FROZEN SHOULDER

Frozen shoulder, or adhesive capsulitis, is a condition that causes restriction of motion in the shoulder joint. The cause of a frozen shoulder is not well understood, but it often occurs for no known reason. Frozen shoulder causes the capsule surrounding the shoulder joint to contract and form scar tissue.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).
The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.
To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

Risks.

Although the exact cause is unknown, certain factors may increase your risk of developing frozen shoulder.

Age and sex

People 40 and older are more likely to experience frozen shoulder. Most of the people who develop the condition are women.

Immobility or reduced mobility

People who have experienced prolonged immobility or reduced mobility of their shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including:

• Rotator cuff injury
• Broken arm
• Stroke
• Recovery from surgery

Systemic diseases

People who have certain medical problems appear to be predisposed to develop frozen shoulder. Examples include:

• Diabetes
• Overactive thyroid (hyperthyroidism)
• Underactive thyroid (hypothyroidism)
• Cardiovascular disease
• Tuberculosis
• Parkinson's disease

Causes.

Frozen shoulder is caused when the flexible tissue that surrounds the shoulder joint, known as the capsule, becomes inflamed and thickened.

It is not fully understood why this happens, although there are a number of things that make developing a frozen shoulder more likely. These include having:

• a shoulder injury or shoulder surgery
• diabetes 
• Dupuytren's contracture - a condition where small lumps of thickened tissue form in the hands and fingers
• other health conditions, such as heart diseaseand  stroke

Symptoms

The typical symptoms are pain, stiffness, and limitation in the range of movement of a shoulder. The symptoms typically have three phases:

• Phase one - the 'freezing', painful phase. This typically lasts 2-9 months. The first symptom is usually pain. Stiffness and limitation in movement then also gradually build up. The pain is typically worse at night and when you lie on the affected side.
• Phase two - the 'frozen', stiff (or adhesive) phase. This typically lasts 4-12 months. Pain gradually eases but stiffness and limitation in movement remain and can get worse. All movements of the shoulder are affected. However, the movement most severely affected is usually rotation of the arm outwards. The muscles around the shoulder may waste a bit as they are not used.
• Phase three - the 'thawing', recovery phase. This typically lasts between one and three years. The pain and stiffness gradually go and movement gradually returns to normal, or near normal.

Symptoms often interfere with everyday tasks such as driving, dressing, or sleeping. Even scratching your back, or putting your hand in a rear pocket, may become impossible. Work may be affected in some cases.

There is great variation in the severity and length of symptoms. Untreated, on average the symptoms last 2-3 years in total before going. In some cases, it is much less than this. In a minority of cases, symptoms last for several years.

Diagnosis

A frozen shoulder is suggested during examination when the shoulder range of motion is significantly limited, with either the patient or the examiner attempting the movement. Underlying diseases involving the shoulder can be diagnosed with the history, examination, blood testing, and X-ray examination of the shoulder.

If necessary, the diagnosis can be confirmed when an X-ray contrast dye is injected into the shoulder joint to demonstrate the characteristic shrunken shoulder capsule of a frozen shoulder. This X-ray test is called arthrography. The tissues of the shoulder can also be evaluated with an MRI scan.

Treatment.

If nothing is done most frozen shoulders improve significantly over 2-4 years after onset. However the pain and limitations of the stiff shoulder generally require treatment. The treatment required depends on the severity of the pain and stiffness. These include:

1. Physiotherapy - to prevent any further stiffness and regain range of motion
2. Painkillers and anti-inflammatories
3. Injections - reduce inflammation and provide pain relief
4. Hydrodilatation Procedure - more effective than simple injections in relieving severe pain and improving range of motion
5. Surgery - Surgery has been shown to be of benefit in both the early and later stages of a Frozen Shoulder. This may involve an arthroscopic Capsular Release or Manipulation Under Anaesthetic (MUA). We prefer the Capsular Release procedure. It is excellent for both pain relief and restoring movement, with a success rate of 96% at 6 months. Intensive physiotherapy is essential after the surgery.

Please Note

When the shoulder pain is severe:

• Avoid using the affected side to lift heavy objects.
• Avoid overuse of the same side. Use both shoulders alternatively.
• Avoid twisting movement of the joint or sleeping on the affected side.
• Avoid using the affected hand to do self-care activities.
• Gentle mobilization exercise like "Pendular exercise" can be performed to improve circulation, relax muscle and relief pain. When performing the exercise, the hand should not carry any weight and the arm should move according to the level of pain.

When pain is relieved, but movement of shoulder is still restricted, we should:

1. Use the affected side more and perform stretching exercise to decrease stiffness.
2. Consult health professional for maintenance exercise.