Wednesday, 6 October 2010

Frozen Shoulder (Adhesive Capsulitis)

What is it?
Frozen Shoulder is a common condition in the middle aged to older population, with reported incidence ~2-5% presenting to GP and affecting women more than men (70% women 40-60 yrs).

As the medical term 'Adhesive Capsulitis' implies, it is when the shoulder capsule (tissue surrounding the glenohumeral joint) becomes stiff (adhesive) and inflamed (capsulitis), leading to significant loss of range of motion (ROM) and pain.
This condition can last from 5-6 months to 2-3 years or more. 

What causes it?
The exact cause of primary frozen shoulder is not known, although some believe there to be an autoimmune-related origin, causing the body to attack normal healthy tissue in the capsule. A lack of synovial fluid in the glenohumeral joint has also been reported to be a possible cause. Frozen shoulder can also be triggered by injury or trauma to the joint and its surrounding tissues (secondary).

Risk Factors
The condition has been linked to other medical conditions such as:
  • Diabetes
  • Stroke, hemiplegia
  • Rheumatic disease (eg. rheumatoid arthritis)
  • Lung disease
  • Connective tissue disorders 
  • Heart disease
  • Following breast or lung surgery 

Signs and Symptoms
  • Pain (constant dull ache, typically worse at night)
  • Stiffness (worse at night)
  • Loss of shoulder ROM (all directions especially external rotation)
  • Shoulder hitching on active movement
  • Active ROM (self-initiated) = Passive ROM (other person-initiated)
  • Inability to perform functional tasks (eg. lifting arm, brushing hair, reaching out, holding phone etc)

The THREE STAGES of Frozen Shoulder
  • Stage 1 - Freezing (painful) phase:
    • Duration: may last 6 weeks to 9 months
    • Pain
    • Loss of ROM in all directions
  • Stage 2 - Frozen (adhesive) phase:
    • Duration: may last 4 to 9 months
    • Pain may improve slightly
    • Stiffness remains and reaches its maximum
  • Stage 3 - Thawing (recovery) phase:
    • Duration: may last 5 months to 2-3 years
    • Pain improves
    • ROM returns to normal

Treatment is aimed at restoring ROM and reducing pain. The first line of management typically comprises of:
  • NSAIDs (non-steroidal anti-inflammatory drugs)
  • Oral steroids
  • Physiotherapy 
    • Joint mobilisation
    • ROM exercises
    • Gentle stretching 
    • Electrophysical agents such as heat, interferential, TENS, laser therapy
    • NB. It is crucial however that the mobilisations and exercises prescribed are gentle (just short of pain limit) and will not aggravate the natural course of the disease itself

If pain and stiffness become severe and functionally disabling, treatment may be advanced and the following may be recommended by the doctor:
  • Corticosteroid injections (fluoroscopy, ultrasound or CT guided)
  • MUA (manipulation under anaesthesia)
  • Surgery (arthrographic distension, arthroscopic release)
  • Suprascapular nerve block
Other alternative therapies that have also been used (with limited evidence) include:
  • Acupuncture
  • Massage
  • Osteopathy
  • Chiropractic
  • Nutrition

Research Evidence
A recent study (published July 2010) looked at the effectiveness of conservative and surgical interventions for treating frozen shoulder. 

Here is a quick summary of the authors' findings:
  • Strong evidence for corticosteroid injections and laser therapy in short-term
  • Moderate evidence for:
    • Steroid injections in mid-term follow-up
    • Mobilisation techniques in short and long-term
    • Arthrographic distension +/- active physiotherapy in short-term
    • Oral steroids in short-term
  • Inconclusive evidence for:
    • NSAIDs
    • Acupuncture
    • MUA
    • Arthroscopic release
Read more about this article and its findings on Latest Research.

Questions or Comments?
If you have any questions or would like to be referred to a physiotherapist, click here.

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