frozen shoulder

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    Overview

    Frozen shoulder (also known as adhesive capsulitis or periarthritis) is used to describe the condition where the glenohumeral joint of the shoulder is stiff and painful. It occurs in about 2-5% of the general population, with a higher prevalence among elderly individuals and those with diabetes. Frozen shoulder is a benign and self limiting condition, usually lasting for 1-3 years, in 20-50% of patients the stiffness and pain only partially resolve, which leads to long lasting effects of shoulder mobility impairment and reduction in sleep quality. Commonly patients who suffer persistent symptoms (over 4-5 years) only suffer mild long term effects.

    Anatomy

    The hallmark pain and stiffness are caused by the formation of adhesions or scar tissue in the glenohumeral (GH) joint. The GH joint is a ball and socket joint between the scapula and humerus, connecting the upper arm to the trunk. Under normal conditions this joint is one of the most mobile in the human body, allowing for a large range of motion in multiple planes. In the case of frozen shoulder the adhesions limit this range of motion and make movement painful.

    Frozen Shoulder

    Symptoms

    There are 4 recognised clinical stages of the condition:

    1. Painful stage- moderate pain and reduction of movement lasting less than 3 months
    2. Freezing stage- severe pain and reduction of movement lasting 3-9 months 
    3. Frozen stage- pain may be present but stiffness predominates lasting 10-14 months 
    4. Thawing stage- minimal pain and gradual improvement in movement lasting 14-24 months

    Causes

    The cause of frozen shoulder is still unclear. Historically researchers into the aetiology of the condition have shown that it is characterised by a thickened, tight capsule with chronic inflammatory cells and fibroblasts found in the joint capsule. It can occur as a primary idiopathic condition or secondary to medical conditions or trauma.

    Diagnosis

    Frozen shoulder is diagnosed by testing positive to three characteristics:

    1. Insidious onset of severe pain over a period of months, night time pain is a common feature 
    2. Shoulder stiffness with markedly reduced external rotation 
    3. Negative radiographic findings

    Some patients describe the pain as a deep ache, poorly localised and non specific without any point of tenderness. In others it presents as a pain which refers to the deltoid origin and radiates down to the bicep area. Manual testing will often return normal rotator cuff strength but a greatly reduced passive and active range of motion. 

    In some cases laboratory tests may be carried out to identify or rule out underlying conditions. Radiographs of the shoulder will also return normal with a patient suffering from frozen shoulder, but may be carried out to exclude conditions such as shoulder dislocation, GH arthritis or calcific tendinopathy.

    Treatment

    There is no universally accepted intervention which is viewed as the most effective treatment for restoring motion and reducing pain. 

    Non-surgical or conservative management is preferred with most patients improving in 6-18 months. This includes analgesics, oral steroids, physical therapies and supra-scapula nerve block. Physical therapy, from a sports massage and remedial therapist or physiotherapist, has traditionally been the first choice of treatment for frozen shoulder. The therapist can work to reduce pain, mobilise the joint and provide the patient with a supervised  stretching and strength maintenance programme.

    Exercises

    Exercises should be carried out under the direction of a qualified therapist and vary according to the stage of the condition. 

    1. Early freezing stage: gentle and short duration stretches e.g. pendulum exercises, passive external rotation and supine passive forward elevation
    2. Later frozen stage: strengthening exercises e.g. isometric external shoulder rotation and posterior capsular stretching 
    3. Thawing stage: combined strength in and stretching exercises with increased frequency 

    Prevention

    As the aetiology of the condition is still unknown advising on how to prevent an incidence of the condition is difficult. Research has suggested that prolonged immobilisation or limited use of the shoulder joint may contribute to the likelihood of developing frozen shoulder. With this in mind regular balanced exercise and stretching can help to maintain the structural support and mobility of the GH joint.

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