Frozen Shoulder

Introduction.

If you have developed shoulder pain out of the blue you might suffer from frozen shoulder syndrome, also called adhesive Capsulitis. This is a painful shoulder condition which is not fully understood. What is certain is that it can have a very aggressive progress and can lead to a severe disabling condition. However, there is hope if the condition is under stood and managed correctly..

Pathology:

The shoulder is a ball and socket joint; the socket is called the glenoid and the ball is the humeral head. The joint is contained within a sack like structure that contains the fluid in the joint ‘this is called the capsule of the joint. This lining gets an inflammation of some sort without any clear reason. This acute inflammation causes the pain. When the inflammation subsides the capsule contracts and the fibres in the capsule shortens, this leads to stiffness and loss of movement of the joint. Eventually the capsule stretches out again and the joint regains its movements. The good news there is that the condition is self limiting and self healing. But it can take a long time, up to 15 months in some cases..

Clinical picture.

It’s therefore clear that the condition has 3 stages..

I.Pain.

This is the acute in inflammatory phase and the patient has severe pain during this phase. The pain can be severely disabling and the patient usually seek medical help during this phase. The correct diagnosis should be made at this stage. This is critically important and it is advised to consult with a properly trained physician to make the correct diagnosis. Frozen shoulder can worsen if for an example the wrong diagnosis is made and the shoulder be operated. Unnecessary surgery will worsen the frozen shoulder. It is very difficult to distinguish between early frozen shoulder and conditions like shoulder impingement. (See diagnosis). It is difficult for the doctor to comfort the patient and to convince the patient that the diagnosis is correct and the treatment is conservatively. The patient usually seeks second opinion during this phase of the disease..

II.Stiffness

During this phase the pain subsides spontaneously but because of the fibrosis the shoulder gets progressively stiff. The stiffness can be severe and the patient can’t lift the arm to reach the head or behind the back. In spite of the disabling stiffness the patients become more relaxed and feel better simply because the pain has subsided. They accept the severe stiffness and are usually just too thankful for a good nights rest without pain..

III.Healing

During this phase the stiffness now subsides and the joint now gradually regains it movement. All the pain has now subsided. The residual stiffness can last for a prolonged period of time, up to 18 months in some cases. Patients accept this, just being so thankful the pain has gone..

Note that not all frozen shouldest take this aggressive route, they come in different degrees of the problem. Some come and go quickly, without severe symptoms. Some come severely and stay for or prolonged period of time, Just hope you have a “friendly” form of the disease. Only time car tell how bad yours will be..

Diagnosis..

Diagnosing this condition can be difficult. It mimic other conditions like shoulder impingement, thoracic outlet syndrome and rotator cuff tears. The give away hower is some form of restricted movement of the shoulder when compared to the normal shoulder. You need a skilled physician, preferably a shoulder surgeon to access and diagnose the problem. Investigations like X ray, ct Scans, MR Scans does nut contribute to the diagnosis and are usually unnecessary. Frozen shoulder is associated with diabetes and should be suspected in patients suffering from diabetes. Also somebody who develops a frozen shoulder should be investigated for underlaying diabetes mellitus. The same apply for an under active thyroid gland. Therefore these patients should be examined for hypothyroidism. It should also be noted that frozen shoulder or adhesive Capsulitis might arise after a minor shoulder injury – should this happen it is very difficult to convince the patient that nothing should be done as they suspect the injury as having caused the problem and will try to put it down to the injury. The condition is also related to cardiac surgery. For instance patients can develop frozen shoulder after placement of a pacemaker. Often the patients believe that the shoulder was injured during the anaesthetic and blame the surgical team. The reason why frozen shoulder can set in after cardiac surgery is not known. This is however well recognised..

Treatment.

Many treatment modalities are aviable and it is very difficult to make sense of what is useful or not. The principles are not difficult to understand. During the acute phase (stage 1 and 2) the focus is on the pain management and to handle the acute problem. This includes the patients emotional status as this disease can put severe strain on the patient as well as the rest of the family. It gives severe sleeping problems and also depression. The assumption that patients suffering from frozen shoulder have some underlaying emotional disorder is wrong. The true fact is that this disease might cause the patient emotional problems in the form of depression and sleep disturbance. Therefore the medication needed is usually directed to pain relieve, sleeping tablets and anti depressants if necessary. Also cortisone injection into the joint will relieve pain and inflammation. Anti inflammatory drug may be of value. Surgery is not indicated during this phase as the pain and stiffness will only recur. Physiotherapy and shoulder exercises are directed to pain relieve and to retain some motion but due to the severe pain it is almost impossible to keep the shoulder mobile. However it is worthwhile to try and keep the shoulder mobile..

During stage 3 the focus changes to regain movement as the pain is not a factor any move. The cornerstone now is stretching exercises and proper shoulder rehab exercises. During this phase one can also consider to do a surgical release of the capsule, with arthroscopic shoulder surgery (keyhole surgery). As the inflammatory phase has gone the chances of being successful is much better than earlier during the disease phase. Simple manipulation of the joint under anaesthesia is not advised as it is a relatively uncontrolled rupture of the capsule and arthroscopic shoulder surgery is much more controlled and less damaging..

Conclusion:.

Your frozen shoulder might not necessarily take the aggressive route and might ease of easily, and we all hope it does. If you do progress to a severe problem ensure that you consult with people that has the knowledge and experience to help you as best as possible.

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