Frozen Shoulder

June 2, 2017 | By | Reply READ MORE...

– Dr Niriksha Khasgiwala

Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very difficult to move and takes 1-3 years to resolve. Women are more predisposed to frozen shoulder and it most commonly affects people between the ages of 40 and 60

ANATOMY:

frozen shoulder

  • The shoulder joint is a ball-and-socket joint made up of three bones: the upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The joint is very mobile.
  • The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.
  • To help the shoulder move more easily, there is fluid that lubricates the shoulder capsule and the joint.
  • The shoulder capsule surrounds the shoulder joint and rotator cuff tendons.

What causes frozen shoulder?

  • In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue called adhesions develop. In many cases, there is less synovial fluid in the joint.
  • The classic sign of this condition is being unable to move your shoulder – either on your own or with the help of someone else.

Stages of frozen shoulder:

There are 3 stages :

  1. Freezing – In the “freezing” stage, pain is the hallmark sign. As the pain worsens, the shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.
  2. Frozen – Painful symptoms may actually improve during this stage, but the stiffness remains. It lasts for 4 to 6 months. Daily activities may be very difficult.
  3. Thawing – Shoulder motion slowly improves during the “thawing” stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

frozen shoulder

Causes and risk factors:

  • Age and sex – People 40 and older, particularly women, are more likely to have frozen shoulder
  • Immobility or reduced mobility – People who’ve had prolonged immobility or reduced mobility of the shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including: Rotator cuff injury, Fracture, Stroke, Recovery from surgery especially chest or neck, Systemic diseases eg. diabetes

Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder. People who have certain diseases or conditions appear more likely to develop frozen shoulder. Diseases that might increase risk include:

  • Diabetes, especially uncontrolled
  • Overactive thyroid (hyperthyroidism)
  • Underactive thyroid (hypothyroidism)
  • Cardiovascular disease
  • Tuberculosis
  • Vitamin D3 and B12 deficiency

SYMPTOMS:

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. As the disease progresses, the pain subside and the shoulder ranges become stiff. The pain is usually located over the outer shoulder area and sometimes the upper arm.

DIAGNOSIS:

In order to achieve a clinical diagnosis, a thorough shoulder examination should be done. Your physiotherapist will ask about what physical activities you are having difficulty to perform.
Common issues include:

  • Unable to reach above shoulder height
  • Unable to quickly reach for something
  • Unable to reach behind your back, eg. wear a bra or tucking a shirt
  • Unable to reach out to your side and behind. eg reach for seat belt
  • Unable to sleep on your side.

In some cases you may be referred for X-rays or MRI to rule out other causes of shoulder pain. X-rays are not able to diagnose frozen shoulder. MRI can provide a definitive diagnosis.

Frozen shoulder is commonly misdiagnosed or confused with rotator cuff injury. It is important to get an accurate diagnosis since the treatment and recovery vary considerably.

PHYSICAL EXAMINATION:

  • After discussing your symptoms and medical history, you will be examined for your shoulder.
  • Range of shoulder will be carefully assessed in all directions to see if movement is limited and if pain occurs with the motion.

frozen shoulder

  • Frozen shoulder has a distinct capsular pattern of stiffness:
    Lateral Rotation > Flexion > Internal Rotation.
  • Normally, the rotator cuff strength will still be normal with the exception of pain inhibition.
  • Frozen shoulders are commonly non-tender on palpation examination due to the pathology being quite deep.

TREATMENT:

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.

  1. Nonsurgical Treatment: More than 90% of patients improve with relatively simple treatments to control pain and restore motion.
  2. Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.
  3. Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.
  4. Physical therapy.

Physiotherapy treatment for frozen shoulder depends on what stage you are in, and is tailored to your specific needs.

1. Freezing –
Pain relieving techniques including gentle shoulder mobilisation, wand exercises , pendular exercises, muscle releases, acupuncture, dry needling and kinesiology taping can assist during this painful inflammation phase. Intracapsular corticosteroid injection is considered when pain is unbearable.
It is important not to aggravate a frozen shoulder during this phase, which is unfortunately a side effect of an overzealous practitioner.

frozen shoulder
frozen shoulder

2. Frozen –
Shoulder joint mobilisation and stretches, muscle release techniques, acupuncture, dry needling and exercises to regain range and strength are useful for a prompt return to function. Care must be taken not to introduce any exercises that are too aggressive.
Overenthusiastic treatment can aggravate your capsular synovitis and subsequently pain.

3. Thawing –
Shoulder mobilisation and stretches are your best chance of a prompt return to full shoulder movement. As your range of motion increases your physiotherapist will be able to provide you with strengthening exercises to control and maintain your newly found range of movement.
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 door. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

frozen shoulder

  • 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. You can use a stick to assist you.

frozen shoulder

  • 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.

frozen shoulder

SURGICAL TREATMENT:

If your symptoms are not relieved by therapy and anti-inflammatory medicines, you and your doctor may discuss surgery.
The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anaesthesia and shoulder arthroscopy.

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