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Frozen Shoulder

Frozen Shoulder Syndrome

Frozen shoulder (adhesive capsulitis) is a chronic condition of the shoulder characterized by severe restriction of both active and passive shoulder range of motion.


Presentation

In patients with frozen shoulder, the movement of the shoulder is severely restricted and there is loss of both active and passive range of motion [7]. Presentation is the same for both idiopathic frozen shoulder and frozen shoulder as a result of injury. Apart from restriction of movement, vertebral pressure, headache and insomnia are among common presentations.

Arm Pain
  • This pain is felt over the shoulder and occasionally on the upper arm. Pain begins gradually, and intensifies with shoulder movement. Pain is usually worse during the early phase of the condition and decreases in later phases of this condition.[sports-health.com]
  • From there, it can extend onto the back, over the scapula, and/or down the back side of the upper arm. Pain usually skips the forearm but appears again as a band around the wrist (see picture at right) .[acutakehealth.com]
  • If the patient suffers arm pain, redness or swelling, or have shortness of breath at any stage, contact [doctor] Serious medical problems can lead to ongoing health concerns, prolonged hospitalisation or rarely death.[shouldersurgery.com.au]
  • If the patient suffers arm pain, redness or swelling, or have shortness of breath at any stage, contact Dr Biggs Surgery Preparation Once Dr Biggs decides that surgery is required, preparation is necessary to achieve the best results and a quick, problem[danielbiggs.net]
  • Problems in your neck can make your shoulder blade or upper outer arm painful. When this happens it’s known as referred pain or radiated pain.[arthritisresearchuk.org]
Rigor
  • RESULTS: 39 articles describing the PTI were analyzed using Sackett's levels of evidence and were examined for scientific rigor. The PTI were given grades of recommendation that ranged from A to C.[ncbi.nlm.nih.gov]
Frozen Shoulder
  • The relative risk of frozen shoulder was 4:1 when all patients with frozen shoulder were compared with a control population. A third study (n 87) showed that 29% of patients with frozen shoulder had a first-degree relative with frozen shoulder.[ncbi.nlm.nih.gov]
  • […] and secondary frozen shoulder.[ncbi.nlm.nih.gov]
  • The prevalence of end-stage diabetic manifestations was increased in patients with frozen shoulder as compared with those without frozen shoulder (p 0.0001).[ncbi.nlm.nih.gov]
  • RESULTS: Frozen shoulder was identified in 11% of the patients after shoulder surgery and was more common in females (15%) than in males (8%). Frozen shoulder was encountered after all types of operative procedures.[ncbi.nlm.nih.gov]
  • BACKGROUND: Frozen shoulder is characterized with thickening and contracture of joint capsular. The mechanism of this disorder is not yet clear, however, some proteins have been related to frozen shoulder.[ncbi.nlm.nih.gov]
Shoulder Pain
  • We measured shoulder pain, shoulder range of motion, and American Shoulder and Elbow Surgeons shoulder scores immediately prior to MUC, 1 week after MUC, and 1 year after MUC.[ncbi.nlm.nih.gov]
  • Complication rates were 1.78% for facial flushing, 0.71% for dizziness owing to vasovagal reactions during injection, 1.07% for chest or shoulder pain, and 0.36% for nausea. Line charts improved in both groups.[ncbi.nlm.nih.gov]
  • Magnetic resonance imaging, taken due to persistence of shoulder pain and reduction of shoulder joint mobility in cases monitored because of proximal humerus fracture associated with electrical injury, revealed a tear of supraspinatus tendon.[ncbi.nlm.nih.gov]
  • Shoulder pain and mobility deficits: adhesive capsulitis. J Orthop Sports Phys Ther . 2013;43(5):A1-A31. PMID: 23636125 www.ncbi.nlm.nih.gov/pubmed/23636125 . Miller RH, Azar FM, Throckmorton TW. Shoulder and elbow injuries.[medlineplus.gov]
Stiffness of the Shoulder
  • Frozen shoulder (FS) is a musculoskeletal disease, and causes pain and stiffness in the shoulder. The relationship between FS and psychological disorders has rarely been investigated.[ncbi.nlm.nih.gov]
  • Adhesive capsulitis, better known as frozen shoulder, is a condition that causes pain and stiffness in your shoulder. Frozen shoulder is a condition that gradually appears over time, and it is not the result of an injury.[deserthandtherapy.com]
  • Frozen shoulder (adhesive capsulitis) is a disorder characterized by pain and loss of motion or stiffness in the shoulder. It affects about two percent of the general population.[health.uconn.edu]
  • Frozen shoulder, also known as adhesive capsulitis, is a common condition that causes pain and stiffness in the shoulder as a result of a tightening or thickening of the capsule that protects the structures of the shoulder.[orthopedicshoulder.com]
  • Stiffness in the shoulder can be the result of the diagnoses described above, such as impingement syndrome, calcific tendinitis, shoulder instability, or rotator cuff rupture.[praxisklinik2000.com]
Shoulder Arthritis
  • A frozen shoulder is, like shoulder arthritis, one of the conditions that can result in a stiff shoulder.[shoulderarthritis.blogspot.com]
  • Additional Information See: The Shoulder Arthritis Book at See: The Rotator Cuff Tear Book at Shoulder arthritis and frozen shoulder - what's the difference? - Shoulder exercises[orthop.washington.edu]
  • Your doctor should also rule out shoulder arthritis via a scan or X-ray, as it produces similar symptoms.[saga.co.uk]

