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Frozen Shoulder

DESCRIPTION

Frozen shoulder (also known as adhesive capsulitis) is a disorder characterized by pain and stiffness in the shoulder.

It affects about two percent of the general population. It is more common in women between the ages of 40 and 70 years.

The causes of frozen shoulder are not fully understood. It usually develops spontaneously.

The process involves thickening and contracture of the capsule surrounding the shoulder joint.

Frozen shoulder is diagnosed based on the history of the patient’s symptoms and physical examination.

An MRI scan may show thickening of the capsule.

RISK FACTORS/PREVENTION

Frozen shoulder occurs much more commonly in individuals with diabetes.

Other medical problems associated with increased risk of frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson’s disease, cardiac disease or surgery on the shoulder, neck or breast.

Frozen shoulder can develop after a shoulder is immobilised for a period of time. To prevent frozen shoulder, early motion of the shoulder after it has been injured is critical.

SYMPTOMS

Pain due to frozen shoulder is usually dull or aching. It can be aggravated by movement.

The pain is usually located over the outer shoulder area and the upper arm.

The hallmark of this condition is stiffness of the shoulder. The affected individual cannot move the shoulder normally. Motion is also limited when someone else attempts to move the shoulder for the patient.

The normal course for a frozen shoulder has three stages:

Stage One: In the “freezing” stage the patient develops a slow onset of pain. As the pain worsens, the shoulder also stiffens up.

Stage Two: The “frozen” stage is marked by a slow improvement in pain, but the stiffness remains.

Stage Three: The final stage is the “thawing”, during which the shoulder motion slowly returns toward normal.

Each stage can last 6 months (range 3 – 9 months). Therefore, if untreated, it will usually take 18 months to resolve.

TREATMENT OPTIONS

a) Non Surgical

Frozen shoulder will generally get better on its own. Most patients make a full recovery.

Treatment is aimed at pain control and restoring movement. Pain control can be achieved with anti-inflammatory medications (Nurofen, Voltaren), and Panadol based drugs (Panadol, Panadeine or Panadeine Forte).

The single most effective treatment for frozen shoulder is cortisone injected into the joint. A shoulder (glenohumeral joint) cortisone injection needs to be done by a radiologist, using ultrasound or CT scanning to get the injection in the joint. Cortisone is a powerful anti-inflammatory. It often produces a marked reduction in pain and improved movement after 2 weeks. A course of injections might run for up to 3 injections on a monthly basis.

“Hydrodilation” involves forcefully injecting saline into the joint to stretch it up. Studies have shown this treatment is inferior to cortisone injections, and I do not recommend it.

To restore motion, physiotherapy is usually started once the pain is coming under control. Therapy includes stretching or “range of motion” exercises for the shoulder. Early painful stretching is not beneficial.

More than 90 percent of patients improve with these relatively simple treatments. Usually, the pain resolves and motion improves. However in some cases, even after several years, the motion does not return completely and a small amount of stiffness remains. In the long run, this small loss of motion does not usually cause major restrictions.

b) Manipulation Under Anaesthetic

Manipulation under anaesthetic involves a general anaesthetic. While the patient is asleep the shoulder is stretched forcefully to restore the movement. At the same time, cortisone injections are performed in conjunction with temporary nerve blocks to help with pain after the procedure.

c) Surgical

Surgery is not usually considered unless symptoms have been present for more than 12 months.

Surgical intervention is considered when there is no improvement in pain or shoulder motion after an appropriate course of non-operative treatment.

Surgery aims to release the contracted joint capsule of the shoulder. This is called arthroscopic capsular release.

With shoulder arthroscopy, the surgeon makes several small incisions around the shoulder. A small camera and instruments are inserted through the incisions. They are used to cut through the tight joint capsule.

After surgery, physical therapy is important to maintain the motion that was achieved with surgery. Recovery time varies. Some patients require six weeks to three months off of work depending on their occupation and speed of recovery.

David Colvin (2016)

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