Frozen shoulder (Adhesive Capsulitis) is a condition where a shoulder becomes very painful and stiff. Shoulder movements become reduced, sometimes completely 'frozen'. It is thought to be due to scar-like tissue forming in the shoulder capsule. Even without treatment, symptoms usually ease off but this may take up to two to three years. Here we look at the condition and the treatments available.
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Inside of a normal joint |
Inside of a “frozen” shoulder |
Scarring and thickening of joint capsule |
Frozen shoulder affects about one in 50 adults at some stage in their life. It most commonly occurs in people aged between 40 and 60 and is more common in diabetics. Either shoulder can be affected but most often it is the non-dominant shoulder. That is, the left shoulder in a right handed person. In about one in 5 cases the condition also develops in the other shoulder at some stage. Frozen shoulder is not a form of arthritis, and other joints are not affected.
What causes frozen shoulder?
The cause is not clear. It is thought that some scar tissue forms in the shoulder capsule, a thin tissue that covers and protects the shoulder joint. The scar tissue may cause the capsule to thicken, contract and limit the movement of the shoulder. The reason why the scar tissue forms is not known.
A frozen shoulder occasionally follows a shoulder injury, but this is not usual and in most cases occurs for no apparent reason.it
What are the 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 lying on the affected side.
Phase two - the 'frozen', stiff 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 but the movement most severely affected is usually the 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 5-24 months. The stiffness gradually goes and movement gradually returns to normal, or near normal.
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| Normal joint capsule - Upper Pic & Adhesions/ scarring
of joint capsule - Below Picture. |
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. In some cases it is much less. In a few cases, symptoms last for several years
What are the treatment options?
The aim of treatment is to ease pain and stiffness, and to keep the range of shoulder movement as much as possible whilst waiting for the condition to clear. One or more of the following may be advised to help ease and prevent symptoms.
Anti-inflammatory painkillers
Drugs such as ibuprofen, diclofenac, naproxen, etc. are commonly prescribed to ease pain. There are many different brands, so if one does not suit, another may be fine. Side-effects sometimes occur with anti-inflammatory painkillers.
Ordinary painkillers
Paracetamol or codeine may be an option if anti-inflammatory painkillers do not suit. These do not have any anti-inflammatory action, but are good painkillers. Constipation is a common side-effect from codeine. You can take painkillers in addition to other treatments.
Shoulder exercises
These are commonly advised, the aim being to keep the shoulder from 'stiffening up', and to keep movement as full as possible. It is important to do the exercises regularly, as instructed by a doctor or physiotherapist.
Physiotherapy
Many people are referred to a physiotherapist who can give expert advice on the best exercises to do. Also, they may try other pain relieving techniques such as heat, cold, TENS machines, etc.
Steroid injection
An injection into, or near to, the shoulder joint brings good relief of symptoms for several weeks in some cases. Steroids reduce inflammation. It is not a 'cure' as symptoms tend to gradually return, but many people welcome the relief that a steroid injection can bring.
Nerve block
This is a technique that a specialist may try. This is an injection to block the nerves that send pain messages from the shoulder. Like a steroid injection, it often eases symptoms for a while, but it is not usually a cure.
Hydrodistension
Again, this is a technique that a specialist may try. This is a procedure where the joint space is expanded (distended) by injecting a liquid. In one study, saline (salt water) mixed with a steroid injected into the painful shoulder improved symptoms in a number of cases.
Surgery
An operation is sometimes considered if other treatments do not help. Techniques that are used include:
Manipulation. This is a procedure where the shoulder is moved around by the surgeon while the patient is under anaesthetic.
Arthroscopic capsular release. This is a relatively small operation, done as 'keyhole' surgery. It is often done as a day-case procedure. Here the tight capsule of the joint is released with a special probe. One recent research study showed that this procedure gave about an 8 in 10 chance of greatly improving symptoms. Because of the encouraging results of this research study, it may become a more popular treatment.
(The writer is Consultant Rheumatologist, Sri Jayewardenepura General Hospital) |
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