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Frozen
Shoulder
Frozen shoulder is characterized by pain
and loss of motion or stiffness in the shoulder. It affects about two
percent of the general population. Frozen shoulder most commonly affects
patients between the ages of 40 and 60 years, with no clear predisposition
based on sex, arm dominance, or occupation.
Cause
Anatomy
of the shoulder, showing the ligaments and bones.
(Reproduced
with permission from Hunt SA, Kwon YW, Zuckerman JD: The Rotator Interval:
Anatomy, Pathology, and Strategies for Treatment. J Am Acad Orthop Surg
2007:15;218-227.)
The
causes of frozen shoulder are not fully understood. The process involves
thickening and contracture of the capsule surrounding the shoulder joint.
Frozen shoulder occurs much more commonly
in individuals with diabetes, affecting 10 percent to 20 percent of these
individuals. Other medical problems associated with increased risk of
frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson's
disease, and cardiac disease or surgery.
Frozen shoulder can develop after a
shoulder is immobilized for a period of time. Attempts to prevent frozen
shoulder include early motion of the shoulder after it has been injured.
Symptoms
Pain due to frozen shoulder is usually
dull or aching. It can be worsened with attempted motion. The pain is
usually located over the outer shoulder area and sometimes the upper arm.
The hallmark of the disorder is
restricted motion or stiffness in the shoulder. The affected individual
cannot move the shoulder normally. Motion is also limited when someone
else attempts to move the shoulder for the patient.
Some physicians have described the normal
course of a frozen shoulder as having three stages:
*
Stage one: In the "freezing" stage, the patient develops
a slow onset of pain. As the pain worsens, the shoulder loses motion. This
stage may last from six weeks to nine months.
*
Stage two: The "frozen" stage is marked by a slow
improvement in pain, but the stiffness remains. This stage generally lasts
four months to nine months.
*
Stage three: The final stage is the "thawing," during
which shoulder motion slowly returns toward normal. This generally lasts
five months to 26 months.
Diagnosis
A doctor can diagnose frozen shoulder
based on the patient's symptoms and a physical examination.
X-rays or MRI (magnetic resonance
imaging) studies are sometimes used to rule out other causes of shoulder
stiffness and pain, such as a rotator cuff tear.
Treatment
Frozen shoulder will generally get better
on its own. However, this takes some time, occasionally up to two to three
years. Treatment is aimed at pain control and restoring motion.
Nonsurgical Treatment
Pain control can be achieved with
anti-inflammatory medications. These can include pills taken by mouth,
such as ibuprofen, or by injection, such as corticosteroids.
Physical
therapy is used to restore motion. This may be under the direct
supervision of a physical therapist or via a home program. Therapy
includes stretching or range-of-motion exercises for the shoulder.
Sometimes, heat is used to help decrease pain. Examples of some of the
exercises that might be recommended can be seen in the following figures.
If these methods fail, nerve blocks are
sometimes used to limit pain and allow more aggressive physical therapy.
More than 90 percent of patients improve
with these relatively simple treatments. Usually, the pain resolves and
motion improves. However, in some cases, even after several years the
motion does not return completely and a small amount of stiffness remains.
Surgical Treatment
Surgical intervention is considered when
there is no improvement in pain or shoulder motion after an appropriate
course of physical therapy and anti-inflammatory medications. When more
invasive measures are considered, the patient must always consider that
most individuals will get better if given sufficient time and that surgery
always has risk involved.
Surgical intervention is aimed at
stretching or releasing the contracted joint capsule of the shoulder. The
most common methods include manipulation under anesthesia and shoulder
arthroscopy:
Manipulation under anesthesia involves
putting the patient to sleep and forcing the shoulder to move. This
process causes the capsule to stretch or tear.
With shoulder arthroscopy, the surgeon
makes several small incisions around the shoulder. A small camera and
instruments are inserted through the incisions. These instruments are used
to cut through the tight portions of the joint capsule.
Often, manipulation and arthroscopy are
used together in combination to obtain maximum results. Most patients have
very good results with these procedures.
After surgery, physical therapy is
important to maintain the motion that was achieved with surgery. Recovery
time varies, from six weeks to three months.
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