Frozen shoulder

Frozen shoulder is a condition where there is loss of shoulder movements, often along with associated pain. It is also referred to as adhesive capsulitis. The term frozen shoulder comes from the loss of “fluidity” of shoulder movements.

Frozen shoulder, in the commonest form, is unrelated to any underlying health conditions. The capsule or the covering of the shoulder joint becomes thickened, thereby losing its natural elasticity leading to loss of movements. Although a majority of times the underlying causes are unknown, there may be an association with diabetes, heart disease, stroke or Dupuytren’s Contracture. Secondary Frozen shoulder can also occur following rotator cuff tears, calcific tendonitis, injury, surgery or immobilisation although purists would call it secondary shoulder stiffness rather than a true frozen shoulder.

In the initial phases of frozen shoulder, the pain may be excruciating. In fact, frozen shoulder can be one of the most painful conditions of the shoulder. The hallmark of frozen shoulder is loss of movements of the shoulder in all directions.

Although frozen shoulder is a clinical diagnosis made on the basis of focussed history and careful clinical examination, investigations are needed to rule out other conditions, which can mimic frozen shoulder. Conditions which mimic frozen shoulder, such as infections, tumours, arthritis of the shoulder joint or locked dislocation can usually be picked up X-rays. Other conditions, which predispose patients to a frozen shoulder, such as calcific tendonitis can also be picked up on an X-ray. One usually does not necessarily need-advanced investigations such as an ultrasound scan or an MRI scan to diagnose a frozen shoulder, however these may be used in atypical cases and to look for an underlying cause of frozen shoulder.

If left on it’s own, it is thought that a majority of patients with frozen shoulder will recover on their own. Such natural history of frozen shoulder is classically described in three phases. The first phase is the freezing phase where the patients present with pain and stiffness around the shoulder. The second phase is the frozen stage where the pain settles down to a large extent and the main symptom remains loss of movements. The third phase is the thawing phase where the mobility gradually improves and the stiffness resolves. Classically, it is said that each phase lasts 6 to 8 months, although, such duration and spontaneous resolution has been disputed. Treatment is designed to reduce pain, improve movements during these stages and to hasten recovery.

The first line treatment for frozen shoulder, after making an accurate diagnosis, is managing pain (with appropriate painkillers), self-directed exercises, physiotherapy and activity modification. Specifically, activities, which cause pain are to be avoided, at the same time maintaining as much movement as possible. Sudden unanticipated movements are usually very painful and some commercially devices may help in avoiding such sudden movements as a temporary measure.

Corticosteroid injections (commonly known as cortisone injections) are often used for treating frozen shoulder. Corticosteroids are anti-inflammatory in action and and are shown to be of benefit in pain control, although the precise mechanism by which they work in frozen shoulder remains debatable.

Hydrodilatation or arthrographic distension is a treatment option for frozen shoulder where the shoulder joint is injected with local anaesthetic, cortisone and saline. This procedure is usually performed under radiographic control, either using an X-ray or an ultrasound scan. The advantage of this procedure is that it can be performed under a local anaesthetic without the risks associated with an anaesthetic or operative treatment. This is currently the first line intervention of choice in the author’s practice.

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