Workup

Frozen shoulder is majorly a clinical diagnosis but imaging can also be used to exclude other causes of shoulder pain and depict findings that increase the confidence in clinical diagnosis. Arthrography is usually seen as the standard for imaging diagnosis [8].

Laboratory studies are rarely required in the evaluation of adhesive capsulitis. However, if a predisposing medical condition that may be contributing to adhesive capsulitis is suspected, the patient may be subjected to the following tests:

  • CBC
  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein
  • Serum blood sugar
  • Thyroid stimulating hormone (TSH)
  • Free thyroxine index (FTI)

Treatment

In managing this disorder, the focus is on restoring joint movement and reducing shoulder pain. This may involve medications, physical therapy and surgical intervention [9]. The treatment may continue for months but there is no clear evidence on the best approach to take for treatment. Surgical evaluation of other complications such as the rotator cuff tear or subracomial bursitis may be needed.

Medications used most of the time are NSAIDs but corticosteroids are used in other cases either locally via injection or systemically. Manual therapists such as chiropractors and physiotherapists may also administer extensive stretches each day and massage therapy. The Spencer technique may also be used to treat the shoulder [10].

Prognosis

As discussed in the pathophysiology, most patients regain function range of motion but 10-15% suffers from remaining handicap which may be either pain or restricted motion [6]. Ten years down the line however, improvement may be seen with the handicap. Recurrence of primary frozen shoulder is very rare.

Etiology

There is a lack of clear evidence linking frozen shoulder to a specific etiology but there are various triggers that may predispose patients to this problem [2]. Some etiologic agents that have been identified in cases of adhesive capsulitis include the following:

  • Various shoulder ailments
  • Diabetes
  • Inflammatory disease
  • Surgery
  • Trauma

Additionally, an autoimmune theory has been postulated with elevated levels of C-reactive protein as well as an increase incidence of HLA-B27 histocompatibility antigen often seen in patients with this condition.

Epidemiology

Adhesive capsulitis is seen in patients aged 40-70 years but incidence is not clear. It is estimated however, that 3% of individuals develop the disease over their lifetime. Males are often affected less frequently than females and there is no clear racial predilection [3].

Adhesive capsulitis has been associated with some conditions. A higher incidence of the condition is seen in patients with diabetes (10-20%) in comparison to the general population (2-5%). In patients with insulin dependent diabetes, the incidence is higher (36%).

