FROZEN SHOULDER

Overview (Adhesive Capsulitis)

The shoulder consists mainly of two joints. The larger glenohumeral joint is a ball and socket type joint formed by the glenoid (socket) and head of the humerus (ball). The second smaller joint in the shoulder is the acromioclavicular or AC joint formed between the clavicle (collar bone) and scapular bone (shoulder blade). The shoulder joint is surrounded by a joint capsule that holds everything together. With a frozen shoulder, the capsule becomes swollen, thick and tight leaving no space inside the joint to move. It is usually associated with pain and stiffness that develops gradually, gets worse and then finally goes away. This can take anywhere from a year to 3 years.

Causes

Even after years of research, the cause of frozen shoulder is not known. However, frozen shoulder happens more often in women, between the ages of 40 and 60 years. The risk is also high in medical conditions like diabetes, stroke, thyroid disease, Parkinson’s disease or surgery of upper limb or mastectomy (breast surgery). About 10% to 20% of diabetic patients get frozen shoulder.

 

Symptoms

Frozen shoulder patients usually present with pain and stiffness of the shoulder that makes it difficult or impossible to move. Pain is usually dull or achy involving one or both (less common) the shoulder. Pain could be just in the shoulder or maybe in the muscles around (neck, arm and shoulder). The pain could be worse at night, disturbing your sleep.

Froze shoulder passes through 3 phases viz. freezing stage, frozen stage and thawing stage in order. Every frozen shoulder passes through these stages to finally settle the condition on its own between 9months to 3yrs. It usually starts with pain which gradually increases affecting night sleep. Along with this shoulder becomes gradually stiff. As the thawing stage ends pain and stiffness disappear.

 

Diagnosis

History and examination are most important to diagnose frozen shoulder. Your shoulder is usually tender and the doctor will find that your passive shoulder motion is restricted in all directions especially external rotation. A physical exam is usually enough to diagnose a frozen shoulder, but you may be advised imaging tests such as X-rays, ultrasound, or MRI to rule out other causes of pain in the shoulder like arthritis or a torn rotator cuff.

 

Treatment and prevention

Conservative treatment is the first-line treatment and is effective in most cases.

  1. Medicines: Analgesic drugs like NSAIDs (Diclofenac, Ibuprofen, Etoricoxib) help relieve the pain and inflammation in your shoulder. If they don’t help, your doctor might prescribe other pain killers like Tramadol or Opioids.
  2. Physiotherapy and exercises: this includes strengthening and stretching exercises to improve your range of motion. Ultrasound therapy, TENS therapy might also help in some patients.
  3. Rest to the shoulder can be given for few days when pain is severe and the patient can not tolerate physical therapy. Ice fomentation also helps to decrease the intensity of pain and is advised liberally.
  4. Joint injections: when the above-mentioned treatment options do not work then your doctor may advise you of corticosteroid injection in your shoulder joint to reduce your pain and improve your range of motion.

 

Surgical treatment

When nothing works and the patient is not showing any signs of improvement then surgical options can be explored which involves

  1. Joint distension where sterile water is injected into your shoulder to stretch the capsule. This can help you move your shoulder more easily.
  2. Shoulder manipulation can help stretch the capsule to break the adhesions in your shoulder. Surgeons would forcefully move the shoulder under general anesthesia.

3. Arthroscopic capsular release: It is a minimally invasive procedure in which a joint is reached with the use of a small telescope (arthroscope) and surgical tools inserted through small incisions into the shoulder joint. The inflamed synovium covering the capsule is ablated and the thickened capsule is cut. This improves the range of motion immediately and settles inflammation and hence the pain. However, the patient will need to start physiotherapy and rehabilitation to avoid shoulder stiffness.