About 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. Often, it occurs in patients around 50 years of age, hence, the Chinese term “50-year shoulder”.
Causes of Frozen Shoulder
Most often, a frozen shoulder occurs with no associated obvious injury or discernible cause. There are patients who develop a frozen shoulder after a traumatic injury to the shoulder, but this is not the usual cause. Most patients do not have trauma to their shoulder.
Normally, the shoulder joint allows more motion than any other joint in the body. When a patient develops a frozen shoulder, the capsule that surrounds the shoulder joint becomes stiff, scarred and contracted. They form bands of scar tissue called adhesions. The contraction of the capsule and the formation of the adhesions cause the frozen shoulder to become stiff and cause movement to become painful.
Other shoulder conditions can cause difficulty with movement of the shoulder, such as a rotator cuff tear. Therefore, it is important to see a specialist familiar with this condition for a proper diagnosis. This has to be excluded, as the treatment plan is very different in terms of whether to rest or to actively rehabilitate.
Symptoms of Frozen Shoulder
- Pain; usually a dull, aching pain, typically associated with movement
- Limited movement of the shoulder (either backwards or upwards)
- Difficulty with activities, such as brushing hair, putting on shirts/bras
- Pain when trying to sleep on the affected shoulder
Stages of Frozen Shoulder
Painful / Freezing stage
This is the most painful stage of a frozen shoulder. Motion is restricted, but the shoulder is not as stiff as the frozen stage. This painful stage typically lasts 6-12 weeks.
During the frozen stage, the pain usually eases up, but the stiffness worsens. The frozen stage can last 4-6 months. Sometimes, the stiffness and spasm are so bad that they form contractures of the upper limb.
Thawing stage (This may not necessarily happen)
The thawing stage is gradual, and motion steadily improves over a lengthy period of time. The thawing stage can last more than 2 years. Some patients do not recover at all. The stiffness and contractures will become permanent.
The primary aim of frozen shoulder treatment is pain relief and physical therapy. The cornerstone of frozen shoulder management is to restore movement to the shoulder joint. Most patients find relief with these simple steps, although the entire treatment process can take several months or longer.
Exercise and Stretching
Stretching exercises for a frozen shoulder serve two functions:
- to increase the motion in the joint
- to minimize the loss of muscle on the affected arm (muscle atrophy)
The importance of stretching and exercises cannot be overemphasized as these are the key to successful frozen shoulder treatment. Patients cannot expect to have successful frozen shoulder treatment if they perform exercises only when working with a therapist. These exercises and stretches must be performed several times daily.
Patient is to stand sideways to a wall, with the affected arm facing the wall. Then, abduct the arm by climbing the fingers upwards on the wall. Alternatively, the “wiping” motion of cleaning a table using a table cloth in a circular motion is also useful.
Physical therapists can help a patient develop a stretching and exercise program, and also incorporate ultrasound, ice, heat and other modalities into the rehabilitation for a frozen shoulder. As said previously, it is important that patients perform their stretches and exercise several times daily – not only when working with the therapist.
Applications of moist or dry heat to the shoulder can help to loosen the joint and provide relief of pain. Patients can apply moist heat to the shoulder, then perform their stretching exercises. This should be done at least three times daily. Moist heat can be applied by using a hot-soaked washcloth or hot pack on the joint for 10 minutes before stretching. Dry heat could be applied using an infra-red lamp.
Anti-inflammatory medications have not been shown to significantly alter the course of a frozen shoulder. Even though painkillers are used in its treatment, the pain relief may not be satisfactory.
Instead, muscle relaxants like Alprazolam and Lyrica may be helpful in offering relief from the painful symptoms.
Nerve Block and Cortisone Injection
Nerve blocks are performed to stop the painful cycle and allow for the inflammation in the shoulder joint to subside. Once the pain abates, the patient can then participate in active rehabilitation and physical therapy. This is often done early to have effective pain relief and good outcomes.
Cortisone injections are also commonly used to decrease the inflammation in the frozen shoulder joint. They can help to decrease pain, and, in turn, allow for more stretching and physical therapy. These injections are done to the muscles and ligaments, and not into the joint.
Will patient need surgery for a frozen shoulder?
If the above treatments do not resolve the frozen shoulder, occasionally, a patient will need to have surgery. If this is the case, the surgeon may perform a manipulation under anaesthesia. A manipulation is performed with the patient sedated under anaesthesia, and the doctor moves the arm to break up adhesions caused by a frozen shoulder. There is no actual surgery involved, meaning incisions are not made when a manipulation is performed.
Alternatively, or in conjunction with a manipulation, an arthroscope can be inserted into the joint to cut through adhesions. This procedure is called an arthroscopic capsular release. Surgical capsular release of a frozen shoulder is rarely necessary, but it is extremely useful in cases of frozen shoulder that do not respond to therapy and rehab. If surgery is performed, immediate physical therapy following the capsular release is of utmost importance. If rehab does not begin soon after capsular release, the chance of the frozen shoulder returning is quite high.
Will the shoulder motion return to normal?
Most patients who have a frozen shoulder will have slight limitations in shoulder motion, even years after the condition resolves. However, this limit in motion is minimal, and often only noticed when performing a careful physical examination. The vast majority of patients who develop a frozen shoulder will recover their functional motion with therapy and stretching alone.