A Family Doctor's Tale - FROZEN SHOULDER

DOC I HAVE A FROZEN SHOULDER

There are many patients with frozen shoulder who have the condition for many months and do not seek treatment until the shoulder is restricted in the movements. 
Some of the patients seek Chinese accupuncture before seeking Western medical treatment. Most of the cases are women. 
There is difficulty in wearing their clothes and pain on turning to the affected side in bed. 
Most of my patients responds to injections of lignocaine and hydrocortisone, followed by the exercises to loosen the shoulder muscles.


Frozen Shoulder (also known as adhesive capsulitis) is a disorder of the shoulder characterized by the slow onset of pain and restriction of movement.


It tends to be chronic and full recovery may take several months.


It is more common in women and diabetes.


Incidence is about 2 in a 1000.


The exact cause is unknown but several conditions has been blamed:

1.bicipital tenosynovitis- inflammation of the biceps muscles and tendon limiting its movements


2.rotator cuff tendonitis - inflammation of the rotator cuff muscles which surrounds the shoulder with resultant adhesion and stiffness causing limitation of movement


3.reflex sympathetic dystrophy-a disturbance in the sympathetic nervous system cause pain in the shoulder joint and hypersensitivity of the muscles surrounding the joint. 
There is swelling of the arm followed by atrophy of the muscles


4.trauma - injury to the joint may cause tightening of the injured muscles around the shoulder joint.

Surgery of the shoulder, breast and lung may also cause frozen shoulder because of the pain resulting from the movement of the shoulder and hence stiffness of the muscles.


Symptoms:
1.Pain in the shoulder radiating down the deltoid muscle and anterior aspect of the arm


2.Pain usually is worse at night especially lying on the affected shoulder


3.Certain movements makes the pain worse


4.Pain is described as constant, dull and aching


5.complaints of stiffness of the shoulder


6.inability to wear a shirt or blouse because of restricted movements


Signs:
1.apprehensive patient who holds the arm protectively


2.Generalized tenderness of rotator cuff and biceps muscles


3.Limited shoulder movement


4..Range of muscle movement is reduced in all directions


5.Arthrogram or MRI of shoulder can be done to confirm the diagnosis and exclude a posterior shoulder dislocation..


Conservative treatment:

Initial phase:
1.rest of the shoulder


2.moist heat


3.Pain killers such as NSAID(non-steroidal anti-inflammatory drugs) for pain


4.Muscle relaxant to relax muscles


5.injection of local anesthetic and long acting steroid into the rotator cuff muscle may help to relieve pain.


Mobilization phase:
1.Physiotherapy such as traction, shortwave diathermy


2.gradual mobilization and exercises to loosen the tight muscles surrounding the shoulder


Maintenance phase:
1.Continual exercises of the shoulder muscles


2.Avoidance of strain on the muscles of the shoulder


Manipulation of the frozen shoulder may be done under anaethesia to break the adhesion and restore some movement.


Surgery is usually not indicated in frozen shoulder.
Rarely surgery is used to cut the adhesions.


Prognosis depends on the underlying cause.


In most cases frozen shoulder may resolve itself with time


Frozen shoulder is a disabilating disease which can last from 5 months to 4 years.
There is chronic inflammation of the muscles surrounding the joint with adhesios formed between joint and muscles causing restriction of movement of the joint.
There is also reduced fluid in the joint further restricting movement.


Stage one("freezing" or painful stage):
There is a slow onset of pain which becomes worse and stiffening of the joint occurs.This lasts 5 weeks to 9 months.


Stage two("frozen" or adhesive stage):
There is a slow but steady improvement in pain, but the stiffness persists. This lasts 4 -9 months.


Stage three("thawing" or recovery):
There is a gradual return to normalcy in the shoulder motion.
This  lasts 5 -26 months.