Adhesive Capsulitis Or Frozen Shoulder

MUHAMMED KOCABIYIK
PHYSICAL MEDICINE & REHABILITATION IV. CLASS V. GROUP

Definition

The glenohumeral joint (ball and socket joint) is surrounded by a fibrous capsule that is reinforced with several ligaments. This capsule/ligament complex serves several functions: 1) keep the joint water tight; 2) provide support to help hold the ball in the socket at the end ranges of shoulder motion; 3) provide sufficient volume to allow the shoulder to move through an incredibly wide range to position the hand in space. When frozen shoulder syndrome occurs, this capsule becomes inflamed, thickened and contracted. This process dramatically affects shoulder mobility. The contracted capsule prematurely reaches maximal stretch before the shoulder reaches its normal end range of motion. As the capsule contracture increases, shoulder motion decreases. Certain types of frozen shoulder can also occur from scar tissue that develops between the muscle layers of the shoulder joint and shoulder girdle.

Causes

Idiopathic: This terms indicates that the cause is unknown.

Idiopathic cases account for the majority of patients presenting with onset of shoulder stiffness.

Systemic Illness: Diabetes, hyperthyroidism (overactive

thyroid), cardiovascular disease, lung disease, depression and Parkinsons disease have all been associated with frozen shoulder syndrome. Diabetes has the most notable association and frozen shoulder may occur in roughly 15% of diabetic patients, particularly those who have been on insulin treatment for greater than 10 years.

Post-operative: Shoulder surgery for conditions such as

rotator cuff tear, proximal humerus fracture, shoulder instability and arthritis may result in stiffness due to aggressive scar formation during the healing process. Prolonged immobilization to protect a surgical repair may lead to stiffness. Frozen shoulder syndrome has also been reported following neck surgery, open heart surgery, and radiation therapy for breast and lung cancer.

Post-traumatic: Shoulder or arm injury may result in a

frozen shoulder from prolonged immobilization, scar formation during tissue healing or from a mechanical block to movement as may occur if bony fractures heal in the wrong position.

Risk Factors

Ageing - In Japan frozen shoulder syndrome is called "Fifties Shoulder".

Posture - especially round-shouldered Shoulder-intensive sports Shoulder intensive or repetitive manual occupation Diabetes - Types I and II Trauma Immobilisation / splinting Fracture of the collar bone or humerus (arm bone) Surgery (especially after shoulder surgery, or mastectomy with breast reconstruction)

Stages of the Disease

Inflammatory Phase: this initial phase occurs over 3

weeks to 3 months and is marked by relatively severe shoulder pain. During this phase, the capsule becomes inflamed and the process of thickening and contracture begin. Initially, pain predominates without significant stiffness, but gradual loss of motion ensues. Pain at rest and night pain accompany pain with active use.

Freezing Phase: during this phase, shoulder motion

continues to decrease until it approaches a minimum range. Pain increases during this phase approaching a plateau. The time course of freezing is variable but generally lasts between 3 months and 9 months after the onset of frozen shoulder.

Frozen Phase: this phase is characterized by fixed loss of

motion that does not increase or decrease. The shoulder remains uncomfortable during active use as well as at night. Pain diminishes relative to the first two phases and is more manageable. The frozen phase also varies in duration but may lasts between 6 months to a year.

Thawing Phase: Thawing is marked by gradual return in

range of motion and progressively decreasing pain. The shoulder is no longer irritable. This phase generally begin somewhere between 1-2 years after the onset of frozen shoulder. Note: These phases apply only to idiopathic frozen shoulder and that which develops from systemic illness. They do not apply to post-operative and posttraumatic frozen shoulder.

Symptoms and Signs

Symptoms: Progressively worsening pain without preceding injury is the

typical history of a frozen shoulder. Patients often think they have bursitis or a rotator cuff tear because the shoulder hurts with active use. Strength is generally unaffected but limited by pain. Increasing difficulty with daily activities including dressing and hygiene are common complaints. Night pain and pain that awakens patients from sleep is one of the most troublesome symptoms. Some patients have pain that radiates into the neck, back or upper arm due to shoulder fatigue.

Signs: the physical exam of a frozen shoulder demonstrates loss of both

active and passive motion. This motion loss may be globally restricted in all ranges or may be focally restricted in specific ranges. Loss of internal rotation (ability to put the hand behind the back) is usually the most affected. Strength testing generally indicates intact rotator cuff function. Rotation of the ball in the socket is smooth and without grating as occurs in arthritis.

Diagnosis

The diagnosis of frozen shoulder is usually made on the basis of your medical history and physical examination. One key finding that helps differentiate a frozen shoulder from a rotator cuff tear is how the shoulder moves. With frozen shoulder, the shoulder motion is the same whether the patient or the doctor tries to move the arm. With a rotator cuff tear, the patient cannot move the arm. But when someone else lifts the arm it can be moved in a nearly normal range of motion. Simple X-rays are usually not helpful. An arthrogram may show that the shoulder capsule is scarred and tightened. The arthrogram involves injecting dye into the shoulder joint and taking several X-rays. In frozen shoulder, very little dye can be injected into the shoulder joint because the joint capsule is stuck together, making it smaller than normal. The X-rays taken after injecting the dye will show very little dye in the joint. Probably the most common test used is magnetic resonance imaging (MRI). An MRI scan is a special imaging test that uses magnetic waves to create pictures that show the tissues of the shoulder in slices.

