Frozen shoulder, also referred to as adhesive capsulitis, is a disabling disorder involving the inflammation and stiffness of the shoulder capsule. The shoulder capsule is the connective tissue around the glenohumeral joint of the shoulder. This disorder causes chronic pain and restricts motion. The involved pain gets worse in cold weather and at night, and is usually constant. Certain bumps and movements will provoke episodes of cramping and extreme pain. This condition is believed to be as a result of trauma or injury to the involved area and can also be associated with an autoimmune component.
Frozen shoulder has risk factors which include stroke, diabetes mellitus, lung disease, seizures, heart disease, thyroid disease and connective tissue disease. Patients suffering from frozen shoulder experience severe pain and prolonged periods of sleep deprivation especially because the pain will get worse in still lying positions and restricted positions and movements.
Frozen shoulder is known to lead to depression, lack of sleep which leads to severe weight loss and problems in the back and neck. This condition causes concentration difficulties especially when performing daily activities for long periods. In most of the cases, the condition is self-limiting and disappears without the need for surgery. A large number of patients report gaining up to 90% of their shoulder function over a certain period.
Signs and Symptoms of Frozen Shoulder
The most common symptom is the severe restriction of shoulder movement and this is accompanied by the loss of passive and active motion ranges. When the condition is caused by injury, lack of use will most likely be caused by the pain. The disorder might also arise spontaneously with no clear trigger factor and is referred to as idiopathic frozen shoulder. Recent shoulder surgeries and the progression of rheumatic disease can also be behind the limitation and pain patterns that resemble frozen shoulder condition. The intermittent periods of use may result in inflammation.
Frozen shoulder is characterized by the lack of synovial fluid, which is the fluid that assists the shoulder joint in movement through the lubrication of the gap that exists between the socket in the shoulder blade and the humerus bone. Bands of scar tissue (adhesion) will form in the capsule and this will lead to the swelling, tightening and thickening of the capsule. This reduces the room in the capsule and makes the joint stiff and painful when moved.
Patients with lung disease, diabetes, stroke, heart disease or rheumatoid arthritis are susceptible to getting frozen shoulder. Surgery or injury may lead to the capsule tightening as a result of reduced movement during the period of recovery. Frozen shoulder has been indicated as a possible effect of some highly active antiretroviral therapy forms.
This condition will appear in people over the age of 40 years and is more common in women than in men with about 70% of the patients being women between the age of 40 and 60 years. Patients of frozen shoulder with diabetes experience more problems when compared to non-diabetic individuals and their recovery is usually prolonged. There are a few cases that have been reported after lung and breast surgery.
Causes of Frozen Shoulder
Frozen shoulder is a condition resulting from the scarring, thickening, inflammation and shrinkage of the capsule surrounding the shoulder joint. Any injury to the shoulder has been found to be a possible cause of frozen shoulder and this may include rotator cuff injury, bursitis, and tendinitis. Frozen shoulder will occur in patients with risk factors such as diabetes, heart disease, chronic inflammatory shoulder arthritis, or patients recovering from lung or breast surgery. Long-term immobility such as when a patient is in recovery has been found to lead to frozen shoulder.
One common sign that is mostly used in the diagnosis of frozen shoulder is the tightening and stiffening of the shoulder joint which makes it difficult for the patient to complete the simplest of daily activities such as moving or raising the arm. The rotation of the shoulder is the movement that is severely inhibited by this condition.
Most of the patients will complain that the pain and the accompanying stiffness worsen at night. The involved pain is usually arching or dull. The pain worsens with a bump or when the patient attempts motion. Limited shoulder movement is one of the signs that will increase the probability of frozen shoulder in physical examinations conducted by chiropractors, osteopaths or physical therapists. The condition can be diagnosed in cases where the limit to active motion range is the same or almost equal to the limit of passive motion range. An MRI or arthrogram may be used in the diagnosis but this is rarely used in practice.
There are three stages in the normal course of frozen shoulder:
Stage 1 – This is the painful or ‘freezing’ stage and last for a period between 6 and 9 weeks and is characterized by onset pain which limits shoulder motion as it worsens.
Stage 2 – This is the adhesive or ‘frozen’ stage which is characterized by slow improvement but the stiffness still remains and will last between 4 and 9 months.
Stage 3 – This is the recovery stage also referred to as ‘thawing’ and this is when the shoulder is returning to normalcy and will last for a period between 5 to 26 months.
Though frozen shoulder is more of a clinical diagnosis, imaging may be employed in an effort to eliminate other causes for a better treatment method. The golden standard for the imaging diagnosis of this condition is arthrography. The thickening of the coracohumeral ligament can be properly assessed with the help of MRI and ultra sound.
One main common preventive measure recommended by health practitioners is keeping the shoulder joint active to reduce the risk of frozen shoulder. In most cases, when a shoulder begins the freezing process, it will start paining. Most people will stop using the shoulder normally once the pain starts and this will encourage further adhesion development. This will restrict the movement of the joint unless full movements are continued. Occupational therapy and physical therapy can be used to prevent the full development of frozen shoulder.
Management of Frozen Shoulder
The management of frozen shoulder is focused on the restoration of shoulder joint movement, alleviation of shoulder pain and may involve physical therapy, medication and in some cases surgery is required. There is no clear evidence that favors any particular treatment approach and there is tentative evidence showing the benefits of low level laser therapy in the treatment of frozen shoulder.
Most commonly used medications include NSAIDs; corticosteroids may be used in some cases and will be administered systematically or via local injection. Physiotherapists and chiropractors might use daily extension stretching and massage to manage the condition. Spencer technique is also another method used in the treatment of frozen shoulder.
If the above methods are not successful in reducing the pain and gaining back shoulder movement, then manipulating the shoulder under general anesthesia to break the adhesion becomes an option. In severe cases which are prolonged, surgery may be used to cut the adhesions and recover shoulder movement.
Since frozen shoulder gets worse with reduced shoulder motion, it is important that an individual experiencing the slightest of pain ensure that they exercise their shoulders regularly to prevent the development of the adhesion. The individual should also seek medical attention for proper diagnosis and treatment.