What Causes Frozen Shoulder and How can it be Treated?

What is Frozen Shoulder?

Frozen shoulder is also known as adhesive capsulitis, peri-arthritis, and painful stiff shoulder. Frozen shoulder occurs as a result of limited movement of the shoulder (glenohumeral) joint.  The joint is made up of a socket (the glenoid) and a ball (the humeral head). 

Frozen shoulder affects both active and passive range of motion - in other words, the movement of your shoulder is limited when you try to move your arm or when someone else tries to move your arm. 

Frozen shoulder affects women more than men, usually between 50 to 60 years of age. 

What causes Frozen Shoulder?

Frozen shoulder can be broadly classified as  

1. Primary Frozen Shoulder is also known as Idiopathic Adhesive Capsulitis. As the name suggests, no known cause can be identified in its pathogenesis. This is very commonly seen in Diabetics. Approximately, 30-35% of people with diabetes develop frozen shoulders at least once in their lifetime. Besides Diabetes, it is also commonly seen in people with Thyroid problems. Other rare associations include scleroderma, parkinsonism, rheumatoid arthritis, etc. 

2. Secondary Frozen shoulder which develops whenever the shoulder is kept still for a long time, for example after fracture or shoulder surgery or even sometimes after a stroke or heart surgery. This is less common when compared with primary frozen shoulder

What are the symptoms of Frozen Shoulder?

Pain and stiffness of the shoulder are two main presenting complaints of people with frozen shoulders.

A person affected by a primary frozen shoulder goes through three stages.

  1. The first stage (freezing) is associated with more pain than stiffness.  

    • The pain worsens at night and during rest. The shoulder becomes stiff and muscle spasm occurs. This stage lasts two to nine months. 

  2. In the second stage (frozen), the stiffness of the shoulder increases, and movement is restricted. The intensity of pain though gradually decreases

    • There is discomfort with extreme movement. This stage lasts four to twelve months. 

  3. In the last stage (thawing), the pain is less and the movement of the shoulder slowly improves. 

    • This phase lasts five to twenty-four months. 

A particularly notable thing is that the duration of these 3 phases is still unpredictable. Whilst some people pass through these 3 phases in a span of 6 months, some may take even 3 years with residual stiffness of the shoulder persisting even after that. This unpredictability makes the management of the primary frozen shoulder challenging.  

How is Frozen Shoulder Diagnosed?

Though diagnosis is mostly clinical, following investigations help in differentiating pain in the shoulder due to frozen shoulder vs other conditions like rotator cuff tendinosis, etc. 

  • ULTRASONOGRAPHY – Emerging as the investigation of choice as it's faster and easier to perform. Thickening of coracohumeral ligament and its adhesions to long heads of biceps is the diagnostic hallmark. However, ultrasound is very much operator-dependent and the efficacy depends on the skill and knowledge of the person performing the ultrasound. This limits its role

  • MRI – More resource-intensive than ultrasound but it benefits with less intra-observer variability. Loss of axillary recess is the hallmark of adhesive capsulitis

  • X-Rays – No role except in identifying other causes that can mimic as adhesive capsulitis such as minor fractures etc. 

How is Frozen Shoulder Treated?

The aim of treating frozen shoulders is to decrease pain and improve movement. 

The treatment choices depend on whether we are dealing with primary or secondary frozen shoulders. 

Secondary Frozen Shoulder - 

Relatively easier to treat. Treatment predominantly consists of physiotherapy, supplemented with moist heat packs and non-steroidal anti-inflammatory drugs

Physical therapy

  • Physical therapy will improve your range of motion. Either you may do the required exercises on your own or a physical therapist will be recommended. 

  • When exercising the first time, start slow and gradually improve your mobility when you feel comfortable. 

  • In the first two to three months, you may rest your shoulder and perform a gentle range of motion exercises. 

  • With time, you may add more exercises without straining yourself. 

Primary Frozen Shoulder

Treatment mainly depends on what stage the patient is diagnosed at

1. Freezing Stage

  • Pain Killers and Physical Therapy – First Line of Management

  • Intra-articular Steroid Injections ( Injections into shoulder joint ) - Beneficial if the pain is severe

2. Frozen Stage

    Unfortunately, many of the patients present late and are diagnosed at this stage. In this stage, the shoulder is very stiff causing hindrance in the performance of day to day activities like wearing clothes etc. 

  • Physical Therapy – First line with emphasis on joint mobilization techniques

  • Intra-articular Steroid Injections – Not recommended. Little benefit in this stage

  • Hydro–Distension – Refers to a technique of insufflating the joint with large amounts of saline so as to break the adhesions. Though promising but it has failed to yield satisfactory results in clinical settings

  • Manipulation Of Joint Under Anaesthesia – Controversial and fraught with complications like tendon tears/ligament ruptures and sometimes even fractures

  • Arthroscopic Capsular Release  - Treatment of choice in patients who fail to improve even after 3 months of physiotherapy. Recent studies by Chan et al show it to be a very effective alternative with high patient satisfaction scores

Secondary Prevention

Post a surgical procedure, physical therapy is important to maintain the movement. The recovery time varies from person to person - it may take six weeks to three months. 

To prevent a second frozen shoulder, underlying causes must be addressed and avoiding prolonged immobilization.

Frequently Asked Questions

1.  Can frozen shoulders recur?

It is unlikely for a frozen shoulder to recur. It may be common to recur if there is a preexisting condition such as diabetes. Therefore, conditions such as diabetes should be addressed to prevent a second frozen shoulder. 

2. What are the outcomes after surgery?

The long-term outcomes of post-surgery are usually good. Most patients have a decrease or no pain and better shoulder movement. 

3. How is a frozen shoulder diagnosed?

Frozen shoulder is diagnosed clinically by your doctor. Your doctor will examine your range of movements and any symptoms associated with your movements. In some cases when it is not easy to diagnose a frozen shoulder, an injection test is done. The movement will not improve after an injection test in patients with a frozen shoulder. Imaging is rarely required but at times, doctors may recommend to rule out other health problems. 

4. How long does it take to recover from a frozen shoulder?

Answer: With physical therapy done under a physical therapist, it may take one to six weeks to recover. Generally, recovery depends on the type of treatment and individual compliance. It may vary from a few months to nine months. 

5. What are the risk factors of a frozen shoulder?

There are various risk factors. Women are more at risk than men. People in the 50s and 60s are higher at risk. Some underlying conditions make some people more at risks such as diabetes, thyroid problems, prolonged immobilization, an autoimmune disorder, stroke, and heart attacks. 

 

 

Dr. Gaurav Rastogi

Consultant - Orthopaedics

Manipal Hospitals, Dwarka, Delhi

 

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