Frozen shoulder, or adhesive capsulitis is a common condition affecting people generally between the ages of 40-65, especially in people with a history of diabetes, thyroid problems, Parkinson’s, or cardiac disease. Patients with frozen shoulder have progressive loss of range of motion and pain with any motion of the affected shoulder.
The shoulder is a ball and socket joint, but the anatomy of the shoulder allows for an amazing amount of flexibility. The humeral head, or ball, sits on the glenoid, a very shallow socket. It resembles a golf ball on a tee. Because the socket is so shallow, the shoulder relies on the soft tissue around the shoulder for stability. The labrum, a thickened cartilage layer around the glenoid, and the ligaments and capsule, provide a majority of the stability to the shoulder. The muscles of the rotator cuff and scapula also provide stability.
Patients with frozen shoulder usually have increasing pain as their shoulder loses motion. The pain is often exacerbated by quick motions of the shoulder. The shoulder becomes more painful as the stiffness worsens, and it is difficult even for other people to move the shoulder. Diagnosis is usually made by physical exam. Radiographs and MRI are often obtained to rule out other problems in the shoulder.
Frozen shoulder causes
Inflammation: Inflammation causes parts of the joint capsule in the shoulder joint to become fibrotic, reducing the volume of the shoulder joint, limiting the shoulder’s ability to move and causing the shoulder to freeze.
No obvious cause: Frozen shoulder can happen with no obvious cause, which is known as primary frozen shoulder.
The cause of frozen shoulder is not understood. Patients with frozen shoulder have thickening of the capsule around the shoulder, which leads to pain and loss of motion. It is more common in diabetics, patients with thyroid disease, and patients who have had a previous shoulder injury and have been immobilized.
Stage 1: “Freezing” Stage:
Characterized by a slow increase in pain, sometimes brought on by an apparently minor trauma. As the pain worsens, the shoulder loses motion.
Stage 2: “Frozen” Stage:
The pain improves, but the stiffness remains.
Stage 3: “Thawing” Stage:
Shoulder motion slowly returns to normal.
Stage 1 can last from 1 month to 9 months; stage 2 from 4 to 9 months, and stage 3 from 5 months to 2 years.
Frozen shoulder is a condition that results in loss of motion and pain or stiffness in the shoulder. The pain and loss of movement can be so severe that the performance of daily activities can become difficult. Also known as adhesive capsulitis, it most commonly affects adults between the ages of 40 and 60 years.
Frozen shoulder risk factors
Primary frozen shoulder is associated with several risk factors, including:
- Age & gender: It tends to affect adults over 40 years and is more common in women.
- Diseases & illnesses: Frozen shoulder also tends to occur more frequently in patients with endocrine disorders such as diabetes, cardiac disease or thyroid problems, Parkinson’s disease or if you have undergone surgery.
- Immobility: In secondary frozen shoulder, this can occur commonly after prolonged immobilisation of the shoulder after injury, or due to pain that limits shoulder motion (such as after injury to the rotator cuff muscles of the shoulder) eventually leading to this disease.
Frozen shoulder symptoms
The most obvious symptoms are shoulder pain and a limited range of motion in the shoulder.
You may also have difficulties moving the shoulder normally and engaging in daily activities such as reaching across the table, putting on a shirt and overhead motions like combing hair. Motion is also limited on both passive and active motion.
Often, in the early stages, pain is a predominant symptom, and can affect sleep.
Frozen shoulder diagnosis
A frozen shoulder can be diagnosed on the basis of medical history and clinical examination. An x-ray or MRI can be used to rule out other causes such as arthritis and rotator cuff tears.
Frozen shoulder treatment
The initial aim of treatment for frozen shoulder is to reduce pain and inflammation as well as increase the range of motion of the shoulder. The course of treatment normally includes medications such as anti-inflammatory drugs. An injection of steroids to reduce the inflammation can sometimes be given. Physical therapy is most useful in restoring full range of motion to the shoulder.
If the frozen shoulder does not respond to non-surgical treatment, then surgery to release or stretch the scar tissue is an option. The most common methods include manipulation under anaesthesia and shoulder arthroscopy.
