Frozen Shoulder

Frozen Shoulder: Description:Frozen ShoulderA condition in which there is limitation of motion in a joint due to inflammatory thickening of the capsule, a common cause of stiffness in the shoulder.Also called as Adhesive Capsulitis.Abbreviation: FSS (Frozen Shoulder Syndrome)Frozen shoulder, or adhesive capsulitis, is a condition that causes restriction of motion in the shoulder joint. The cause of a frozen shoulder is not well understood, but it often occurs for no known reason. Frozen shoulder causes the capsule surrounding the shoulder joint to contract and form scar tissue.No one really understands why some people develop a frozen shoulder. For some reason, the shoulder joint becomes stiff and scarred. The shoulder joint is a ball and socket joint. The ball is the top of the arm bone (the humeral head), and the socket is part of the shoulder blade (the glenoid). Surrounding this ball-and-socket joint is a capsule of tissue that envelops the joint.Normally, the shoulder joint allows more motion than any other joint in the body. When a patient develops a frozen shoulder, the capsule that surrounds the shoulder joint becomes contracted. The patients form bands of scar tissue called adhesions. The contraction of the capsule and the formation of the adhesions cause the frozen shoulder to become stiff and cause movement to become painful.Frozen shoulder syndrome usually affects patients aged 40-70 years. Incidence of FSS is not precisely known; however, it is estimated that 3% of people develop the disease over their lifetime. Males tend to be affected less frequently than females, and there is no predilection for race.Adhesive capsulitis has been associated with several conditions. A higher incidence of frozen shoulder exists among patients with diabetes (10-20%) compared with the general population (2-5%). Incidence among patients with insulin-dependent diabetes is even higher (36%), with an increased frequency of bilateral shoulder involvement.Most patients with FSS have a period of shoulder immobilization. Reasons for immobilization can be diverse; however, the common finding in all of these patients is a period of restricted shoulder motion. In a study of neurosurgery patients who immobilized their shoulders for varying periods.The predominant complication arising from adhesive capsulitis is residual shoulder stiffness or pain. Several reports have indicated that most patients may continue to have pain and/or stiffness for up to 3 years following conservative treatment. In addition, humeral fracture, biceps tendon rupture, and subscapularis tendon rupture have been reported after shoulder manipulation.Symptoms:Shoulder pain; usually a dull, aching pain. Causes and Risk factors:The cause of frozen shoulder is unknown, but it probably involves an underlying inflammatory process. The capsule surrounding the shoulder joint thickens and contracts. This leaves less space for the upper arm bone (humerus) to move around. Frozen shoulder can also develop after a prolonged immobilization because of trauma or surgery to the joint. Usually only one shoulder is affected, although in about one-third of cases, motion may be limited in both arms.Some risk factors for developing a frozen shoulder include:Age & Gender: Frozen shoulder most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women than in men.Endocrine Disorders: Patients with diabetes are at particular risk for developing a frozen shoulder. Other endocrine abnormalities, such as thyroid problems, can also lead to this condition.Shoulder Trauma or Surgery: Patients who sustain a shoulder injury, or undergo surgery on the shoulder can develop a frozen shoulder joint. When injury or surgery is followed by prolonged joint immobilization, the risk of developing a frozen shoulder is highest.Other Systemic Conditions: Several systemic conditions such as heart disease and Parkinson's disease have also been associated with an increased risk for developing a frozen shoulder.Diagnosis:Prior to examining the patient, a thorough clinical history should be elicited. Specifically, information should be gathered regarding onset of symptoms, any antecedent trauma or surgery, affected side(s), and duration of symptoms. The patient should be queried about any existing conditions. Since adhesive capsulitis is associated with diabetes, it is imperative to screen any new patient presenting with suggested frozen shoulder syndrome for diabetes. Adhesive capsulitis has also been reported in patients with hyperthyroidism, ischemic heart disease, and cervical spondylosis. Any previous treatments that the patient has received for this condition should be documented, as should the individual's current medication list. Questions should be directed toward any upper extremity neurologic complaints, including cervical radiculopathy. Any history of cervical pain or radiculopathy should be thoroughly evaluated during the clinical examination to exclude a diagnosis of cervical spondylosisor cervical disc disease.The patient's posture should be observed while he or she is wearing a gown and sitting on a stool. It should also be noted whether the patient is listing to one side secondary to pain