Injury Management

Frozen Shoulder : Risk Factors & Management

Frozen shoulder (FS) is also known as Adhesive capsulitis (AC). Simply put, it is a condition that restricts the shoulder’s normal movement (range of motion). It is a painful condition persisting for more than three months. 

FS causes progressive stiffness and significant restriction in the range of motion (ROM) of the shoulder (typically external rotation) due to fibrosis of the glenohumeral joint capsule. The symptoms for FS may develop suddenly, but the recovery rate is prolonged. Complete recovery may take two to three full years in some cases.

Adhesive capsulitis occurs in up to 5% of the population. However, females are four times more often affected than males. At the same time, the non-dominant shoulder is more prone to be affected.

An individual can prevent FS by maintaining the mobility of the joint. However, unfortunately, the shoulder starts to hurt with the onset of inflammatory conditions in the joint capsule. Furthermore, since the pain discourages the individual from continuing movement, this immobilization enables scar tissue deposits, which thickens the surface area of the capsule, eventually causing the shoulder to freeze.

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Frozen shoulder (FS) occurs in three stages

The gradual restriction of passive shoulder motion characterizes a natural course of AC. Therefore, the development is commonly described as progressing through 3 overlapping phases.

Freezing (2 to 9 months) – Early-stage. 

The freezing stage is characterized by pain over the outer shoulder or the upper arm. The pain worsens at night, with gradually increased glenohumeral joint ROM restriction.

Frozen (4 to 12 months) – Developed stage. 

The second stage has stiffness and glenohumeral joint motion limitation but less pain than the “Freezing” stage. 

Thawing (4 to 12 months) – Developed stage.

The thawing stage is where an individual may regain most or all shoulder movements. However, the process may take months or even years.

The duration of AC is from 1 to 3.5 years, with a mean of 30 months. In about 15% of patients, the contralateral shoulder becomes affected within five years. The complications seen are residual pain and stiffness, fracture of the humerus, and rupture of the biceps tendon after shoulder manipulation. 

Management of Frozen Shoulder (FS)

It includes surgical and non-surgical treatment options. Moreover, it aims to speed up the natural recovery phase of the disease. Therefore, the focus area for treatment should be controlling the pain and restoring the movement.

Non-surgical treatment options include the following-

  1. Non-steroidal anti inflammatory drugs (NSAIDs).
  2. Corticosteroid injections. 
  3. Physical therapy. 
  4. Mobility and flexibility drills.

A doctor would recommend surgical treatment if the individual’s response to conservative management has failed. However, a few of the options include:

  1. MUA i.e. manipulation under anaesthesia – While the individual is unconscious, the doctor forcefully moves the patient’s shoulder in all planes of motion, causing it to loosen or rupture the joint capsule.
  2. Arthroscopic capsular release – While the individual is unconscious, the surgeon cuts the tighter portion of the joint capsule using small instruments which are inserted through keyhole incisions around the shoulder.

Some Plausible Risk Factors identified for Frozen Shoulder

  • Diabetes mellitus (with a prevalence of up to 20%) – Research has shown that people with diabetes are up to twice as likely to suffer from frozen shoulders. Dr. Richard Bernstein reports, this is due to the collagen’s effects on the shoulder, which holds the bones together in a joint. Collagen can become sticky if sugar molecules attach to it, restricting movement and the shoulder begins to stiffen. This process is known as glycosylation. In addition, poorly controlled diabetes is linked to muscular and skeletal problems, with consistently high blood sugars likely to increase the risk of complications such as the frozen shoulder.
  • Stroke
  • Thyroid disorder
  • Shoulder injury
  • Parkinson disease
  • Cancer

Author: Pankaj Narsain (INFS Faculty)

References

  1. Mezian, K., Coffey, R. and Chang, K.V., 2020. Frozen shoulder. StatPearls [Internet].
  2. Editor. 15th January 2019. Diabetes.co.uk. [Online]. [24 November 2021]. Available from: https://www.diabetes.co.uk/diabetes-complications/frozen-shoulder.html

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