Frozen shoulder -causes , symptoms, investigation , treatment (physiotherapy next part)

FROZEN SHOULDER

(Syn: Periarthritis, Adhesive Capsulitis)

Paradoxically shoulder joint privileged as the most mobile joint in the body has its nemesis because of this very advantage. Its mobility makes it very vulnerable to problems which ultimately "freeze" its movements. Unable to come to terms with the paucity of liberal movements hitherto enjoyed, the hapless patient resigns himself or herself to suffer the agony in silence!

Causes

The causes are mainly idiopathic and are due to fibrosis following chronic inflammation. This could be due to:

Primary Shoulder causes Problems directly related to shoulder joint which can give rise to frozen shoulder are tendinitis of rotator cuff, bicipital tendinitis, fractures and dislocations around the shoulder, etc.

Secondary Non-shoulder causes Problems not related to shoulder joint like diabetes, hyperthyroidism, hyper triglyceridemica, cardiovascular diseases with referred pain to the shoulder which keeps the joint immobile, reflex sympathetic dystrophy, frozen hand shoulder syndrome, a complication of Colles' fracture can all lead to frozen shoulder. The reason could be prolonged immobilization of the shoulder joint due to referred pain, etc.

Pathogenesis

During abduction, and repeated overhead activities of the shoulder, long head of biceps and rotator cuff undergo repeated strain. This results in inflammation, fibrosis and consequent thickening of the shoulder capsule which results in loss of movements. If the movements are continued, then the fibrosis gradually breaks, movements return but never come back to normal.

Prolonged activity causes small scapular and biceps muscles to waste faster, load on joint increases and degenerative changes sets in. Capsule is fibrosed and shoulder movements are decreased.

Stage I (stage of pain) Patient complains of pain with insidious onset, decreased movements, external rotation greatest followed by loss of abduction  and then forward flexion. Internal rotation is least affected. This stage lasts for 10 to 36 weeks. Pain due to frozen shoulder is predominantly nocturnal and usually will not radiate below the elbow unlike in cervical spondylosis.

Stage II (stage of stiffness) In this stage pain gradually decreases and the patient complains of progressive stiff shoulder in a capsular form. Slight movements are present.

Stage III (stage of recovery) Patient will have no pain and movements will have recovered but will never be regained to normal. It lasts for 6 months to 2 years. ADL is severely affected.

Note Apprehension test indicates impending frozen shoulder.

Investigations

Plain X-ray of the shoulder is usually inconclusive but may show sclerosis (Golding's sign). Arthrographic evaluation of the shoulder shows contracted capsule and is the gold standard.

Treatment

Stage I In this stage long-acting once a day NSAIDs are usually preferred as this condition usually runs a long course (10-36 weeks). Intra-articular steroids may help. Thermo therapy using TENS or alternative therapies like acupuncture helps in this stage.

Stages II and III A stiff shoulder is a stiff challenge to the physiotherapist and the patient alike since its thwarts the best of attempts to restore back the earlier free shoulder movements. A 'sustained approach' rather than an 'aggressive approach' is the 'mantra' in these patients.