Sex distribution
Age distribution

Pathophysiology

Primary adhesive capsulitis is often considered to be a self-limiting disease that will last for 18-24 months but will heal in most cases, not leaving any residual handicap behind [4]. The condition often develops in three periods with duration of six months in each.

  • The first period is freezing
  • The second period is frozen
  • The third period is thawing

The freezing stage shows an insidious onset where pain is the major clinical picture. Most of the time, subacromial impingement is suspected due to the involvement of the subacromial bursa. By the end of this period, it becomes difficult to carry out a range of motion, making diagnosis very simple.

During the frozen period, there is a reduction of pain but the restricted mobility remains.

The thawing stage shows successive reestablishment of normal or near normal range of motion.

In frozen shoulder, there is a lack of synovial fluid which makes it possible for ball and socket joints to move with its lubricating action between the humerus and the shoulder blade socket [5]. The shoulder capsule also thickens, swells, and tightens due to bands of scar tissue (adhesions) which have formed inside the capsule. As a result of this, there is far less room in the joint for the humerus and this makes movement of the shoulder not only stiff but also painful. The main difference between stiff shoulder and adhesive capsulitis is this restricted space between the capsule and the ball of the humerus.

Prevention

One of the most common causes of frozen shoulder is the immobility that often results during recovery from a shoulder injury, broken arm or following a stroke. People who have had injuries that make it difficult for them to move their shoulders, should talk to their doctors on what exercises will be best for them to maintain a range of motion in their shoulder joint and avoid a frozen shoulder.

Summary

Frozen shoulder or adhesive capsulitis is a disorder that is both painful and of an unclear cause where the shoulder capsule becomes stiff and inflamed [1]. The shoulder capsule is the connective tissue surrounding the glenohumeral joint of the shoulder and its inflammation brings about chronic pain. The pain is often constant, worse at night and with cold weather. Certain movements can also provoke episodes of tremendous pain and cramping. The condition is believed to be caused by injury or trauma to the area and may have an autoimmune component.

Patient Information

Adhesive capsulitis or a frozen shoulder is a condition that brings about pain and stiffness in your shoulder joint. The signs and symptoms start gradually but worsen over a period of time before resolving. Everything happens within one or two years.

People who are recovering from a medical condition or procedure are the ones at the most risk of developing adhesive capsulitis. Medical procedures like mastectomy can also bring about the condition.

The treatment for frozen shoulder generally involves some stretching exercises and in some cases the injection of corticosteroid and other such medications into the affected shoulder joint. In a very small percentage of cases, surgery may be needed to loosen the joint capsule for it to be able to move more freely.

References

Article

  1. Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl. 1969;119:1-59.
  2. Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen shoulder: a long-term prospective study. Ann Rheum Dis. Jun 1984;43(3):361-4.
  3. Binder AI, Bulgen DY, Hazleman BL, Tudor J, Wraight P. Frozen shoulder: an arthrographic and radionuclear scan assessment. Ann Rheum Dis. Jun 1984;43(3):365-9.
  4. Lloyd-Roberts GC, French PR. Periarthritis of the shoulder. A study of the disease and its treatment. Br Med J. 1959;1:1569-71.
  5. Tveita EK, Sandvik L, Ekeberg OM, Juel NG, Bautz-Holter E. Factor structure of the Shoulder Pain and Disability Index in patients with adhesive capsulitis. BMC Musculoskelet Disord. Jul 17 2008;9:103.
  6. Morén-Hybbinette I, Moritz U, Scherstén B. The clinical picture of the painful diabetic shoulder--natural history, social consequences and analysis of concomitant hand syndrome. Acta Med Scand 1987; 221:73.
  7. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975; 4:193.
  8. Rizk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum 1982; 11:440.
  9. Grey RG. The natural history of "idiopathic" frozen shoulder. J Bone Joint Surg Am 1978; 60:564.
  10. Simmonds FA. Shoulder pain with particular reference to the frozen shoulder. J Bone Joint Surg Br 1949; 31B:426.

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Last updated: 2018-06-22 09:02