Adhesive capsulitis, which is more commonly referred to as frozen shoulder, occurs in 2-5% of the population at one point or another. It typically occurs in adults ages 40-70, and is more often seen in women compared to men. It is also interesting to note that individuals with diabetes are more likely to develop frozen shoulder, with an occurrence rate of 10-20% of diabetic individuals. Considering how many people are at risk for this disorder, it is important to understand its progression and different ways to treat it.
Frozen Shoulder vs. Adhesive Capsulitis
Although “Frozen Shoulder” and “Adhesive Capsulitis” technically have minor differences between them, the terms are used similarly to describe the slow loss of motion in the shoulder joint, along with increasing pain during movements. The exact cause of frozen shoulder is unknown even though it affects so many people. One of the main theories is that it can occur after a period of immobilization, such as being in a sling after an injury or fracture in the arm. True Adhesive Capsulitis, or Primary Adhesive Capsulitis, may develop after due to inflammation from trauma, an autoimmune response, or autonomic dysfunction. True Frozen Shoulder, or Secondary Adhesive Capsulitis, occurs from something that originally happened outside of the shoulder joint itself. This can include rotator cuff tears, impingement, bursitis, biceps tendinitis, and arthritis. In both cases, there tend to be three main stages of progression. The first stage is called the Freezing Stage, and it is characterized by the increasing loss of motion of the shoulder and increasing pain. This stage can last anywhere from ~10-36 weeks, and it is very difficult to start treatment in this stage since there is a continued loss of motion. The second stage is called the Frozen Stage, which begins when the pain has stabilized and starts decreasing. This stage is characterized as the “stiff period”, and it can last anywhere from months 4-12 months. Finally, the third stage is considered the Thawing Stage, and occurs when shoulder motion increases and pain continues to decrease. This is the stage where treatments are most effective, and can last up to 12 months. Although the whole process can take anywhere from 6 months to 3 years to resolve, the good news is that the majority of people do regain most or all of their shoulder motion.
Taking a Deeper Look
So, what is actually happening in the shoulder joint to make it so painful and stiff? Although it is unknown exactly how frozen shoulder initially happens, we do know what is going on inside the shoulder once this problem begins. The shoulder joint connects your arm bone, the humerus, to a socket-like area of bone called the glenoid fossa. This creates a ball and socket joint that looks like a golf ball sitting on a tee. This whole structure is then encased in a capsule, which is like a bubble around the bones. This capsule has fluid in it, which helps to make shoulder movements easy and painless. Once frozen shoulder begins, the capsule shortens around the bones, becomes thicker, and eventually scar tissue can build up. The combination of these things can also decrease the amount of fluid inside the joint, and movements become much more difficult and painful.
Diagnosing Frozen Shoulder
Some key components to look out for that may help diagnose frozen shoulder are: random onset (no traumatic incident), unable to sleep on the involved side, restrictions with multiple movements (lifting arm above head, reaching to the side or behind back, dressing, etc.), increasing pain, normal x-ray appearance, and possible weakness. Since there is no direct way to diagnose this condition, it is important to rule out other possibilities such as arthritis, tendinitis, bursitis, or other pain syndromes. MRI can help to determine if any of these underlying issues are present. Once diagnosed, it is important to determine which stage an individual is in, since this will help decide the best treatment option.
Treatment Options
As stated before, most people with frozen shoulder will see a spontaneous resolution of symptoms within 3 years, however exploring different treatment options may help to speed up the process. Three main treatment options include: steroid injections, physical therapy, and manipulation under anesthesia. Steroid injections, such as Cortisone, are powerful anti-inflammatory medicines that are injected directly into your shoulder joint. This may help to loosen up the tissues and capsule around the shoulder and restore some of the motion that has been lost. Physical therapy will include specific exercises to help loosen up the shoulder, as well as hands on treatment from the therapist, which will also include different stretching techniques. A physical therapist will be able to work with you to help perform activities of daily living, work, and recreation that may have become difficult. Finally, the last resort option would be manipulation under anesthesia, which has become an emerging treatment for this condition. During this procedure, the patient is placed under anesthesia for 10-15 minutes while the shoulder is forced through full range of motion in all directions. This breaks up everything in the shoulder that is causing it to be stiff. Following the procedure, patients are recommended to see a physical therapist daily for 2 weeks for aggressive stretching exercises, pain relieving treatments, patient education and review of home exercise program.
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