Treatment of Frozen Shoulder

   As this condition involves inflammation with subsequent thickening and scarring of the shoulder capsule (the tissue which envelopes the joint), the main problem that most patients face is stiffness of the affected shoulder. Almost all movements will be restricted and their daily activities will be disturbed by this limitation in movement. Overhead activities (wiping the windows, combing hair, playing racket sports) will be difficult and, in the early stage, painful. The patients will also find it difficult to wash or scratch their own back, and strapping bras for ladies will be a nightmare.

   After a careful evaluation and after ruling out other causes, the Doctor will usually start the treatment by thoroughly explaining the condition - it is very important for patients to realize that frozen shoulder is a SELF-LIMITTING condition, meaning that the condition will improve by itself after a period of time even without treatment. Nevertheless, certain situations will need to be treated by surgical means, as will be described later.

   Treatment starts with physical therapy (range of motion exercises). This is the mainstay or the gold standard in all frozen shoulder conditions. Physical therapy ensures that the patient will continue to move the joint despite having a painful shoulder. This is particularly important in the second stage of this condition where the stiffness will be at its maximum and even though the pain is subsiding.

   Passive stretching of the joint in all directions using the opposite limb is done 3-4 times a day, every day. Assistive devices such as a towel, table or wall, and a broom- or walking-stick could also be used to provide maximum effect (see picture).

   Pain can be treated by heat therapy, or analgesics usually prescribed by the treating doctor. This is often unnecessary unless the pain is unbearable and is very much disturbing daily activities. Long-term intake of analgesics is often discouraged.

   In conditions where the stiffness cannot be overcome even with frequent stretching exercises, manipulation of the shoulder (where the surgeon will 'break' the thickened capsular tissue by forced movement under general anesthesia) is an option. Often a surgery is not needed after this procedure, unless the stiffness is persistent. In this rare instance, the surgeon will perform an arthroscopic capsular release whereby the thickened capsule is divided under direct vision (using an arthroscope - see picture below).

An arthroscopic image of the divided capsule (white tissue on the top right area) exposing the underlying muscles (red color).

  

Please visit your Orthopedic Surgeon for further information on this condition.

Shoulder Pain in a 50-year-old Lady

Madam S is a 50-year-old government servant who came to see me about a year ago with a complaint of right shoulder pain for 3 months' duration. The pain started as vague discomfort in her shoulder whenever she does overhead activities such as wiping her house windows, combing her hair or hanging clothes at home. She also has pain in the shoulder whenever she lies on the affected shoulder at night.

Lately, she thinks that the pain had gotten worse as she also started to have pain even on slight movement in her shoulder while doing her administrative work at the office. She found it difficult to button her bra and also to clean her back while bathing.

Madam S was diagnosed to have diabetes mellitus 3 years ago when routine blood checks revealed that she had elevated fasting blood glucose. She has quite a strong family history of diabetes, with her late father and two brothers were diagnosed to have diabetes.

Examination of her shoulder revealed subtle reduction in movement in her shoulder especially when she was asked to touch her back. Otherwise the examination was unremarkable.

Her X-rays were normal.

“What's wrong with my shoulder Doc?” she asked with a rather concerned face. “Does this condition have something to do with my diabetes? Is it an infection Doc?”

Answer :


This lady was suffering from 'frozen shoulder' - a condition caused by inflammatory shrinking and thickening in the shoulder capsular tissue (the encasing tissue of the shoulder joint).  The inflammation causes the shoulder to become increasingly painful, and, with time, the shoulder becomes stiff and it will be quite difficult to move the affected shoulder in almost all directions. 


The causes of frozen shoulder are :

1. Unknown cause - this condition is also called 'adhesive capsulitis'; in the majority of cases the cause is not identified but there is an association with certain medical conditions such as diabetes mellitus, ischemic heart disease, thyroid gland problems (hyper or hypo-) and Parkinson's disease (a neurological condition that is progressive and characterized by involuntary movements and generalized rigidity of joints). 
   This type of frozen shoulder affects around 2% of the population and typically involves those in the 40-60 years age group. Women are more commonly affected than men.


2. Prolonged immobilization - patients with shoulder injury particularly fractures or dislocations involving or near the shoulder that was operated upon or managed by immobilizing the shoulder joint has a high risk of developing this type of frozen shoulder. 


3. Irradiation to the shoulder region - patients who received radiation therapy (e.g. in breast cancer patients) may also develop this condition.


4. Secondary to a specific shoulder problem for example in shoulder impingement syndrome. Impingement syndrome occurs as a result of tightening of space for the tendons of the shoulder to move, making overhead movements painful and limited. As a result of patients not moving their shoulder due to this pain, the shoulder gets stiffened and a 'secondary' frozen shoulder results.
   A tear in the tendon of shoulder movement (termed rotator cuff tear) may also result in secondary frozen shoulder. 




Stages of Frozen Shoulder 

Frozen shoulder has three stages - these stages tend to overlap and could take as long as two years to resolve even with proper treatment. 


Stage I - 'freezing stage', characterized by increasing pain in the shoulder with movement; however shoulder motion is only mildly affected. This stage lasts from 2 to 4 months.


Stage II - 'frozen stage'. As  the name denotes, the main feature of this stage is stiffness of the shoulder, pain is slowly improving despite worsening in stiffness. The first movement to be affected is inward movement of the arm (for example - difficulty in scratching one's back or strapping the bra), however in advanced stage II all movements are restricted. Duration - 4 months to 1 year.


Stage III - 'thawing stage'. Pain is completely alleviated and stiffness improves during this final stage. This stage takes a year or longer to complete.




** Next week, DocNiz will describe the management options for this condition. Please visit this website again next week
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