Frozen Shoulder or Adhesive capsulitis is a common condition of the shoulder presenting with pain and limited range of motion especially rotation of the shoulder. At first patient finds it difficult to reach out to the back pocket or inability to reach the upper back. Later other movements are also affected with increasing pain especially with a sudden jerk which makes the pain even worse. This condition commonly affects non-dominant shoulder left more than right with about 25% to 50% chances of the other shoulder getting affected in the lifetime. Though it is a self limiting condition it can have a clinical course to last from 1 year to 3 years. This itself gives us insite into the loss of working hours or functional loss to a patient suffering from Adhesive capsulitis. Hence it should be treated as early as possible to decrease the overall course to a minimum period.
The incidence of Adhesive capsulitis is 3% to 5% in the general population. This Incidence increases to 20% in people suffering from Diabetes mellitus. More than 70% of the patients are females.
Frozen shoulder is a diagnosis of exclusion. Conditions like the Partial cuff tear versus Rotator cuff tear, Long Head of biceps conditions like tendinitis, SLAP tear, Subacromial Bursitis, Calcific Tendinitis and Glenohumeral arthrosis/ Arthritis. Patient usually present with excessive pain. This is followed by restriction of movements to global restriction of range of motion. Pain in the initial Stage of frozen shoulder is due to inflammation affecting the shoulder joint leading to synovitis of the glenohumeral joint. Synovitis progresses to involve the capsule which is marked by the stage of stiffness due to the thickened capsule which leads to decrease overall volume of the joint. As the disease progresses the stage of stiffness is followed by stage of thawing. The overall course of the frozen shoulder can follow from few months to few years as well. During the course of this disease the patient suffers lot of pain and disability leading to overall decreased Quality of life. Due to the long course it is a financial burden. Hence early diagnosis and interventional helps in reducing the overall morbidity from the condition.
The patients presenting early with this condition may have pain as the only sign of adhesive capsulitis. An experienced Shoulder Surgeon rules out all the other possible causes and starts early Treatment. Actually it is a clinical diagnosis to make with X-ray as a supportive test. The target of the therapy in the initial stage (Stage of Pain) is to reduce pain, Rule out Diabetes (if Diabetic Document the HBA1C) , If Diabetic ensure strict diabetic control. Pain in the initial stages can be controlled with NSAIDs or synthetic opoids. Reducing pain helps in initializing the ROM (Range of Motion) exercises which helps in getting the range back.
Intra-Articular injection in to the glenohumeral joint in the stage of pain( Stage of inflammation and Synovitis) and Stage of Stiffness( Second Stage) causes marked decrease in pain probably because of decreased markers of inflammation. The Intraarticular injection commonly used are Methlyprednisolone or Triamcinolone acetonide. The use of corticosteroids in frozen shoulder has been well studied and is a very safe procedure which can be performed in the OPD with or without ultrasound guidance. The use of corticosteroid decreases Fibromatosis and myofibroblasts in adhesive shoulders. Patients undergoing corticosteroid injections have rapid decrease in the symptoms with faster progression to Rehabilitation.
Definitive role of physiotherapy exists in the treatment of Frozen Shoulder. Though in the first stage of frozen shoulder simple exercises taught to the patient also has a equivalent result. But Aggressive mobilisation of the shoulder in the stage of pain and stiffness has not been found to be helpful in the long term. In short exercises not causing too much discomfort or pain to the patient are well tolerated in the initial stages. But once the pain has settled for a patient then the scapular exercises with the rotator cuff strengthening goes a long way in reducing the overall course of this condition.
The shoulders with persistent symptoms and a prolonged course are candidates to undergo Arthroscopic capsular release. Advantages of Arthroscopy is that all the structures are visualised during arthroscopy. The structures to be released especially the rotator interval, Thickened CHL( Choracohumeral Ligament), and the anterior inferior capsule along with posterior capsule are examined and released for immediate benefit of increased range of motion along with decreased pain. Post operative pain management is utmost important as there is a subtle balance between early mobilization and recurrence of pain. Most of the patients are benefitted by the 3rd week and sustained till later. Recurrence is a theoretical possibility, but chances are less than 10%.
Adhesive Capsulitis remains to this date an unresolved problem with still ongoing research to clearly narrate the etiology and help in understanding of the pathology.
