Frozen Shoulder is a condition with no known cause in the majority of cases, with spontaneous onset. It is most common in females (40-50 years) but could affect males and other age groups. It may follow injuries, operations or be associated with medical conditions like diabetes mellitus. It is referred to as “adhesive capsulitis” suggesting that the capsule is inflamed and adhering (clinging) to the joint, causing pain and limitation of motion.

Fig. 1. An inside view of a frozen shoulder: note the extremely red and inflamed inner lining (synovium) of the shoulder. Any motion, especially if it is a quick and excessive movement pulls on this tissue and causes an intense experience of pain

 

Severe pain and restriction of movement. Night pain can be especially troublesome and with sudden movements intense pain may follow, e.g. reaching out to grab something. Reaching the hand up behind the back is usually a problem due to the restriction. To reach overhead the shoulder blade has to be lifted (see picture below).

Pain may be felt in the shoulder, spreading up the neck and even down the arm into the hand.

In some cases the shoulder blade may protrude at the back, referred to as “pseudo-winging” of the scapula (Fig. 4).

Injections in different spaces: 
1. Injection in shoulder joint (Ground floor), 
2. Injection in subacromial space (First floor), 
3. Injection in AC joint (attic).

 

Injections in different spaces: 
1. Injection in shoulder joint (Ground floor), 
2. Injection in subacromial space (First floor), 
3. Injection in AC joint (attic).

 

Injections in different spaces: 
1. Injection in shoulder joint (Ground floor), 
2. Injection in subacromial space (First floor), 
3. Injection in AC joint (attic).

 

Due to this abnormal position of the shoulder blade (Fig 4.) there is traction on the large nerves in the neck (brachial plexus) and this causes pain in the neck, shoulder and down the arm and at times into the hand.There may even be nerve-like symptoms down the arm and into the hand e.g. numbness and tingling. The position of the shouder blade may also result in a dragging feeling in the back muscles attaching to the shoulder blade ( the “peri-scapular muscles” or rhomboids as they are called)

Natural Progression

Most clear up in anything from 6 months to as long as 3years, even without any treatment and the fact that the condition always clears up in time should relieve the anxiety of patients “that it will last forever”.

The Four Stages

Stage 1: ”Inflammation”” (0-3 months). The lining of the joint (synovium) is inflamed. Moderately severe pain

Stage 2: “Freezing Stage” (3-9 months ) Synovitis and scar formation in the underlying capsule. Severe pain.

Stage 3: “Frozen Stage” (9-15 months). Minimal pain,marked stiffness due to scar formation in capsule.

Stage 4: “Thawing Stage” (15-24 months). Little pain, movement increases.

Medication: A person suffering from frozen shoulder may suffer severe pain and should be aided with pain killers, anti-inflammatories and sleeping tablets if necessary. As this is a self-limiting condition with an “end point” the medication will only be necessary for a limited period
Cortisone Injection into the joint may be helpful in stage 1and 2 (see above). Given early, such an injection may be of great benefit. During the later stages it has no effect. The injection has to be placed accurately into the joint as an injection into any adjacent area around the shoulder will not be effective

In diabetic patients with “diabetic frozen shoulder” there may be a problem with using a cortisone injection due to the fact that cortisone may elevate the blood glucose.It is imperative to check the blood sugar in such a patient to avoid injecting cortisone into a patient with an uncotrolled level of blood glucose.

“Brisement” (Hydrodilatation) In this procedure a large volume of sterile fluid (Saline solution) is injected into the joint to stretch and “pop” the capsule. The fluid is injected with ultrasound control to ensure accurate intra-articular placement.In some patients this has shown to have good results.

Physiotherapy consisting of gentle stretching exercises may be done although aggressive stretching should be avoided. The latter is not only very painful but has been shown to prolong the course of the condition

Surgery is seldom needed as the condition is self-limiting and always clears up if the patient waits long enough.

The operation favoured by some surgeons is that of arthroscopic capsulotomy where the inflamed capule is cut with the intention to accelerate the process to full healing. Nor all experts agree that this operation helps to relieve the pain of the condition.

In some instances we have done a procedure which we call “arthroscopic capsulectomy” whicn is removal of most of the affected capsule with arthroscopic srugery. The results have been most gratifying in select patients.

Manipulation under anaesthesia. The inflamed capsule is torn under anaesthesia, with the intention that it should improve the condition- not universally favoured by surgeons

Frozen Shoulder (adhesive capsulitis)

Frozen shoulder (adhesive capsulitis) is a condition with no known cause in the majority of cases, in other words with spontaneous onset. Frozen shoulder is most common in females (40 to 50 years old) but could affect males and other age groups. Although most cases are due to spontaneous onset it may follow other causes like injuries, operations or medical conditions. The most common medical condition which is associated with frozen shoulder is diabetes.

Frozen shoulder is also referred to as “adhesive capsulitis” suggesting that the capsule is inflamed and clinging (adhering) to the joint causing pain and limitation of motion.

Frozen shoulder symptoms

People suffering with this condition would complain of severe pain and restriction of motion. Night pain can be especially troublesome and with sudden movements intense pain may follow e.g. reaching out to grab an object. Reaching the hand up behind the back is usually a problem due to the restriction. To reach overhead the shoulder blade has to be lifted.

Natural progression of frozen shoulder:

As frozen shoulder starts spontaneously it may also “disappear” without any treatment. It must therefore be regarded as a self limiting condition with an end point that will cure itself. Frozen shoulder goes through different stages:

  1. The phase of “inflammation”: this is mostly associated with pain.
  2. The phase of “freezing”: this is associated with pain and stiffness.
  3. The phase of being “frozen”: the shoulder is now very stiff and pain may start subsiding.
  4. The phase of “thawing”: the condition is now improving and will eventually improve to a point where pain has disappeared and full range of motion is achieved.
    Each of these stages may last for several months and the whole process may take one to two years to go through its cycle.

Frozen Shoulder Treatment:

Medication such as pain killers and anti-inflammatories may be of value.
Cortisone injection:
Cortisone injected into the main joint in the early phase of inflammation may be of great help and may even help to stop the condition there and then. If given in the later phases of frozen shoulder it is usually less likely to be improved by such an injection. On the other hand ,in such a case, the condition is closer to improvement.

Physiotherapy / stretching:

Physiotherapy may relieve pain but it has to be guarded against aggressive stretching as this aggravates the pain and will prolong the course of the condition.

Surgery:

Surgery is seldom needed as this condition is self limiting. Frozen shoulder is therefore a self limiting condition and although a patient may suffer severe pain during the presence of this condition it has to be guarded against interventions like surgery and one can expect it to clear up as time goes on.

Procedures

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