Frozen shoulder

Dr M K Mam
Frozen shoulder also known as peri-arthritis or adhesive capsulitis of shoulder is a fairly common condition and is characterised by severe pain with progressive restriction of both active and passive movements of the shoulder.
With the result there is lot of disability that affects the person’s ability to work, perform daily activities and household tasks.  Often patients   have to take off from work, thus affecting the economy of the individual, family and the society.
It is usually primary (idiopathic) in nature as the cause is unknown in majority of cases. People of 40 to 60 years age, particularly women are more often affected. There is a progressive inflammation of the joint, fibrosis and contracture of the capsule, rotator cuff and biceps tendon leading to the gross restriction of movements of the shoulder joint. It is usually insidious in onset and progresses slowly. Painful restriction of the movements affects his ability to do normal activities of daily living, more so if the dominant arm is involved. However, the good thing is that in many of the cases it is a self resolving condition, as with passage of time pain decreases and movements return to a large extent. It may take six months to eighteen months or more to recover, however completely normal range movements may not be restored in some of the cases. The people having medical problems like diabetes, cardiovascular diseases are more often affected, as they may have some sort of referred pain to shoulder which keeps shoulder immobile and this then leads to frozen shoulder.
Frozen shoulder can also be secondary in nature when it is associated with trauma, rotator cuff disease and impingement. People having had  surgery of breast like mastectomy  or a medical problem like stroke that  prevents them from moving the arm are certainly at a higher risk of having frozen shoulder .People who have had prolonged immobility or reduced mobility of the shoulder  are also at a higher risk of developing frozen shoulder.
Staging: The condition progresses through the following stages: i) Stage of pain: Patient has diffuse pain in the shoulder with radiation to upper arm associated with restriction mainly of abduction- sideways raising of arm, external rotation and then forward flexion movement of the shoulder. Pain is usually worst at night and then gradually progresses to the whole day. ii) Stage of stiffness- pain gradually decreases however the stiffness progressively increases- all the movements are restricted with some pain at the end range of movement. iii) Stage of recovery- There is no or may be mild pain and there is progressive increase in the range of movements of the shoulder.
Investigations: X-rays of the shoulder and blood investigations are usually normal. X-ray shoulder is done to rule out other problems such as arthritis, avascular necrosis or injury of the shoulder. Again specialized investigation like Magnetic resonance imaging scan (MRI) is normally not required, however it is very useful when there is a doubt in diagnosis and we want to rule out a tear in rotator cuff or any other pathology.
Treatment: The goal of the treatment is pain relief, improve range of movements, and reduce duration of symptoms and finally return of normal activities. Pain has to be controlled with analgesics –pain killers and anti-inflammatory drugs. A gentle range of motion exercises done at home and a supervised physiotherapy is very important for improving range of movements of the shoulder. Normal human tendency is that we try not to move the shoulder or move it less and less to have some relief from the pain. However it has to be well explained that moving the shoulder less and less, increases its stiffness, so range of motion exercises with in the comfort zone is absolutely necessary.
When physiotherapy and pain killers do not work, local injection of hydrocortisone and  local anaesthetic  help in reducing pain and inflammation.
Majority of the patients usually improve with non-operative treatment, however there may be cases with persistent and severe functional restriction of movements, and are not responding to non-operative treatment. Such refractory cases can be considered for operative options like manipulation under anesthesia (MUA), distension arthrolysis (DA) or arthroscopic release of capsular (ARC) adhesions. MUA involves manipulation of shoulder under general anaesthesia to break the contracted shoulder capsule in a controlled fashion, thus restoring movements of the shoulder. DA is a procedure where we inject saline and local anaesthetic under pressure to distend and break the adhesions in capsule. ACR involves release of contracted capsule in a controlled fashion using arthroscopic instruments. All the surgical procedures have to be religiously followed by physiotherapy to maintain the range of motion in the affected shoulder and this has to be well understood and carried on by the patient. It is important that the patient and the family are well explained about the nature, usual course of the problem and the options of the treatment. Last but not the least, for the better outcome the treatment has to start early, and must be tailored as per the needs of the individual and the severity of the problem.
(The author is former Vice Principal, Prof & Head, Department of Orthopaedics CMC & Hospital, Ludhiana)