Frozen Shoulder

Adhesive capsulitis of shoulder (Frozen Shoulder)

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Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder 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.

Adhesive capsulitis is a painful and disabling condition that often causes great frustration for patients and caregivers due to slow recovery. Movement of the shoulder is severely restricted. Pain is usually constant, worse at night, and when the weather is colder; and along with the restricted movement can make even small tasks impossible. Certain movements or bumps can cause sudden onset of tremendous pain and cramping that can last several minutes.

This condition, for which an exact cause is unknown, can last from five months to three years or more and is thought in some cases to be caused by injury or trauma to the area. It is believed that it may have an autoimmune component, with the body attacking healthy tissue in the capsule. There is also a lack of fluid in the joint, further restricting movement.

In addition to difficulty with everyday tasks, people who suffer from adhesive capsulitis usually experience problems sleeping for extended periods due to pain that is worse at night and restricted movement/positions. The condition also can lead to depression, pain, and problems in the neck and back.

Risk factors for frozen shoulder include diabetes, stroke, accidents, lung disease, connective tissue disorders, thyroid disease and heart disease. The condition very rarely appears in people under 40.

Signs and diagnosis

One sign of a frozen shoulder is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. The movement that is most severely inhibited is external rotation of the shoulder.

People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion, or if bumped. A physical therapist may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder). An arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.

The normal course of a frozen shoulder has been described as having three stages:

  • Stage one: The “freezing” or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.
  • Stage two: The “frozen” or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to nine months.
  • Stage three: The “thawing” or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months.

Management

Management of this disorder focuses on restoring joint movement and reducing shoulder pain, involving medications, physical therapy, and/or surgical intervention. Treatment may continue for months, there is no strong evidence to favor any particular approach. Surgical evaluation of other problems with the shoulder, e.g., subacromial bursitis or rotator cuff tear may be needed.

Medications frequently used include NSAIDs; corticosteroids are used in some cases either through local injection or systemically. Physiotherapy may include massage therapy and daily extensive stretching.

If these measures are unsuccessful, manipulation of the shoulder under general anesthesia to break up the adhesions is sometimes used. Hydrodilatation or distension arthrography is controversial. Surgery to cut the adhesions (capsular release) may be indicated in prolonged and severe cases; the procedure is usually performed by arthroscopy.