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Frozen Shoulder

Adhesive capsulitis (frozen shoulder) can be difficult to treat. It is important to try and identify the cause and to appropriately council the patient.

First stage:
This is managed with analgesia for pain relief. On average it can last for 3-6 months. It is important to rule out other causes for the pain such as infection, acute calcific tendonitis, acute cuff tear, etc.

Glenohumeral steroid injection can be considered. The entry point for this is posterior; 2cm medial and 2 cm inferior to the postero-lateral corner of the acromion. The needle is then directed towards the tip of the coracoid. This only has a 60% success rate. Physiotherapy is not indicated at this stage.

Second stage:
Physiotherapy can be tried here including stretching exercises. Other treatment includes hydro-distension. This includes the injection of fluid under high pressure to stretch the tight capsule. This is still in the early stages and has a success rate of 60 – 70 %.

Surgery is indicated at this stage. This can be in the form of manipulation under anaesthetic (MUA) or arthroscopic release. MUA must be carried out with a short lever arm and by avoiding forced passive rotation to avoid risk of fracture. Other documented risks include rotator cuff tears and neurovascular injuries. MUA is contraindicated in the presence of shoulder prosthesis and previous fracture of the shoulder.

Arthroscopic release involves the circumferential division of the tight capsule under direct vision, using an arthroscopic vaporiser. This is said to carry a higher chance of success but has all the associated risks of infection, bleeding and particularly nerve injury.

If surgical intervention is considered, it is important that the patient commences physiotherapy immediately afterwards. To achieve this, pain relief is essential and interscalene nerve block should be considered.

Third stage:

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