Frozen shoulder

What is Frozen shoulder?

Frozen shoulder or adhesive capsulitis is a painful condition of the shoulder, associated with stiffness. The pain could be so bad that it affects your sleep and activities of daily living. Neither you nor your physician can move the affected joint freely. It is also called as retractile capsulitis, adhesive capsulitis, check rein shoulder, contracted shoulder and steroid-sensitive arthritis. It usually affects people aged between 40 and 60 years and is common in women. It commonly affects people with diabetes (10-36%) and does not respond well to treatment in this selected group of patients. It affects the other shoulder in 6-17% of patients within 5 years. Most of the cases are idiopathic, however it could occur secondarily to trauma, rotator cuff disease, impingement, cardiovascular disease, surgery of chest or breast, inflammatory arthritis, hormonal imbalance, thyroid problems, immobilisation, Parkinson’s disease and stroke.

In this condition, the capsule around your shoulder joint becomes inflamed, thicker and tighter with scarring and less flexibility.  The joint capsular volume reduces from a normal value of 10-15 ml to 3-4 ml in patients with Frozen shoulder.

 

What are the symptoms of Frozen shoulder?

The symptoms of Frozen shoulder can be divided into three phases-

  • Phase 1 (Pain predominant)- it starts with severe pain in the shoulder joint with gradual loss of mobility. It usually lasts between 2 and 9 months.
  • Phase 2 (Stiffness predominant)- you may feel less pain in this phase, but you can’t move the joint freely in all direction due to stiffness. There can be only a 50% or less movement of the joint. It will affect your day to day activities and lasts from 4 to 12 months.
  • Phase 3 (Resolution)- it is also called as thawing phase. This phase lasts from 12 months to 42 months and the movements will gradually return back with resolution of pain and stiffness.

 

How is it diagnosed?

For the diagnosis of Adhesive capsulitis, your surgeon will ask you about the history of your health and he will perform a physical exam to observe specific movements and measure your joint’s range of motion. An X-ray is done to check for arthritis and rarely your surgeon might suggest MRI (Magnetic Resonance Imaging Scan) to asses the extent of the ailment and rule out associated shoulder problems.

 

What happens if nothing is done?

In the past this disease was considered as a self-limiting condition, however various studies with longer term follow-up have shown otherwise. Based on the results of largest published series to date, 59% recovered completely, 35% had mild to moderate symptoms and 6% had severe symptoms at follow-up of 4.4years from onset.

 

How is it treated?

The treatment of Frozen Shoulder depends on your severity of pain, limitation of the movement, handedness and occupation/hobbies. Generally patients have conservative treatment in early stages and in recalcitrant cases surgery could be of benefit..

The conservative treatment includes

  • Painkillers –NSAIDS, Paracetamol
  • Physiotherapy
  • steroid injections and
  • Hydrodistension or capsular dilatation.

Surgery is indicated in

  • Failure of conservative treatment
  • Chronic shoulder stiffness
  • Diabetic patients in whom steroid therapy is contradicted

 

What are the non-operative treatments?

Most patients (90%) recover from the condition through non-operative treatments. It includes

  • steroid injections and
  • Hydrodistension or capsular dilatation.
  • Painkillers like paracetamol, and codeine are prescribed to get relief from the pain.

Anti-inflammatory drugs such as aspirin and ibuprofen are effective in reducing the swelling due to inflammation and pain.

  • Injections of steroids such as Triamcinolone (an anti-inflammatory medicine) are given directly to your shoulder joint.
  • Physiotherapy can restore motion of the shoulder joint. It focuses on stretching or range of motion exercises to release the stiffness. Moist heat is often applied on the shoulder before stretching. These exercises include
  1. Crossover arm stretch: Pull the affected arm (holding upper arm) across in front of you, under the chin and hold for 30 seconds. Repeat this with breaks.
  2. Pendulum exercises: Lean forward to allow the arm to hang down. Swing the arm in a circular motion of around a foot diameter – 10 clockwise and 10 anticlockwise.
  3. Towel stretch: place the towel behind your back and grab the ends with both hands. Use the good hand to pull the towel upwards to stretch the affected shoulder – 10 times.
  4. Finger walk: stand 3/4ths of arm length from wall, use your palm to rest on the wall at waist level and gradually climb with your fingers – 10 times.
  5. Armpit stretch: Place the affected arm on to a shelf about chest high. Bend knees to stretch your armpit 10 times a day.
  • Your doctor can refer you for hydro dilatation if other non-operative methods fail to relief. This is a procedure of injection of a large amount of sterile fluid in the affected shoulder joint with the help of an X-ray/Ultrasound to break the adhesions and to stretch and expand the capsule of the shoulder joint.
  • Acupuncture, Transcutaneous Electrical Nerve stimulation (TENS)

 

What does the operation involve?

Surgery in Frozen shoulder is usually performed in Stage 2. The aim of the surgery is to stretch and release the capsule of the affected shoulder joint.

  • The operation is performed under general anaesthesia. The contracted shoulder capsule can be released by manipulation under anaesthesia or shoulder arthroscopy (capsular release) or both.
  • Shoulder manipulation: Though its commonly performed, its uncontrolled and studies have shown that this could damage other vital structures in the shoulder. Besides its not safe in post traumatic frozen shoulder and and as effective as key hole surgery in diabetics.
  • Arthroscopic capsular release (Author’s preferred treatment) –The ACR is safe controlled and minimally invasive procedure. Through 2-3 keyholes, the inflammatory material is removed, capsule released, and usually full mobility is achieved at the end of procedure.
  • The skin is stitched using absorbable sutures and an arm sling may be applied for 1 week, and you are allowed to mobilise as tolerated.

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What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts for at least 48 hours from there. This way most of our patients report little or any pain.
  • Cold compression packs (bag of frozen peas) can help with the pain.
  • The patients will be seen by the therapists before surgery and taught exercises that need to be done post surgery. These exercises should be regularly done to prevent further adhesions/contracture.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness helps scar to mature).
  • Patients are encouraged to return to pre-injury level of activities as early as they could.
  • Physiotherapy is important to regain normal functioning and mobility of the shoulder.

 

Are there any risks?

You can have the following risks after surgery (<5%)-

  • Infection
  • Axillary nerve injury
  • Chondral injury
  • Rotator cuff tendon disruption
  • Recurrent stiffness
  • Fracture or dislocation
  • Excess Loosening of the joint
  • Labial tears
  • Brachial plexus injury

 

What are the results of the operation?

Arthroscopic capsular release has consistently shown good to excellent outcomes in 90 % of the cases. Most patients report no pain and improved range of motion. The diabetic patient may have some stiffness left after surgery. The outcome is more predictable in the author’s experience.

 

When can I return to driving and work?

When you are comfortable and in control of your shoulder, you could return back to work and driving. This usually is after 2-4weeks from surgery. The recovery could be prolonged in patients with diabetes and those with severe symptoms before surgery, your surgeon can advise you more accurately.

Frozen shoulder

  1. Normal shoulder capsule
  2. Frozen shoulder – Inflamed capsule, leads to severe pain and stiffness.

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