FROZEN SHOULDER

What is frozen shoulder?

Frozen shoulder (Adhesive Capsulitis) is stiffness, pain, and limited range of movement in your shoulder.In frozen shoulder, there is a lack of synovial fluid, which normally helps the shoulder joint, a ball and socket joint, move by lubricating the gap between the humerus (upper arm bone) and the socket in the shoulder blade. The shoulder capsule thickens, swells, and tightens due to bands of scar tissue (adhesions) that have formed inside the capsule. As a result, there is less room in the joint for the humerus, making movement of the shoulder stiff and painful.  Pain is usually constant, worse at night, and with cold weather. Certain movements or bumps can provoke episodes of tremendous pain and cramping. The condition is thought to be caused by injury or trauma to the area and may have an autoimmune component. The risk of developing frozen shoulder increases if patient’s recovering from a medical condition or procedure that prevents you from moving your arm — such as a stroke or a mastectomy.

Epidemiology :

Frozen shoulder syndrome (FSS) usually affects patients aged 40-70 years. The incidence of FSS is not precisely known; however, it is estimated that 2% of people develop the disease over their lifetime. Females tend to be affected more frequently than males. ON SIDE, unilateral involvement is more. Diabeticmellitus patients are more susceptible to it. People with stroke, lung disease, rheumatoid arthritis, or heart disease are at a higher risk for frozen shoulder. I

Causes:

Frozen shoulder occurs when this capsule of connective tissue thickens and tightens around the shoulder joint, restricting its movement.

Diabetes: Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

Other diseases: Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, rheumatoid , inflammatory diseases and cardiac disease.

Immobilization :Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury (trauma). Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Signs &Symptoms:

Movement of the shoulder is severely restricted, with progressive loss of both active and passive range of motion(ROM).  Shoulder will be so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm. For some people, the pain worsens at night, sometimes disrupting sleep.Frozen shoulder typically develops slowly, and in three stages. Each stage can last a number of months.

• Freezing stage. Any movement of your shoulder causes pain, and your shoulder's range of motion starts to become limited.
• Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and using it becomes more difficult.
• Thawing stage. The range of motion in your shoulder begins to improve.

DIAGNOSIS:

Doctor Examination:

After discussing your symptoms and medical history, your doctor will examine your shoulder. Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion." Your doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.

X-rays.

Dense structures, such as bone, show up clearly on x-rays. X-rays may show   other problems in your shoulder, such as arthritis.

Magnetic resonance imaging (MRI) and ultrasound.

 These studies can create better images of problems with soft tissues, such as a torn rotator cuff.

TREATMENT / MANAGEMENT:

Frozen shoulder generally gets better over time, although it may take up to 3 years.The focus of treatment is to control pain and restore motion and strength through physical therapy.

Nonsurgical Treatment:

Non-steroidal anti-inflammatory medicines. Drugs to reduce pain and swelling.

Steroid injections. Injecting corticosteroids into your shoulder joint may help decrease pain and improve shoulder mobility, especially in the early stages of the process.

Physical therapy. Specific exercises will help restore motion. These may be under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before the stretching exercises.. Below are examples of some of the exercises that might be recommended.

• External rotation — passive stretch. Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

 

External Rotation - Passive Stretch

• Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.

Forward Flexion - Supine Position

• Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

 

Crossover Arm Stretch

Surgical Treatment:

The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods includeJoint distension, manipulation under anesthesia and shoulder arthroscopy.

Joint distension. Injecting sterile water into the joint capsule can help stretch the tissue and make it easier to move the joint.

Manipulation under anesthesia. During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.

Shoulder arthroscopy. In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.

In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have very good outcomes with these procedures.

 

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining damaged by frozen shoulder.

RECOVERY:

 After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to three months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.

Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion. In some cases, however, even after several years, the motion does not return completely and a small amount of stiffness remains.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.