and whether he or she is holding the neck to one side secondary to spasm or pain. Observations during this period help determine whether a cervical condition may be contributing to the patient's symptomatology.Most often, a frozen shoulder can be diagnosed on examination, and no special tests are needed. An x-ray is usually obtained to ensure the shoulder joint appears normal, and there is not evidence of traumatic injury or arthritic changes to the joint. An MRI is sometimes performed if the diagnosis is in question, but this test is better at looking for other problems, rather than looking for frozen shoulder. If an MRI is done, it is best performed with an injection of contrast fluid into the shoulder joint prior to the MRI. This will help show if the capsule of the shoulder is scarred down, as would be expected in patients with a frozen shoulder.Treatment:The treatment of a frozen shoulder usually requires an aggressive combination of antiinflammatory medication, cortisone injection(s) into the shoulder, and physical therapy. Without aggressive treatment, a frozen shoulder can be permanent.Diligent physical therapy is often key and can include ultrasound, electric stimulation, range-of-motion exercise maneuvers, ice packs, and eventually strengthening exercises. Physical therapy can take weeks to months for recovery, depending on the severity of the scarring of the tissues around the shoulder.It is very important for people with a frozen shoulder to avoid reinjuring the shoulder tissues during the rehabilitation period. These individuals should avoid sudden, jerking motions of or heavy lifting with the affected shoulder.Sometimes frozen shoulders are resistant to treatment. Patients with resistant frozen shoulders can be considered for release of the scar tissue by arthroscopic surgery or manipulation of the scarred shoulder under anesthesia. This manipulation is performed to physically break up the scar tissue of the joint capsule. It carries the risk of breaking the arm bone (humerus fracture). It is very important for patients that undergo manipulation to partake in an active exercise program for the shoulder after the procedure. It is only with continued exercise of the shoulder that mobility and function is optimized.Exercise and stretching:Stretching exercises for frozen shoulder serves two functions:
  1. Increase the motion in the joint.
  2. Minimize the loss of muscle on the affected arm (muscle atrophy).
Patients cannot expect to have successful frozen shoulder treatment if they perform exercises only when working with a therapist. These exercises and stretches must be performed several times dailyMoist Heat: Applications of moist heat to the shoulder can help to loosen the joint and provide relief of pain. Patients can apply moist heat to the shoulder, then perform their stretching exercises--this should be done at least three times daily. Moist heat can be applied by using a hot-soaked washcloth on the joint for 10 minutes before stretching.Physical Therapy: Physical therapists can help a patient develop a stretching and exercise program, and also incorporate ultrasound, ice, heat, and other modalities into the rehabilitation for frozen shoulder. As said previously, it is important that patients perform their stretches and exercise several times daily--not only when working with the therapist.Surgery:
  • If the above treatments do not resolve the frozen shoulder, occasionally a patient will need to have surgery. If this is the case, the surgeon may perform a manipulation under anesthesia. A manipulation is performed with the patient sedated under anesthesia, and the doctor moves the arm to break up adhesions caused by frozen shoulder. There is no actual surgery involved, meaning incisions are not made when a manipulation is performed.
  • Alternatively, or in conjunction with a manipulation, an arthroscope can be inserted into the joint to cut through adhesions. This procedure is called an arthroscopic capsular release. Surgical capsular release of a frozen shoulder is rarely necessary, but it is extremely useful in cases of frozen shoulder that do not respond to therapy and rehab. If surgery is performed, immediate physical therapy following the capsular release is of utmost importance. If rehab does not begin soon after capsular release, the chance of the frozen shoulder returning is quite high.
Medicine and medications:Anti-inflammatory Medications: Anti-inflammatory medications have not been shown to significantly alter the course of a frozen shoulder, but these medications can be helpful in offering relief from the painful symptoms.Cortisone Injections: Cortisone injections are also commonly used to decrease the inflammation in the frozen shoulder joint. It is unclear the extent of the benefit of a cortisone injection, but it can help to decrease pain, and in turn allow for more stretching and physical therapy. What is known, is the cortisone is only effective when used in conjunction with physical therapy for the management of a frozen shoulder.DISCLAIMER: This information should not substitute for seeking responsible, professional medical care. 


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