Adhesive capsulitis or frozen shoulder or arthrofibrosis is a pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint (shoulder joint), leading to pain, stiffness and dysfunction. The condition can be either primary (idiopathic) or secondary. The incidence of adhesive capsulitis in the general population is approximately 3% to 5% but is high as 20% in patients with diabetes. Adhesive capsulitis is often regarded as a self-limiting disease that resolves within 3 years of onset.
Shoulder joint is formed by head of humerus articulating within glenoid cavity of scapula and the joint is surrounded by capsule (tough sheet like tissue). The head of the humerus usually moves smoothly in the glenoid cavity which is a depression in the scapula. A shoulder is “frozen” when the capsule protecting the glenohumeral joint contracts and stiffens. Scar tissue (adhesions) may also form between the joint capsule and the head of the humerus. The connective tissue surrounding the glenohumeral joint and the joint capsule thickens and contracts losing its normal capacity to stretch. Since shoulder movement causes pain, patients tend to avoid shoulder movement which further causes capsule contraction. The head of humerus gradually has decreased space to move within the joint and the joint may gradually lose its lubricating synovial fluid. In advance cases, bands of scar tissue (adhesions) form between the joint capsule and the head of the humerus.
Risk factors for adhesive capsulitis include
Patients with adhesive capsulitis will often report:
PHASE 1: Painful phase with progressive and increasing pain on shoulder movement. This phase lasts for 2 months to 9 months.
PHASE 2: Freezing or Stiffening phase with gradual reduction of pain. There is considerable restriction in range of motion in this phase lasting from 4 months to 12 months. Pain in shoulder joint decreases and is persistent at end range of motion.
PHASE 3: Resolution or thawing phase, where there is improvement in range of motion with resolution of stiffness. Pain on end range movement may persist until full resolution. The phase usually lasts from 12 months to 42 months.
The diagnosis of frozen shoulder is based upon a thorough history and physical examination Clinically, patients with this condition usually ﬁrst present with shoulder pain followed by gradual loss of both active and passive range of motion (ROM) due to ﬁbrosis of the glenohumeral joint capsule. External rotation is often the ﬁrst motion aﬀected on clinical examination, with steady global loss of range of motion with disease progression. Pain is generally worse at the extremes of motion, when the contracted capsule is stretched. Passive range of motion is lost with ﬁrm painful endpoints of motion.
In most cases of adhesive capsulitis, all laboratory investigations are normal unless there is an associated illness. Radiography is most useful in ruling out other shoulder disorders. Plain films of the shoulder may reveal osteopenia in patients with prolonged adhesive capsulitis. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) may reveal thickening of capsular and pericapsular tissues. Dynamic sonography may reveal limited sliding movements of supraspinous tendon.
Frozen shoulder when diagnosed early and treated promptly has excellent prognosis. Cornerstone of treatment is establishing shoulder range of motion by physical therapy. Pain management is key to allow patients to tolerate physical therapy to improve range of motion.
1. Pharmacological Therapy
Medications are prescribed for decreasing pain and inflammation in the joint, for short duration mainly during the acute inflammatory phase. They act as adjunct to physiotherapy.
Non-Steroidal Anti-inflammatory drugs (NSAIDs) – Painkillers like Naproxen, Indomethacin, Aceclofenac, Etoricoxib, Piroxicam, Ibuprofen, Etodolac and others are prescribed to decrease pain and inflammation occurring in the joint. They can be given orally as tablets or as intramuscular injections (i.m).
Corticosteroiods: Prednisolone tablets may be given in severe cases to decrease inflammation in the joint. In Diabetics monitoring of blood sugar levels are mandatory when taking steroid medications.
2. Physical Therapy
For patients with early stages of adhesive capsulitis, physical therapy is the first line of treatment. Early mobilization with physical therapy is recommended. Physical therapy protocol for frozen shoulder includes various components:
Duration and intensity of physical therapy is customized as per patient’s disease severity and tolerance. Each patient should receive a customized plan for therapy.
Various interventions can be done to decrease the pain associated with frozen shoulder. These injection techniques decrease pain and allow pain free physical therapy and rehabilitation.
How do these injections benefit in case of frozen shoulder?
Inflammation of the tendon of the supraspinatus muscle results in a condition – Supraspinatus tendinitis. Acute pain along with tenderness and swelling in the upper front part of the shoulder is the main symptom of this ailment. The affected person will find it difficult to raise arm up to his shoulder level. The condition can be treated with Non-Steroidal Anti-inflammatory Drugs (NSAIDs) along with an ice massage in the affected area. Electrical stimulation, and physical therapy can also help in treating this condition.
Biceps Tendinitis is a common reason for acute shoulder pain. Inflammation in the long head of the biceps tendon results in this condition. Biceps Tendinitis is common in people involved in activities that require repetitive overhead motion of the arm. The person affected will experience pain in the front of the shoulder. In the initial stage, anti-inflammatories are provided to lessen the inflation and pain. The patient is also asked to apply ice on the affected area, along with restricting over-the-shoulder movements, reaching, and lifting. Physiotherapy treatment is advised for a speedy recovery.
Broken Collarbone (Clavicle Fracture)
A broken collarbone can happen as a result of a hard fall, which may lead to a direct blow to the shoulder. This condition is common in people involved in activities like football, lacrosse, hockey, biking, skiing, snowboarding, and skateboarding, among others. The symptoms include swelling, tenderness, and bruising in the affected area, and also acute pain when moving the shoulder. If the fracture is a minor one, you can use a splint or brace to keep your shoulder from moving. This helps in fast healing. Application of ice is also a remedy to alleviate pain and inflammation. Surgery might be needed in severe cases.
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