Manipulation, under anaesthesia, allows the surgeon to move the arm to break up the adhesions. No incisions are made.
In shoulder arthroscopy, a small camera and instruments are inserted through the small incisions made around the shoulder to cut through the tight portions of the joint capsule. Physiotherapy must follow the surgery to minimise the chance of the frozen shoulder returning.
What is Frozen shoulder?
Frozen shoulder is essentially a chronic fibrosing condition in which the fibroblast cells become overactive and lay down abnormally thick layers of collagen causing a marked thickening of the shoulder joint capsule. This capsular lining of the joint subsequently contracts and leads to shoulder stiffness and pain
What are the medical terms for this condition?
Various terms such as adhesive capsulitis, scapulohumeral periarthritis and checkrein shoulder have been used to describe this poorly understood disorder of the glenohumeral joint
What are the features of frozen shoulder?
The classical features of frozen shoulder were described by Codman in 1934 who described a condition characterised by a slow onset of pain, felt near the insertion of the deltoid, with inability to sleep on the affected side and restriction in both active and passive elevation and external rotation, yet with a normal radiographic appearance. Although this description was made more than 70 years ago, it is probably still the most accurate and comprehensive account
What is primary and secondary frozen shoulder?
Primary frozen shoulder occurs without any known precipitating cause. Secondary frozen shoulder arises as a result of an underlying problem such as fracture, tendon injury, labral tear or a systemic condition
What systemic conditions are commonly associated with frozen shoulder?
These include diabetes, dupuytrens contracture, thyroid disorders, hyperlipidaemia, heart and chest disease such as bronchitis. The incidence of frozen shoulder in diabetic patients is as high as 36%
Who gets frozen shoulder typically?
Frozen shoulder occurs more commonly in women than men and has its highest incidence in the age group 35-60. About 15-20% of people get it on both sides
How do you diagnose frozen shoulder?
The diagnosis of frozen shoulder is made during the clinical examination. An isolated loss of external rotation is the key to diagnosis. There are no specific blood tests or radiographic examinations needed to make the diagnosis. Ultrasound or MRI scans are not necessary to make the diagnosis but may help to exclude structural problem within the shoulder such as a torn tendon
What treatment options are available?
The treatment options include:
- Non steroidal anti-inflammatory drugs
- Ice packs
- Steroid Injection
- Surgery – arthroscopic contracture release
What does surgery involve?
Surgery involves a gentle manipulation under anaesthetic, followed by key hole surgery in which two to three little stab incisions (about 0.5 to 1cm each in size) are made around the shoulder. Through these arthroscopic portals, the camera as well as a variety of surgical instruments is inserted into the shoulder and the layers of thickened scar tissue inside the shoulder are divided under direct magnified vision
What is the recovery like after surgery?
The operation can be carried out as a day case procedure with no need to stay overnight in hospital. There is no need to wear a sling afterwards and there is no restriction on activity. Physiotherapy can start as soon as possible
What is the natural history of frozen shoulder?
Frozen shoulder is typically said to progresses through 3 stages over a period of about 2-3 years. The first stage is the Painful stage (1-8 months) characterised by severe pain on any movement of the shoulder, worse particularly at night. Simple daily tasks such as combing the hair, reaching to the back trousers pocket or scratching the back from behind becomes progressively more difficult. The second stage is the Frozen stage (9-16 months) in which pain starts to decrease in intensity but the shoulder is becoming stiff and the range of movements is noticeably less. The third and final stage is the Thawing stage (12-40 months) in which the range of movement starts to improve
Do all frozen shoulders get better on their own?
Traditionally, it was believed that frozen shoulder is a self limiting condition which resolves spontaneously after a period of 2 to 3 years. Recent studies have shown that up to 50% of patients have an incomplete recovery with persistent pain and stiffness even after a period of 7 years. (B Shaffer Journal of Bone and Joint Surgery)
When is surgery indicated?
Most people would agree that if you have tried and not responded to anti-inflammatory drugs, corticosteroid injections as well as physiotherapy, then surgery can be considered. It must be noted that surgery is not a ‘quick fix’ but it can reduce the intensity of the pain and expedite the recovery process