Recovering a shoulder from absolute zero
The instance of a frozen shoulder
To help ‘unfreeze’ a patient’s shoulder joint to help them return to normal function involves addressing the connective tissue which has thickened and tightened over time. In some instances, capsulitis can mimic infection or other painful inflammatory shoulder conditions. "Most capsulitis is idiopathic, we don't know why it occurs," says Mr Walton. Mr Mike Walton has a specialist shoulder practice at The Arm Clinic in The Wilmslow Hospital, part of HCA Healthcare UK. He has a strong interest in complex shoulder instability and shoulder replacement surgery.
He states that frozen shoulder has several phases. The first is the freezing phase, where shoulders are acutely painful but are not stiff. The frozen phase is then divided into two halves – a predominant ‘pain’ phase where the shoulder begins to stiffen and is very painful. Mr Walton says "this is normally the phase that people present to us in." This phase continues into the predominant ‘stiffness’ phase where the shoulder is very stiff, but pain starts to resolve. The last stage is the thawing phase where the shoulder starts to normalise again.
Treating a frozen shoulder
Mr Walton confirms that this condition, if given enough time, will resolve. However, "In most people with capsulitis, the phases can be very long, taking up to two to three years to recover. Part of the problem is patients are often informed that ‘capsulitis will get better if left alone.’ These patients then have very painful symptoms for a very long time." Mr Walton reiterates, "Some patients will even take themselves to accident and emergency because capsulitis is so painful. This is a condition with symptoms which we are fully able to treat and is usually straightforward to diagnose."
A disproportionate number of patients with capsulitis also have diabetes. Mr Walton states, "Statistically, if you are diabetic, you are three to four times more likely to have capsulitis. If you develop it on one side, there is also a risk, of about 40%, of getting it on the other side."
The impact of diabetes on a frozen shoulder
In patients with diabetes, the phases are lengthened and are more aggressive. It is extremely painful and very debilitating because it leads to both a functional loss of movement as well as significant pain, which can be especially problematic at night.
One of Mr Walton’s patients had both severe capsulitis and diabetes and was within the NHS system for four years. His initial diagnosis was neck pain, he was referred again and diagnosed with rotator cuff pain. Through this four-year journey, the patient wasn’t given a specific diagnosis of capsulitis. When he arrived with Mr Walton, the diagnosis was clear because the shoulder was stiff and still in the 'pain' phase.
The patient received a high volume hydrodistension injection. "Hydrodistension is an effective, simple treatment. Under ultrasound guidance, a local anaesthetic and steroid is injected into the shoulder," says Mr Walton, who regularly performs this procedure. A large volume of water (20 to 30 millilitres) is then injected into the joint to stretch the shoulder, freeing up the joint adhesions to allow the range of motion to improve.
"A frozen shoulder is very tight, so it's very difficult to inject into a shoulder joint. Traditional injection mechanisms have often not been accurate enough to ensure that the medicine gets into the joint itself, and so we now do these under ultrasound guidance. We now offer it as a same day service. An examination confirms the capsulitis diagnosis, imaging excludes other causes of stiffness and then a radiologist performs hydrodistension the same day."
The Arm Clinic has performed over 1,500 of these procedures and has had excellent results. Between two-thirds to three-quarters of patients do not need any further treatment.
However, in the case of the patient with severe capsulitis and diabetes, this procedure wasn't effective enough. The hydrodistension injection gave the patient a very good resolution of their pain, but the stiffness remained. Mr Walton decided to proceed with an arthroscopic capsular release. "We were able to identify that he wasn't progressing as fast as we would like, due to the severity of his condition."
"We find patients who present to us early with capsulitis respond more effectively to hydrodistension. All patients respond to a degree, but the earlier in the journey the condition is caught, the more predictable it is. In this person's case he was young, and he needed his movement back and so that's why we decided upon an operation."
Surgical treatment
A day case arthroscopic capsular release was performed. After two incisions in the shoulder, an arthroscope was inserted, containing a camera to evaluate the joint. Mr Walton identified contracted tissue and removed it by excision, from the inside out. Radiofrequency waves cauterised any remaining tissue.
Overall, the patient journey was under two months, from initial assessment, hydrodistension injection and then ultimately surgery. "We narrowed his duration of treatment from four plus years down to three months," says Mr Walton. The patient now has no pain and a near full range of motion. He needs to work on his strength because his shoulder has not moved for such a long time, requiring a schedule of physiotherapy.
"For capsulitis, it's about recognising it, understanding it, diagnosing it quickly, and then accessing treatment. That comes from having early specialist assessment and an accurate diagnosis. Our highly specialised teams work together to make the procedure as efficient as possible."