Frozen shoulder, also known as adhesive capsulitis, is an inflammatory condition affecting the shoulder joint capsule. It occurs in approximately 5% of the population and is more common in women aged 40-60. 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 administer a cortisone shot for a frozen shoulder to alleviate severe pain and improve mobility. What is a frozen shoulder steroid injection, and when should you use it?
What are the Typical Findings of Frozen Shoulder?
A frozen shoulder usually presents with shoulder pain and stiffness. Initially, people report increased pain, followed by shoulder stiffness or restricted movement. People often find simple movements, such as brushing their hair or removing a bra, difficult. Sleep also becomes a problem because of intense pain.
How Do We Diagnose a Frozen Shoulder?
Generally, a painful and stiff shoulder is the usual presentation. However, it is essential to rule out other causes of shoulder pain and stiffness, such as arthritis or tendon calcification. In this situation, further investigations, such as X-rays, are crucial. For more complex cases, imaging such as ultrasound or MRI may be needed.
Will this Frozen shoulder get Better on its Own?
Most cases get better after 18-24 months. However, recent studies suggest that some people can have symptoms for more than two years and even ten years.
What are the Best Treatment Options?
Generally, there is no consensus on the most effective treatments.
Firstly, there is no evidence that tablets such as steroids or anti-inflammatories are effective. Secondly, physiotherapy, including stretching and strengthening exercises, is an integral part of treatment and is effective in milder cases. However, there is no consensus on the most effective type of physiotherapy. In severe cases, a cortisone injection for a frozen shoulder can help.
More about Frozen Shoulder Injection
Generally, a cortisone shot for a frozen shoulder is helpful in the early or freezing stages to reduce pain and halt its progression. We have evidence that an injection can relieve pain for up to four months. To improve accuracy, injections should be performed with ultrasound guidance.
Frozen shoulder hydrodilatation, also known as shoulder hydrodistension, is a specific injection technique that involves the administration of a high volume of water along with a corticosteroid injection. We think injecting a high volume into the joint leads to a build-up of pressure and a faster ‘thawing’ out of the frozen shoulder.
Additionally, studies suggest that early injection in frozen shoulder is more effective than later injection. For example, in a study on injections for frozen shoulder, subjects who received an injection at stage 1 recovered within 2-6 weeks, whereas those at stage 2 resolved their symptoms within 7-12 weeks. Therefore, early assessment and injection ensure a more effective outcome.
Is a frozen shoulder hydrodilatation better than a simple frozen shoulder steroid injection?
We think so. We have some evidence for hydrodilatation or hydrodistension. Previous high-level studies have shown little difference in the effect of frozen shoulder hydrodilatation compared with a simple cortisone injection. However, a recent study suggests that frozen shoulder hydrodilatation is more effective than a simple cortisone injection in improving pain and range of motion.
Shoulder hydrodilatation (hydrodistension) should be performed under ultrasound guidance to improve accuracy and effectiveness.
PRP injections for frozen shoulder
Platelet-rich plasma (PRP) injections are used to treat various musculoskeletal conditions.
In a study comparing PRP with cortisone injections for frozen shoulder, PRP showed a greater reduction in pain and improved range of motion. However, more investigations are needed to determine whether PRP is more effective than cortisone in frozen shoulder. Nonetheless, the early results are promising and suggest that PRP may be a potential alternative to cortisone.
In addition, hyaluronic acid has been used in frozen shoulder, with good initial results. One study found that the effects were similar with hyaluronic acid compared to corticosteroid.
Is Surgery a Good Option for a Frozen Shoulder?
Surgery, also known as capsular release, is beneficial only in cases that are persistent. You must remember that surgery has risks and is not always successful. A recent study suggests that surgical outcomes for frozen shoulder are comparable to those of physiotherapy, but with a higher incidence of serious adverse effects (4-5%). Overall, your decision regarding surgery should not be taken lightly.
Other Frequently Asked Questions About a Cortisone Shot for Frozen Shoulder:
Is the volume of fluid injected significant for a successful shoulder hydrodistension?
Potentially yes. We can inject either a moderate volume (20- 40 mL) or a high volume (> 40 mL). High volumes often rupture the shoulder joint capsule.
We believe that shoulder hydrodistension with moderate volume stretches the capsule more effectively than very high volumes, which can rupture it. One study found that stretching the capsule is more effective for pain relief and improved function than rupturing it.
Is a frozen shoulder steroid injection more effective if done early?
Yes, we think so. One study found that an early injection significantly reduced the time to complete resolution compared with a later injection.
Can an injection cause a frozen shoulder?
Yes. We know that immunisations in the upper arm can trigger a reaction that can lead to a frozen shoulder. During the COVID-19 vaccination program, we observed an increase in frozen shoulder cases, partly due to the higher vaccination rate.
Are steroid injections for frozen shoulder painful?
Yes, they can be particularly so during the initial freezing stages of this disease. However, we use a local anaesthetic, which improves tolerability.
Can a frozen shoulder show up on an MRI?
Yes. While a frozen shoulder is a clinical diagnosis, an MRI can help confirm it. We often observe swelling surrounding the biceps tendon and thickening of the capsule at the inferior aspect of the shoulder joint. Additionally, MRI can help exclude other potential causes of a stiff and painful shoulder, such as shoulder arthritis or calcific tendonitis.
Is a multi-site injection better than a one-site injection for steroid injection for a frozen shoulder?
We are not sure. A recent study found 3-4 injeciton sites are better than one for a frozen shoulder. However, the differences were insignificant. However, one study found that a suprascapular nerve block performed with a steroid injection in the joint was more effective than a steroid injection alone. Therefore, multiple site injections may be more effective than a single injection. One study combined both hydrodistension and suprascapular nerve block in one sitting.
Can you drive after a cortisone injection in your shoulder?
We advise against driving after a shoulder cortisone injection. Most insurance companies do not cover car accidents immediately after a medical procedure, so it is safer to use a taxi or take public transportation after a shoulder injection.
Can I go to work after a frozen shoulder injection?
As these injections often cause significant post-injection pain, we recommend you take the rest of the day off work or other activities.
Final word from Sportdoctorlondon about a Frozen Shoulder Steroid Injection
Depending on the stage, a combination of treatments for frozen shoulder exists. In the early phases, we think a frozen shoulder steroid injection is helpful, and a hydrodistension is more effective than a simple cortisone injection. Most cases settle without the need for surgery. The most crucial part of management is ensuring that the diagnosis is correct. Therefore, it is recommended that you consult a doctor with expertise in shoulder care and experience with ultrasound-guided injections.
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