Frozen shoulder (sometimes called adhesive capsulitis of the shoulder) is a condition where a shoulder becomes painful and stiff. Shoulder movements become reduced, being sometimes completely 'frozen' or stiff.
Patients experience ongoing shoulder stiffness and pain that lasts at least several weeks at a time. It is thought to be due to an unyielding scar-like tissue forming in the shoulder capsule. Without treatment, symptoms usually resolve but this may take up to 2-3 years & still leave behind residual stiffness. Various treatments may ease pain and improve the movement of your shoulder.
Dr. Raju Easwaran, Orthopaedics doctor at Max Shalimar Bagh says, there are several causes of frozen shoulder & it may be a manifestation of disease outside the shoulder! Frozen shoulder sometimes occurs when someone is wearing a sling or cast for a wrist or elbow fracture, healing from surgery in the upper limb, after cardiac catheterisation for stenting to remote causes like receiving chemotherapy, especially after Breast cancer. The most common cause remains diabetes. It is estimated that 1 in 5 diabetics especially insulin dependent diabetics may experience frozen shoulder in one or both their shoulders!
What are the symptoms of frozen shoulder?
The most common symptoms of frozen shoulder include:
- Stiffness in and around the shoulder. This usually happens in one shoulder at a time.
- Severe pain limiting activities of day to day life, in & around the shoulder, especially at night. The pain worsens while lying on the affected shoulder & may prevent good sleep.
- Limited range of motion, simple activities like tucking in a shirt for men or wearing a bra for women become challenging.
- The nature & extent of the symptoms & ensuing disability varies depending upon which shoulder is affected, the dominant one or the non-dominant one.
The majority of frozen shoulders typically develop gradually, with symptoms becoming worse over several weeks or months. Doctors usually categorise frozen shoulder progression into three stages, each one typically lasting 1 to 3 months and causing different levels of pain and stiffness. The symptoms of frozen shoulder depend on which stage they are in.
There are 3 stages: The initial “freezing stage,” the “frozen stage” and the final “thawing stage. In the freezing stage, movement of the shoulder is limited and the area around the shoulder starts causing noticeable pain. The pain can be severe during the freezing stage, and stiffness can set in at this point and then become severe.
The frozen stage is characterised by a stiff shoulder, but it’s no longer as painful as before especially at rest. The thickness and scarring of the shoulder capsule limits range of motion and causes pain during stretching or reaching. During the final thawing stage, the range of motion in the shoulder can improve, but pain might still come and go, especially at night when sleeping on the affected shoulder.
Phase one - The 'freezing', painful phase. This typically lasts 2-9 months. The first symptom is usually a pain. Stiffness and limitation in movement then also gradually build up. The pain is typically worse at night and when you lie on your affected side.
Phase two - The 'frozen', stiff (or adhesive) phase. This typically lasts 4-12 months.The pain gradually eases but stiffness and limitation in movement remain and can become worse. All movements of your shoulder are affected. However, the movement most severely affected is usually rotation of the arm outwards. The muscles around the shoulder may waste a bit as they are not used as vigorously as before.
Phase three - The 'thawing', recovery phase. This typically lasts between one and three years. The pain and stiffness gradually go and movement gradually returns to normal, or near normal. Symptoms often interfere with everyday tasks such as driving, dressing, or sleeping.
There is great variation in the severity and length of symptoms. If untreated, on an average the symptoms last for 2-3 years in total. In some cases, it is much less than this duration. In a minority of cases, symptoms last for several years.
Who develops frozen shoulder?
It most commonly occurs in people aged between 40 and 65 years. It is more common in women. It is more common than average in people who have diabetes and in some other conditions, including thyroid disease. Either shoulder can be affected but most commonly it is the non-dominant shoulder - that is, the left shoulder in a right-handed person.
What causes frozen shoulder?
The cause is not clear. It is thought that some scar tissue forms in the shoulder capsule. The capsule is a thin elastic tissue that covers and protects the shoulder joint. The scar tissue may cause the capsule to thicken, contract and limit the movement of the shoulder. The reason why the scar tissue forms are not known.
What are the treatment options for frozen shoulder?
The aim of treatment is to ease pain and stiffness; also, to keep the range of shoulder movement as good as possible whilst waiting for the condition to clear.
Ordinary painkillers: Medicines like paracetamol combined with an opioid agent like tramadol relieve pain & improve sleep.
Anti-inflammatory painkillers: Medicines like diclofenac reduce the inflammation in the shoulder joint & thereby reduce pain. They are very useful in the first stage of frozen shoulder. Sometimes oral steroids are also prescribed for a short duration.
Shoulder exercises: Focussing on stretching the tight capsule & strengthening the shoulder muscles forms the cornerstone of treatment.
Physiotherapy: Modalities like a laser, tens, ultrasonics & moist heat work marvellously to reduce the pain & improve the flexibility of the shoulder through exercises.
A steroid injection: Is usually required to settle the inflammation inside the joint. It is a very potent method of settling the inflammation in the joint & shorts the recovery time to as low as 6-8 weeks. Combined with appropriate exercises this treatment modality should suffice for curing nearly 95% of patients who have frozen shoulder. Up to 2-3 injections can be safely given in a span of 6-8 weeks. Diabetics need to control their blood sugar before being administered the injection.
Manipulation under anaesthesia: Consists of taking the joint forcefully under the full range of motion under general anaesthesia to 'break' the adhesions. It has been largely given up due to its high rate of unwanted complications like rotator cuff tears, fractures etc.
Arthroscopic capsular release: Is reserved for resistant cases of frozen shoulder that haven't responded to at least 3 months of conservative treatment. In a rare instance, severe primary cases with bad joint deformities are selected for this procedure. This minimally invasive procedure is done through 2-3 tiny 4 mm cuts, wherein the interior of the joint is inspected with a medical camera & the tight tissues are directly released with a radiofrequency device (often mistaken for a laser). This is done as a day care procedure & almost immediate pain relief & a full range of motion is ensured thence.