The MRI scan shows tendons and other soft tissues as well as the bones.

Colorized to illustrate soft tissues revealed in MRI

Treatment

Activity Modification: patients with frozen shoulder are encouraged to remain active and use the affected extremity. Activities which stress the shoulder and cause significantly worsening pain, however, may increase the inflammation in the shoulder capsule. This is particularly true in the inflammatory and freezing phases of the disease. Trying to work through the pain is not recommended, and patients may have to modify their work and recreational activities until the pain reaches a plateau.

Physical Therapy: the goals of physical therapy are as follows: 1) gently stretch the shoulder to prevent worsening stiffness and improve mobility;

2) decrease pain and inflammation through techniques such as ultrasound and cold therapy;
3) gently strengthen the rotator cuff and shoulder girdle muscles to prevent atrophy from disuse of the shoulder; 4) instruct patients on the proper techniques for a home exercise program. We generally recommend that patients attend a structured physical therapy program for about 6 weeks to accomplish these goals. Physical therapy may be most effective in the frozen phase of the disease. Overly aggressive stretching during the inflammatory and freezing phases may actually worsen inflammation and prolong the disease and patients should avoid trying to work through the pain.

Home Exercise Program: gentle stretching exercises should be performed 2- 3 times daily to prevent adhesions from reforming between therapy sessions. As much as possible, these sessions should be performed after the shoulder has been relaxed by a hot shower, bath, or aerobic exercise. An important principle of the stretching exercises is to allow the muscles to relax so that the stretch can be applied to the soft tissues without muscle interference. Tissues of a tight shoulder do not like to be stretched suddenly, roughly, or with a lot of force. Thus the strategy is to apply a gentle stretch so that at most minimal soreness results. Any soreness should go away within 15 minutes after you stop the exercises. Improvement in the range of motion and comfort may not begin until six weeks of persistence with the program. One should not stop these exercises until the frozen shoulder has regained normal motion and comfort.

Non-steroid Anti-inflammatory Medications (NSAIDS): these medications include Ibuprofen, Motrin, Advil, Naprosyn, Alleve, Bextra, Celebrex, and many others. They act both to reduce inflammation and to relieve pain. They may be more effective in the early phases of frozen shoulder syndrome when the shoulder capsule is inflamed. Once the inflammatory process has plateaued and patients reach the frozen phase, these medications are not likely to have significant benefit. Long term use of NSAIDS may be associated with risks such as irritation of the stomach lining, ulcers and kidney problems. Patients should become informed about the possible short and long-term side effects of each medication prior to use. Other Medications: Narcotic pain medications, muscle relaxants and sleepingpills are generally not recommended for frozen shoulder syndrome as prolonged use may diminish their effectiveness and may cause medication dependence or even addiction.

Other non-operative treatments

Cortisone Injections: Cortisone is a powerful anti-inflammatory medication that can be injected directly into the shoulder joint so that it acts locally on the inflamed shoulder capsule. As with oral medications, it may be most effective in the inflammatory and freezing phases of the process which are dominated by inflammation. Occasionally, 2-3 shots spaced over several months may be necessary to have an effect. The results of this treatment are variable and some patients do not respond. Nevertheless, cortisone injections remain a reasonable alternative in patients with moderate to severe discomfort whose quality of life is significantly affected by the disease. The injections are generally well tolerated and have minimal sideeffects. In patients with diabetes, cortisone shots may temporarily elevate the blood sugar and careful glucose level monitoring is recommended for the first few days after treatment.

Nerve Blocks: the suprascapular nerve supplies sensation to the shoulder capsule. There is growing evidence that blocking this nerve with a series of injections may help alleviate some of the discomfort of frozen shoulder. These injections are performed by the anesthesiologists who use a device called a nerve stimulator to target the injection into the proper location. Nerve blocks are not a cure for frozen shoulder. Rather, their purpose is to reduce the effect of shoulder discomfort on the patients quality of life and facilitate a home exercise program.

Acupuncture: This is an ancient medicinal art that uses needles inserted into the body at points along the meridians just under the skin. These needles stimulate, disperse and balance the flow of energy, relieve pain, and treat a variety of chronic, acute and degenerative conditions. There is anecdotal evidence that acupuncture may be helpful in managing the pain associated with frozen shoulder. As with most other treatments, however, acupuncture is not a cure and does not necessarily shorten the course of the disease.

Surgery may be considered if a concerted effort at non-operative

treatment has failed to result in improvement in comfort and function after 6-9 months.

Exercises for Frozen Sholder

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