Frozen Shoulder (Adhesive Capsulitis)
Frozen shoulder is a contracture of the shoulder joint capsule.
Either spontaneously or following a minor injury the capsule and ligaments of the shoulder joint contract causing pain and stiffness.
The cause of this condition is not completely understood and the trigger for the onset is unknown.
The condition can occur following minor trauma or sometimes spontaneously. There are some associations with the disorder – patients with Diabetes and Dupuytrens Disease are more likely to develop frozen shoulder.
Symptoms
Classically there are 3 phases. The natural history is that all 3 phases of the condition take approximately 18 - 36 months to resolve. Most patients are left with little long term disability in terms of function but will note loss of end range movements and will never have a completely normal shoulder. The amount of long term permanent disability has generally been underestimated in the orthopaedic literature over the years.
Phase 1 – PAIN – Insidious onset with increasing severity over weeks to months. In this freezing phase the shoulder loses active and passive motion. This initial phase can be very painful. The pain is bad at night time and made worse by sudden shoulder movements.
Phase 2 – STIFFNESS – "frozen" phase, pain begins to decrease and leaves global stiffness – this phase usually develops after about 2-3 months. The key sign appears now that of inability to externally rotate the arm with the elbow at the side.
Phase 3 – THAWING – Return of motion to near normal. This can take 1-5 years.
The key point is that you realise the natural course of the condition and its length of time to recovery
Diagnosis
This is made on the basis of the history and examination.
The key distinguishing examination feature of Frozen Shoulder is the loss of outward rotation of the shoulder with the arm / elbow at the side.
This is due to contracture of the shoulder capsule and in particular an an area called the Rotator Interval. This triangular area of the shoulder capsule is found at the front of your shoulder between the tendons surrounding your shoulder.
It is normally thin, loose and pliable. In frozen shoulder this interval region contracts and some of the cells can even develop features of muscle cells.
Contracture of the rotator interval locks the shoulder up and the classic motion loss is the loss of external rotation as described above.
X-rays are usually normal. Ultrasound scans reveal no tendon tearing. MRI scans will show loss of volume inside the joint due to shoulder capsule shrinkage. MRI is not indicated in classic frozen shoulder...
Treatment
Treatment for the majority of patients is non operative.
There has however been a trend towards early surgical intervention in the shoulder literature. This is to decrease the pain and length the condition affects the patient.
Generally most patients once they know their diagnosis prefer to have non operative management rather than go straight to surgery.
Non – Operative
The majority of patients will respond to a non-operative regime. This involves
- Administration of approximately 2-3 steroid injections into the joint and
- A stretching exercise program to free the shoulder that is either done on your own or with physiotherapy supervision.
Operative
- A small group of patients fail to recover satisfactory motion and do not progress to acceptable motion / thaw out. The aim of surgery is to accelerate recovery and regain motion
- These patients are offered a 15 - 20 minute daystay keyhole procedure to release the contracted shoulder capsule
- This operation involves a general anaesthetic and the placement of a local anaesthetic block in the neck to eliminate pain for 2-4 days while they perform intensive physio
- This modern surgical approach of releasing the capsular contractions is a significant advance on the old fashioned manipulation of the shoulder under anaesthetic that has been shown to cause collateral damage to internal structures in the shoulder joint.
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