Frozen Shoulder – What is it and how can it be released?
What is ‘Frozen Shoulder’?
Frozen shoulder is a condition in which the shoulder joint becomes painful and stiff. In a majority of patients there no particular cause that can be identified.
The lining tissue around the shoulder joint (capsule) becomes inflamed for unknown reasons, which causes pain and tightness. This tightening combined with the pain restricts the movements.
How common is it?
It is most common in people between the ages of 40 and 70 years and has been estimated to affect at least one in 50 people every year.
About shoulder Joint
The shoulder is designed to undergo extensive movements so that we can use our hands/arms in a wide variety of positions. Some movements occur between the shoulder blade (scapula) and chest wall. However most shoulder movements are at the ball and socket joint.
The ball at the top of the arm bone (humerus) fits into the shallow socket called glenoid which is a part of your shoulder blade. A loose bag or capsule surrounds the joint which is supported by ligaments and muscles.
About 10% of people may develop frozen shoulder in the other shoulder within 5-7 years of the first one. However it tends to resolve more quickly than the first. Although it is widespread, it is a difficult condition to treat. We hope that this article will help to explain what we know about it so far.
Why does frozen shoulder occur?
A primary frozen shoulder is one whose exact cause is not known. It is more common in people with diabetes and those with thyroid problems. About 15% of patients link it to a minor injury to the shoulder, which most likely is not the cause of the condition.
A secondary frozen shoulder can develop if the shoulder area is kept still (without allowing it to move) for some time, for example, after a stroke or heart attack. It can also occur after major injury or surgery to the shoulder, elbow or hand.
Some experts think the inflammation starts with a problem in the shoulder itself, some other experts feel it is related to factors away from the shoulder (e.g. stiff neck, certain diseases). Research is ongoing to answer some of these questions.
What tests may be done to diagnose frozen shoulder?
The diagnosis of this problem is usually made after analyzing symptoms and examining the shoulder joint. Sometimes an X ray, or MRI scan will be done to check there are no bone or tendon changes in your shoulder joint.
What is likely to happen?
There are 3 main phases
1. Painful phase (which can last from 2 to 9 months)
The pain often starts gradually and builds up. It may be felt on the outside of the upper arm and can extend down to the elbow and even into the forearm. It can be present at rest and is worse on movements of the arm. Sleep is often affected, as lying on it is painful or impossible. During this phase, shoulder movements begin to reduce.
2. Stiff phase (which can last from 4 to 12 months)
The ball and socket joint become increasingly stiff, particularly on twisting movements such as trying to put your hand behind your back or head. These movements remain tight even when you try to move the shoulder with your other hand or someone tries to move the shoulder for you.
It is the ball and socket joint which is stiff and not the shoulder blade. The shoulder blade (scapula) is still free to move around the chest wall, and you may become more aware of this movement.
3. Recovery phase (which can last from 5 to 26 months)
The pain and stiffness starts to resolve during this phase, and you shall be able to use your arm in a more normal way. The total duration of the process is from 12 to 42 months, on an average lasting for 30 months.
It is important to note that although the pain and stiffness can be very severe, usually the problem will resolve. It will not bother you forever! This operation is not done routinely for frozen shoulder, only for those which are very slow to resolve.
A review of people who had frozen shoulder approximately 7 years earlier show that only 11% still had mild interference with everyday activities. However, 60% continued to have some stiffness in the shoulder joint when it was measured. So ultimately, it should have little effect on your daily life, although the joint may remain stiffer when tested.
What are your treatment options to release frozen shoulder?
There is no single agreed treatment option that can decrease the time it takes for full recovery. Ultimately the shoulder appears to go through the three phases described and no treatment has altered this pattern.
The passage of time is the main treatment!
During the painful phase the emphasis is on pain-relief.
Pain killers and physiotherapy:
Therefore pain-killer tablets and anti-inflammatory tablets may be prescribed. Using hot pack or ice packs also will help. Injections into the joint may also be offered if the pain continues. Physiotherapy at this stage is directed at pain relief (heat, cold and other pain relieving modalities such as electrotherapy). Forcing the joint to move can make it more painful and is best not pursued.
Some people find TENS machine (transcutaneous nerve stimulation) helpful or try alternative therapies such as acupuncture.
Once stiffness is more of a problem than pain, physiotherapy is indicated. You will be shown specific exercises to try and get the ball and socket moving. In addition, the therapist may move the joint for you, trying to regain the normal glides and rolling of the joint.These are known as joint mobilisations. Muscle based movement techniques may also be used.
If movement does not improve with these measures, physiotherapy will be discontinued. However, it is appropriate to continue with the suggested exercises to try and maintain the movement that you have.
Hopefully, as the recovery phase starts you will find that the movement gradually increases. This, again, can be a useful time to have physiotherapy to help maximise the movement.
If you have significant pain and stiffness the doctors may offer you a ‘Manipulation under Anaesthetic’(MUA) or Arthroscopy Surgery.
Arthroscopy involves a key-hole surgery in which the joint capsule is stretched or cut to make it loose around the shoulder joint. The tight capsule may be released or removed. In addition the joint is stretched in certain directions to try and free the joint up.
Here we show a few exercises to stretch your shoulder. They may be modified for your particular shoulder.
Do exercises regularly 1-2 times a day. You may find them easier to do after a hot shower or bath. Using a hot water bottle is another alternative.
It is normal for you to feel aching or stretching sensations when doing these exercises. However severe and lasting pain (e.g. more than 30 minutes) is not normal. If the pain persists longer, reduce the exercises by doing them less often or less forcefully.
If the pain is still severe discontinue the exercises and see the physiotherapist or doctor.
Please note: Raising your arm forwards often improves first. Getting your hand behind your low back appears to be the last movement to return. Do not do these movements if they are painful rather than stiff.
About Author –
Dr. G Veda Prakash, Consultant Orthopedic & Trauma Surgeon, Yashoda Hospital, Hyderabad.
MS (Ortho), DNB (Ortho), MRCS (Ed), FRCS (Tr & Ortho)