Frozen shoulder or Adhesive Capsulitis occurs in 3 -5 % of general population and commonly seen in the age group of 40-70 years. It is seen much more commonly in individuals with diabetes, affecting about 20% to 40 % of these individuals. Bilateral involvement is seen in about 30 percent cases and females are affected more often.

More commonly, frozen shoulder can develop after a shoulder is injured or immobilized for a period of time. Often an Insidious or minimal traumatic event resulting in temporary inactivity can trigger the onset of this debilitating shoulder pathology. Because of the incapacitation caused by this debilitating disease, it contributes significantly to loss of man hours and hence an economic burden for the society.

Frozen shoulder is a biological puzzle, and a common one. It’s hard to define precisely, diagnose accurately, or treat effectively. In fact, frozen shoulder treatment is one of the best examples of how musculoskeletal medicine is surprisingly still so primitive.

The shoulder is the only joint that often “freezes” like this and the etiology is varied with difference in respective presentations.

Credit: JP Williams GR eds. Disorders of the Shoulder: Diagnosis and Management. Philadelphia PA Lippincot Williams and Wilking 1999

SYMPTOMS

Shoulder joint is the most mobile joint of the body and suddenly the patient notices that the range of motion fails, slowly and painfully, usually just on one side. Most of the patients first notice that they are having trouble reaching bra clasps, hip pockets, and back itches. The painful early stage mostly involves aching or burning deep in the shoulder joint, sometimes extending into the upper arm, often worst at night. Sudden movements can cause surges of much sharper and more extreme pain.

Slowly, the range of mobility gets more restricted with increase in pain score often at rest. Many frozen shoulder patients consider it the worst pain they’ve ever endured.

The characteristic signs and symptoms include

Significant pain in the shoulder joint which gradually increases and eventually persisting as night pain

Significant limitations of active and passive shoulder motion in more than 1 plane especially rotations.

The Dilemma for the Physician

·        Pathology of the disease is poorly understood.

·        Treatment protocols not well defined and vary with different surgeons.

·        Recovery is delayed and often incomplete.

·        Not all frozen shoulders are contractured. That suggests that quite a few cases are functionally frozen.

Image Credit: https://www.painscience.com/tutorials/frozen-shoulder.php

ANATOMICAL PERSPECTIVE

Your shoulder is made up of three bones that form a ball-and-socket joint. They are your upper arm (humerus), shoulder blade (scapula), and collarbone (clavicle). There’s also tissue surrounding your shoulder joint that holds everything together. This is called the shoulder capsule.

With frozen shoulder, the capsule becomes so thick and tight that it’s hard to move. Bands of scar tissue form and there’s less of a liquid called synovial fluid to keep the joint lubricated. These things limit motion even.

STAGES OF FROZEN SHOULDER

• Acute/freezing/painful phase: Gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 2-9 months.

• Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of shouldermotion. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last till about 12 months.

• Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion which can last anywhere from 5 to 24 months. Many studies have shown that up to 40% of patients may have persistent symptoms and restriction of movement beyond three years. It is estimated that 15% may have persistent pain and long term disability. Effective treatments which shorten the duration of the symptoms and disability will have a significant value on reducing the morbidity.

INVESTIGATIONS

Radiographs are usually normal in a frozen shoulder patient and to rule out primary pathologies MRI can sometimes be of use. However, MRI is not mandatory for the diagnosis of frozen shoulder, and it is essentially a clinical diagnosis.

PREVENTION OF FROZEN SHOULDER: DOs & DONTs

1. Maintain movements of the shoulder as much as possible: One of the most common causes of frozen shoulder is the immobility that may result during recovery from a shoulder injury, broken arm, or a stroke. If you've had an injury in any part of upper limb that makes it difficult to move your shoulder, talk to your doctor about exercises you can do to maintain the range of motion in your shoulder joint.

2. Control diabetic profile and hypothyroidism.

3. Avoid immobilization of shoulder unless until it is unavoidable. Even if it has to be immobilized keep doing pendulum exercises as far as possible under Treating Doctor’s guidance.

