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Frozen shoulder is a shoulder joint with a significantly diminished range of movement. The restriction is due to inflammation of the tissues around the joint (the joint capsule), which then become stiff and cannot stretch normally. Adhesions may then form, sticking the joint surfaces together, and decreasing the space available for lubricating joint fluid.
Associated conditions and risk factors
Frozen shoulder is more common in women than in men, and affects mainly the 40-60-year age group. In some patients, no underlying cause can be found, and these are called idiopathic.
Common predisposing conditions include:
- previous injury with pain, leading to immobility of the shoulder,
- rotator cuff tendonitis,
- rheumatic disease,
- recent shoulder surgery (pain, disuse, frozen shoulder)
- diabetes,
- hypothyroidism or hyperthyroidism,
- Parkinson's disease,
- stroke,
- recent open-heart surgery, and
- possible side effects of antiretrovirals used in HIV treatment.
Symptoms
The main symptoms of frozen shoulder are pain and stiffness which interfere with normal everyday activities, such as brushing hair, putting on a coat, hanging up laundry or even scratching your back. The pain, usually a dull ache, is often worse at night, or with attempted movement.
Diagnosis
The diagnosis is clinical, based on the patient's symptoms and the finding on examination. If other joint problems - or other underlying disorders - are suspected, relevant tests must be done. These may include shoulder X-rays, scans or even arthroscopy in extreme cases, and blood tests.
Treatment
The aim of treatment is to reduce pain and restore normal shoulder movement.
In the acute period, extreme positions such as overhead reaching are discouraged. Instead, special gentle exercises are recommended, such as:
- passive stretching by physiotherapists, and
- weighted pendulum exercises.
Non-steroidal anti-inflammatories help to minimise pain and inflammation, and steroids (like cortisone) may also be considered, either taken orally or injected.
Transcutaneous electrical nerve stimulation (TENS) may bring relief by blocking pain impulses.
Manipulation under anaesthesia is another option for unresponsive cases.
Surgery may be considered in selected cases, and may consist of incising ligaments and removing any visible scar tissue.
Outcome
This condition is often self-limiting, but may take up to 18 months for full recovery. Patients with more than 50 percent loss of movement may not have full recovery, especially if they are diabetic.
Symptomatic treatment, good physiotherapy and the correct exercises will be successful in about 50 percent of patients.
The condition must be reassessed after 6-8 weeks, to decide whether further treatment is needed.
Steroid injection may appear to speed up recovery, but long-term result may be little changed, and there is an added risk of later complications.
Surgery may aggravate symptoms in some patients, or may lead to muscle wasting and recurrent adhesions afterwards. Manipulation under anaesthesia may be risky, as excessive force may be required to break down the adhesions. This may result in an uncontrolled tear of the capsule, bleeding within the joint, or even a fracture of the arm bones, especially in the elderly.
(Dr A G Hall)
