder
A frozen shoulder usually presents with pain and stiffness in the shoulder. Initially, people report increasing pain, followed by shoulder stiffness or restriction of movement. Often, people find that simple movement such as brushing hair or removing a bra becomes difficult. Sleep also becomes a problem because of pain.
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Will A Cortisone Shot Help Torn Shoulder Labrum
A torn labrum such as a SLAP tear can cause excessive movement or instability of the shoulder. Generally, episodes of instability will cause inflammation and pain. Usually, we perform a cortisone shot into the shoulder joint to reduce inflammation from a torn labrum. However, this injection must be followed by an exercise program to strengthen the shoulder and stop further instability.
Pain After A Steroid Injection In The Shoulder
One of the possible side effects of a cortisone injection is called a cortisone flare, or a steroid flare. This is associated with pain at the injection site, particularly early on. The pain can show up immediately, or within a day or two of having the injection done. The cause of a steroid flare is the make up of a corticosteroid, which is made of slow-release crystals to give you lasting pain relief. However, in some people this can irritate your joint which causes pain at the injection area. Not everyone has a cortisone flare, and they can be managed by your doctor.
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