HEALTH TIPS: FROZEN SHOULDER (ADHESIVE CAPSULITIS)

Dr Tariq Jagnarine
Family Medicine, Endocrinology/Diabetes

Frozen shoulder is the common name for adhesive capsulitis, which is a shoulder condition that limits one’s range of motion. When the tissues in the shoulder joint become thicker and tighter, scar tissue develops over time, and this limits the range of motion of the shoulder, with the joint not having enough space to rotate properly.
Common symptoms of this condition include swelling, pain, and stiffness; and this condition is more frequent between the ages of 40 and 60.

CAUSES OF FROZEN SHOULDER
Having a hormonal imbalance, diabetes, or a weakened immune system makes individuals more prone to joint inflammation. A long period of inactivity due to an injury, illness, or surgery also makes persons more vulnerable to inflammation and adhesions, which are bands of stiff tissue. In serious cases, scar tissue may form, and this severely limits the range of motion of the shoulder. Usually, the condition takes two to nine months to develop.

RISK GROUPS FOR A FROZEN SHOULDER
Common risk factors for frozen shoulder are:
* Age: Being over 40 years of age.
* Gender: 70 percent of people with frozen shoulder are women.
* Recent trauma: Surgery or and arm fracture can lead to immobility during recovery, and this may cause the shoulder capsule to stiffen.
* Diabetes: 10 to 20 percent of people with diabetes develop frozen shoulder, and symptoms may be more severe. The reasons are unclear.

Other conditions that can increase the risk are:
* Stroke
* Hyperthyroidism, or overactive thyroid
* Hypothyroidism, or underactive thyroid
* Cardiovascular disease
* Parkinson’s disease

SYMPTOMS
Persons can become aware of a frozen shoulder when it begins to hurt.
* The pain then results in limited movement of the shoulder.
* Moving the shoulder less and less increases its stiffness.
* Eventually, persons are unable to move the affected shoulder as they once did. Reaching for an item on a high shelf becomes difficult, if not impossible.
* When it’s severe, everyday tasks that involve shoulder movement, such as dressing, become a monumental task.

STAGES
Symptoms are usually classified in three stages, as they worsen gradually and then resolve within a 2-to-3-year period. The American Academy of Orthopaedic Surgeons (AAOS) describes three stages:
* Freezing, or painful stage: Pain increases gradually, making shoulder motion harder and harder. Pain tends to be worse at night. This stage can last from 6 weeks to 9 months.
* Frozen: Pain does not worsen, and it may decrease at this stage. The shoulder remains stiff. It can last from 4 to 6 months, and movement may be restricted.
* Thawing: Movement gets easier and may eventually return to normal. Pain may fade but occasionally recur. This takes between 6 months and 2 years.
Over 90 percent of people find that, with simple exercises and pain control, symptoms improve. A frozen shoulder normally recovers, but it can take 3 years.

DIAGNOSIS
The feeling of pain with stiffness of the shoulder would be one of the first signs of a new, developing frozen shoulder. A physical exam would help to assess the range of motion through specific movements, such as touching the opposite shoulder with the other hand.
A few tests may also be necessary, such as an X–ray to check for arthritis or other abnormalities. This may sometimes require an arthrogram for the X-ray, which involves injecting dye into the shoulder joint to help visualise the structures in more detail.
* Magnetic resonance imaging scan (MRI) to rule out a tear in the rotator cuff or other pathology.

TREATMENT
Conservative therapy: Involves leaving a frozen shoulder untreated, but the pain and stiffness can remain for up to three years. A combination of the following can speed up the recovery and help with the symptoms:
* Physical therapy
* Medication
* Surgery
* Home care

Physical Therapy
Physical therapy is the most common treatment for a frozen shoulder. The goal is to stretch the shoulder joint and regain the lost motion. Results can take as much as a few weeks to nine months to resolve. A home exercise programme of gentle range of motion exercises is important. If no change is observed after six months, consider other treatment modalities.

Medications
To treat the pain and reduce the joint inflammation, it is recommended that an anti- inflammatory medication like aspirin, ibuprofen, or naproxen sodium or diclofenac be used. A steroid injection in the shoulder joint may also help.

Home Care
Placing an ice pack on the shoulder for 15 minutes at a time at several times per day can help to decrease pain. Physical therapy exercises can be done at home. Most people with a frozen shoulder can improve their condition without surgery.

Surgery
If physical therapy doesn’t improve the condition, surgery is an option. From a surgical standpoint, options include manipulating the shoulder and putting it through a full range of motion under a general anaesthetic to help break up any adhesions. Another option is arthroscopic surgery. This type of surgery involves making a small cut in the shoulder and using a camera called an “arthroscope” to remove scar tissue or release it. This allows the shoulder to recover its lost motion.
If the frozen shoulder is the result of an injury, surgery is usually more successful if it’s performed within a few weeks of the injury. Surgery is usually done on an outpatient basis. Postoperative physical therapy is usually required as well.
Many patients have their full range of motion back within three months. Some people still have pain or stiffness afterwards, or can’t handle the pain of physical therapy.

PROGNOSIS
Most people recover within two years without treatment. Physical therapy and pain medications speed up this progress. If surgery is needed, it’s important to continue the therapy exercises in the following months, so that the problem doesn’t return. Early treatment helps keep the condition from getting worse.
Persons who are diabetic need to properly manage their blood sugar levels in order to help reduce the risk of contracting a frozen shoulder.
Frozen shoulder cannot be prevented if it is caused by an injury that makes shoulder movement difficult. Anyone who experiences such an injury should consider exercises for maintaining mobility and flexibility of the shoulder joint.