4. Start Physiotherapy as soon as possible and don’t delay.

5. Never massage the shoulder joint which can actually increase the stiffness.

TREATMENT PROTOCOLS: “USE IT OR LOOSE IT”

Treatments should be tailored to the stage of the disease because the condition may not have a predictable progression. Moreover, we need to consider the causative factors (the primary and the secondary factors) of the disease for the individual.

We also need to be upfront with our patients with regards to the nature of the disease as well as factors which may not be directly addressed with physiotherapy (for example, if the patient is diabetic, it will potentially be a longer recovery and require the intervention of a multi-disciplinary team). Managing expectations with the patient is key to a successful recovery.

We, as clinicians, need to consider an appropriate intervention at the right stage. We need to manage the pain levels as soon as possible. It's very important, and again, if we can do things that can help them sleep, that can have a massive benefit on their pain levels, but also their emotional state.

Treatment protocols are broadly divided in two parts

NON-INVASIVE PROTOCOLS: PHYSIOTHERAPY

Physiotherapy is the mainstay and an integral part of any treatment modality for Frozen shoulder. The patient must visit a well-equipped physiotherapy center at the earliest where Thermal therapy such as ultrasonic therapy/wax therapy/Laser Therapy and exercise therapy such as shoulder wheel and pulley systems are available.

The therapy needs to be supervised by a qualified physiotherapist in the beginning for about 2 weeks and then depending on the response of the patient protocol can be changed to home based.

The therapy should be started at the earliest to avoid disease progression as it becomes more painful and incapacitating as the disease progresses. The patient should continue the physiotherapy exercises at home also while attending to a physiotherapy center.

PHARMACOLOGICAL TREATMENT: Analgesics/Anti-inflammatory medicines

 INVASIVE TREATMENT METHODS (Physiotherapy has to be done with all the modalities)

• A Corticosteroid injection in shoulder joint to reduce Edema, Inflammation and thereby decreasing pain and facilitating good physiotherapy can improve range of motion. The injection can be repeated up to three times at specified intervals. However, the results are unpredictable and the patient needs to be counseled properly.

• Biological treatments: Autologous PRP/PRF Injection in shoulder joint controls inflammation in the joint and promotes healing by growth factors and facilitates achieving normal ROM of shoulder.

• Shoulder manipulation under Anaesthesia can help loosen up your shoulder tissue but is very rarely done anymore because arthroscopic surgery has replaced it. Surgeons would forcefully move the shoulder under general anesthesia. With this method, there was an increased risk of complications including fractures.

 • Arthroscopic Surgery (key-hole surgery of shoulder)

This may be necessary to treat frozen shoulder which fails to respond to physiotherapy and injections. This is highly advanced technique in which a release of capsule is done by using a camera with multiple key holes, without the need of an open surgery.

ARTHROSCOPIC RELEASE OF SHOULDER

Needless to say, physiotherapy is an integral part of management irrespective of the invasive modality used. Recurrence rate in absence of an effective physiotherapy protocol can be as high as a whopping 75 percent.

A home-based physiotherapy protocol is also effective with makeshift arrangements at home with the help of basic things.

Early recovery from frozen shoulder is dependent on multiple factors

1. Early identification of ROM restriction by the patient during activities of daily living.

2. Early reporting to an Orthopaedic surgeon for assessment of the restriction, medications and advice for Physiotherapist.

3. Regular visit to a well equipped physiotherapy center for exercises and thermal therapies under supervision by a well qualified physiotherapist. ( An uncontrolled vigorous physiotherapy can lead to more damage to shoulder)

4. Good patient compliance for Home based exercise schedule everyday.

5. Regular follow-up with the Orthopaedic surgeon.

The bottom line remains individualizing the treatment plan to every patient as well as focusing on the quality of the shoulder movement. It is always a combined effort by the three components, an Orthopaedic surgeon, the Physiotherapist and good Patient compliance for an effective treatment and for an optimal result none of the components can be compromised.