Frozen shoulder

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Definition

Adhesive capsulitis (also known as frozen shoulder) is a painful and disabling disorder of unclear cause in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain. 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.

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Risk factors for frozen shoulder include tonic seizures, diabetes mellitus, stroke, accidents, lung disease, connective tissue diseases, thyroid disease, and heart disease. Treatment may be painful and taxing and consists of physical therapy, occupational therapy, medication, massage therapy, hydrodilatation or surgery. A physician may also perform manipulation under anesthesia, which breaks up the adhesions and scar tissue in the joint to help restore some range of motion. Pain and inflammation can be controlled with analgesics and NSAIDs.

People who suffer from adhesive capsulitis usually experience severe pain and sleep deprivation for prolonged periods due to pain that gets worse when lying still and restricted movement/positions. The condition can lead to depression, problems in the neck and back, and severe weight loss due to long-term lack of deep sleep. People who suffer from adhesive capsulitis may have extreme difficulty concentrating, working, or performing daily life activities for extended periods of time. The condition tends to be self-limiting and usually resolves over time without surgery. Most people regain about 90% of shoulder motion over time.

Causes

Frozen shoulder occurs when the sleeve that surrounds the shoulder joint, known as the capsule, becomes swollen and thickened. It’s unclear why this happens.

The shoulder is a ball and socket joint. The end of your upper arm bone (humerus) sits in contact with the socket of your shoulder blade (scapula).

The shoulder capsule is fully stretched when you raise your arm above your head, and hangs down as a small pouch when your arm is lowered.

In frozen shoulder, bands of scar tissue form inside the shoulder capsule, causing it to thicken, swell and tighten. This means there’s less space for your upper arm bone in the joint, which limits movements.

Risk factors

It’s not fully understood why frozen shoulder occurs, and it’s not always possible to identify a cause. However, a number of factors can increase your risk of developing it. These are outlined below.

Age and gender

Most people affected by frozen shoulder are aged between 40 and 60. The condition is more common in women than men.

Previous shoulder injury or surgery

Frozen shoulder can sometimes develop after a shoulder or arm injury, such as a fracture, or after having surgery to your shoulder area.

This may partly be a result of keeping your arm and shoulder still for long periods of time during your recovery. Your shoulder capsule may tighten up from lack of use.

Because of this, it’s very important not to ignore a painful shoulder injury and to always seek medical advice.

Diabetes

If you have diabetes, you have a greater risk of developing a frozen shoulder. The exact reason for this is unknown.

It’s estimated that people with diabetes are twice as likely to develop a frozen shoulder.

If you have diabetes, the symptoms of frozen shoulder are likely to be more severe and harder to treat. You’re also more likely to develop the condition in both shoulders.

This means it’s important to have your diabetes checked regularly to make sure it’s controlled with the right medication.

Other health conditions

You may have a greater risk of developing a frozen shoulder if you have other health conditions, such as:

  • heart disease
  • stroke
  • lung disease
  • an overactive thyroid (hyperthyroidism) or an underactive thyroid (hypothyroidism)
  • breast cancer
  • Dupuytren’s contracture – where small lumps of thickened tissue form in the hand, causing the fingers to bend into the palm

Other shoulder conditions

Frozen shoulder can sometimes develop alongside other shoulder conditions, such as:

  • calcific tendonitis – where small amounts of calcium are deposited in the tendons of the shoulder
  • rotator cuff tear – the rotator cuff is a group of muscles that control shoulder movements

Immobility

Not moving for long periods of time can also increase your risk of a frozen shoulder. This can sometimes happen if you spend time in hospital.

http://www.nhs.uk/Conditions/Frozen-shoulder/Pages/Causes.aspx 

Symptoms

A symptom is something the patient feels and/or reports, while a sign is something others, including the doctor observe. For example, pain is usually a symptom, while a rash could be a sign.

The most pervasive sign or symptom of frozen shoulder is a persistently painful and stiff shoulder joint. Signs and symptoms of frozen shoulder develop gradually; usually in three stages in which signs and symptoms worsen gradually and resolve within a two – year period.

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There are three stages of frozen shoulder:

  • Painful stage – the shoulder becomes stiff and then very painful with movement. Movement becomes limited. Pain typically worsens at night.
  • Frozen/adhesive stage – the shoulder becomes increasingly stiff, severely limiting range of motion. Pain may not diminish, but it does not usually worsen.
  • Thawing stage – movement in the shoulder begins to improve. Pain may fade, but occasionally recur.

http://www.webmd.com/a-to-z-guides/tc/frozen-shoulder-topic-overview 

Diagnostics

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.

Imaging Tests

Other tests that may help your doctor rule out other causes of stiffness and pain include:

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.

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Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of problems with soft tissues, such as a torn rotator cuff.

http://orthoinfo.aaos.org/topic.cfm?topic=a00071 

Treatment 

Treatment for a frozen shoulder will vary, depending on the stage of the condition and the severity of your pain and stiffness.

A frozen shoulder may get better over time without treatment, but recovery is often slow and can take at least 18 to 24 months. In some people, the condition may not improve for five years or more.

A number of different treatments can be used to treat frozen shoulder, although it’s uncertain how effective they are and which is best.

The treatments described below can help reduce shoulder pain and keep the joint mobile while the shoulder heals.

Early stage treatments

The first stage of a frozen shoulder is the most painful. Therefore, treatment is mainly focused on relieving the pain.

During this stage, your GP may recommend avoiding movements that make the pain worse, such as stretching. However, you shouldn’t stop moving altogether.

Painkillers

If you’re in pain, you may be prescribed painkillers, such as:

  • paracetamol
  • a combination of paracetamol and codeine
  • a non-steroidal anti-inflammatory drug (NSAID) – such as ibuprofen

Some painkillers are also available from pharmacies without a prescription. Always follow the manufacturer’s instructions and make sure you’re taking the correct dose.

