Adhesive Capsulitis (Frozen Shoulder)

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What is it?

Often referred to as ‘frozen shoulder’ adhesive capsulitis refers to inflammation and scarring of the capsule which surrounds the shoulder joint (See figure1). Frozen shoulder is a condition that causes shoulder pain and limits the shoulder’s range of motion. The limitation in movement affects both active and passive range of motion. That means that your movement is restricted at the shoulder joint both when you try to move your own arm and when someone else (such as your doctor) tries to move your arm for you. Frozen shoulder is also called “adhesive capsulitis”, “painful stiff shoulder”, and “peri-arthritis”.

Figure 1 

How did I get it?

Frozen shoulder is fairly common, affecting 2 to 5 percent of the general population. The condition is most common in people in their 50s and 60s and rarely affects anyone younger than 40. Women are more often affected than men. Frozen shoulder usually affects only one shoulder (left or right) and gets better on its own but it can last two to three years or even longer. People who get frozen shoulder on one side can go on to develop it on the other. Frozen shoulder most often happens as a result of a shoulder injury such as a rotator cuff tear, a bone fracture affecting the shoulder, or shoulder surgery. Frozen shoulder can also happen without a preceding injury and tends to preferentially affect people with certain diseases and conditions. People with diabetes for example, have an increased risk of developing frozen shoulder. In fact 10 to 20 percent of people with diabetes develop the condition. The exact reason why adhesive capsulitis develops is not known. However it is believed to result from some form of irritation to the shoulder joint and its surrounding capsule which results in an inflammatory response. This inflammation of the shoulder joint capsule is referred to as ‘capsulitis’. Associated with the capsulitis is the formation of adhesions or small scars between folds within the capsule.

What are the symptoms?

The two main sensations felt with adhesive capsulitis are pain and a loss of movement in the shoulder. The pain may be aching, dull or stabbing, and is most frequently
felt deep in the shoulder and over the outside of the upper arm. It is generally aggravated by almost all movements of the shoulder and arm, and its intensity or strength may vary from day-to-day depending on how much you use the arm. The pain is often strong enough to interfere with your normal activities and you may feel it at night when sleeping. The loss of movement in the shoulder results from the adhesions or scars forming within the joint capsule. These generally develop gradually resulting in a progressive rather than sudden loss in the range of motion in the shoulder. Stretching of these adhesions may aggravate your pain. People who have frozen shoulder often go through three phases of symptoms:

• The first phase lasts two to nine months and involves diffuse, severe and disabling shoulder pain that is worse at night. During this phase, the shoulder becomes increasingly stiff.

• The second is an intermediate phase which lasts 4 to 12 months. During this phase, the shoulder becomes very stiff and has limited mobility but the pain gradually reduces.

• The third is the recovery phase which lasts 5 to 24 months. During this phase people gradually regain range of motion.

What should I do?

If you have or suspect you have adhesive capsulitis you should avoid provocative activities such
as reaching with the arm. You should see a medical practitioner for definitive diagnosis. There are some conditions which can mimic adhesive capsulitis and so it is critical to get the correct diagnosis. If you have or suspect you have adhesive capsulitis you shouldn’t simply ignore the problem. The longer you leave the condition without treatment, the worse it may become. This may make your pain and restriction in movement worse and prolong your recovery. Adhesive capsulitis usually gets better on its own however this normally takes a number of months and there is little that can be done to accelerate this time frame. Treatment can markedly reduce some of the worse aspects that accompany this condition during the recovery phases. Fortunately, once recovery does occur the long-term outlook is good, unless there is some other underlying condition affecting the shoulder such as a tear of the rotator cuff.

Exercises to help recovery

Once the initial pain of frozen shoulder decreases you may need to start certain exercises to improve your shoulder mobility. This is best done supervised by a physiotherapist. Begin slowly and do not push yourself too much initially. During the first two to three months of recovery rest your shoulder and do gentle range of motion exercises. As you start to improve you can add in more exercises that build strength but don’t do exercises which cause you pain.

Cortisone injections — Cortisone injections can be used for diagnostic and therapeutic purposes. If there
is dual pathology i.e. there are two problems with the shoulder then sometimes an injection can be considered. The response to the injection can often indicate which problem is affecting you the greatest. The other reason an injection maybe given is simply it can provide pain relief. The cortisone does not modify the course of the symptoms but can provide effective symptom relief. Another treatment, called “hydrodilatation” involves injecting the shoulder with glucocorticoid and saline to expand the joint and this often provides effective short- term relief.

How is a diagnosis made?

The diagnosis can be straightforward or very difficult depending on the nature of the symptoms. Many patients can be diagnosed easily based on the nature of the pain, physical examination and x-rays. Sometimes extra tests such as ultrasounds and MRI are performed to either rule out other possibilities or confirm the diagnosis.

What does rehab involve?

In most cases frozen shoulder gets better on its own even without treatment. However, there are cases in which people never regain the full range of motion they had before. There are a few treatment options for frozen shoulder which can be combined but there’s no obvious course of action that is right for everyone. Treatment options include physical therapy, medications to manage pain and inflammation, and in extreme cases only surgery.

If you are being treated for frozen shoulder remember that recovery can be a slow process and that you need to give treatment time to work. If you are in pain you can take non- prescription pain medications i.e. Panadol or Nurofen.


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