Taking painkillers, particularly NSAIDs, in the long term can increase your risk of side effects. See the patient information leaflet that comes with your medication for more information.

Read more about the side effects of NSAIDs.

Corticosteroid injections

If painkillers aren’t helping to control the pain, it may be possible to have a corticosteroid injection in your shoulder joint.

Corticosteroids are medicines that help reduce pain and inflammation. They may also be given with a local anaesthetic.

These injections can help relieve pain and improve the movement in your shoulder. However, injections won’t cure your condition and your symptoms may gradually return.

Corticosteroid injections won’t be used after the pain has gone from your shoulder and only the stiffness remains.

Having too many corticosteroid injections may damage your shoulder, and the injections often become less effective over time, so your doctor may recommend having no more than three injections. You’ll need at least three to four weeks between these.

Read more about corticosteroids.

Later stage treatments

After the initial painful stage, stiffness is the main symptom of a frozen shoulder. Your GP may suggest stretching exercises, and you may also be referred to a physiotherapist.

Shoulder exercises

If you have a frozen shoulder, it’s important to keep your shoulder joint mobile with regular, gentle stretching exercises. Not using your shoulder could make the stiffness worse, so you should continue to use it as normal.

However, if your shoulder is very stiff, exercise may be painful. Your GP or physiotherapist can give you some simple exercises to do every day at home that won’t damage your shoulder any more.

Physiotherapy

A physiotherapist can use a number of techniques to keep the movement and flexibility in your shoulder. If you’re referred to one, you may have treatments including:

  • stretching exercises that use specific techniques to move the joint in all directions
  • massage
  • thermotherapy, with warm or cold temperature packs

There’s no clinical evidence to show that certain other treatments are effective in treating frozen shoulder, including:

  • transcutaneous electrical nerve stimulation (TENS)
  • Shiatsu massage
  • acupuncture

Read more about physiotherapy.

Surgery and procedures

It’s uncommon to need surgery for a frozen shoulder, but it may be recommended if your symptoms are severe and other treatments haven’t worked after six months.

If this happens, you may be referred to an orthopaedic surgeon (a specialist in conditions that affect the bones and joints). Some of the procedures used to treat frozen shoulder are described below.

Manipulation under anaesthetic

If you’re finding the pain and movement restriction difficult to cope with, you can have your shoulder manipulated (moved) while you’re under general anaesthetic.

During this procedure, your shoulder will be moved, in a controlled way, to stretch the sleeve (shoulder capsule) surrounding the shoulder joint.

After the procedure you’ll usually have corticosteroid and local anaesthetic injected into your shoulder joint to help reduce any pain or swelling.

You can normally go home the same day. Physiotherapy is usually recommended afterwards to help maintain mobility in your shoulder.

Arthroscopic capsular release

Arthroscopic capsular release is an alternative procedure to manipulation. It’s a type of minimally invasive or “keyhole” surgery, carried out under general anaesthetic, where two or three small incisions are made around your shoulder.

The surgeon will insert a thin tube containing a light and camera (arthroscope) into one of the incisions, so they can see inside your shoulder. A special probe that emits high-frequency radio waves is inserted through the other incisions, and this is used to divide or cut out the thickened parts of the shoulder capsule. Opening up the shoulder capsule in this way should greatly improve your range of movement.

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As with manipulation, you can usually go home the same day you have this operation, and you’ll probably need physiotherapy afterwards to help you regain a full range of movement in your shoulder joint. Stretching exercises need to be continued for at least three months after surgery.

Shoulder stiffness may return, despite manipulation or surgery, and further treatment may be necessary.

Arthrographic distension (hydrodilatation)

Although it’s less commonly performed than the operations described above, a procedure called arthrographic distension or hydrodilatation may sometimes be recommended to treat your frozen shoulder.

This treatment is carried out under local anaesthetic, which means you’ll be awake while it’s carried out, but your shoulder will be numbed.

It may be performed by a specialist orthopaedic surgeon using a local anaesthetic and corticosteroids, or saline with corticosteroids. X-ray guidance may sometimes be needed.

This procedure usually only takes about 15 minutes, and you can go home the same day. As with the other procedures described above, physiotherapy may be recommended afterwards to help you regain a good range of movement in your shoulder.

There’s some evidence that hydrodilatation may result in less pain and greater movement, although the effects may be no better than a corticosteroid injection.

http://www.nhs.uk/Conditions/Frozen-shoulder/Pages/Treatment.aspx 

Prophylaxis

One of the most common causes of frozen shoulder is the immobility that may result during recovery from a shoulder injury, broken arm or a stroke. If you’ve had an injury that makes it difficult to move your shoulder, talk to your doctor about exercises you can do to maintain the range of motion in your shoulder joint.

http://www.mayoclinic.org/diseases-conditions/frozen-shoulder/basics/prevention/con-20022510

Useful advice

Continue to use the involved shoulder and extremity as much as possible given your pain and range-of-motion limits. Applying heat or cold to your shoulder can help relieve pain.

http://www.mayoclinic.org/diseases-conditions/frozen-shoulder/basics/lifestyle-home-remedies/con-20022510 

Outcome 

Treatment with physical therapy and NSAIDs often restores motion and function of the shoulder within a year. Even untreated, the shoulder may get better by itself in 2 years.

After surgery restores motion, you must continue physical therapy for several weeks or months. This is to prevent the frozen shoulder from returning. If you do not keep up with physical therapy, the frozen shoulder may come back.

Complications

Complications may include:

  • Stiffness and pain continue even with therapy
  • The arm can break if the shoulder is moved forcefully during surgery

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