|
Frozen Shoulder - also known as Adhesive Capsulitis
This article is not intended as a substitute for medical advice. You should consult your doctor or physical therapist for diagnosis and advice about your shoulder condition. Shoulder pain can be a symptom of other conditions and needs investigation.
Summary
This article reviews symptoms, diagnosis and traditional treatments for frozen shoulder. A pioneering osteopathic treatment is described which is very effective and can significantly reduce recovery time.
Index to page
Have you got a frozen shoulder?
What has happened to your shoulder?
Why have you got a frozen shoulder?
How can your frozen shoulder be treated?
How osteopaths treat frozen shoulder using the Niel-Asher technique®
How can you avoid developing frozen shoulder?
How you can help your shoulder
Have you got a frozen shoulder?
If one or both of your shoulders is painful and you have difficulty moving your arm away from your side or reaching behind your back, you could be suffering from a frozen shoulder.
Frozen shoulder is more common in females and usually occurs between ages of 40 to 70 years. It generally affects the non-dominant side. You may have had an injury and been unable to use your arm, or your symptoms may have started spontaneously, for no apparent reason.
Simple movements such as reaching a shelf or your back pocket may be impossible as your shoulder joint becomes increasingly stiff and painful. Stiffness and pain are usually worse at night. The pain is mostly a dull ache but you can have cramping or sharp shooting pain particularly with over-stretching or sudden movements.
Diagnosis is usually made from the typical pattern of signs and symptoms together with physical examination of the shoulder. An arthrogram, or MRI scan, can confirm the diagnosis but is not usually necessary.
There may be a period of pain before a frozen shoulder begins to develop. Three stages characterize the development and healing of a frozen shoulder, the natural progression of which is 18 months - 2 years on average. Each stage has its own characteristics:
Pre-Freezing - first signs of a problem
Gradual onset of pain.
Pain particularly when lifting arm away from the side of the body.
No stiffness or decreased movement in the shoulder.
Stage 1: Freezing - lasts weeks to months
Constant pain.
Pain disturbing sleep at night, particularly in early hours of the morning.
Range of movement in shoulder reducing, stiffness increasing.
Sharp shooting pains down the arm with agonising pain for 30 seconds to 1 minute on certain movements or impact of the shoulder.
Pain decreases towards the end of this stage.
Stage 2: Frozen - lasts up to 1 year
Less pain, no pain at rest.
Pain with reaching or over stretching the shoulder.
Weakness of the shoulder muscles.
Movement of shoulder very restricted.
Stage 3: Thawing - lasts up to 9 months
Gradual improvement of range of movement in shoulder.
No pain.
Last movement to return is reaching up behind the back.
What has happened to your shoulder?
The shoulder joint is where the upper arm bone (humerus) joins the shoulder blade and collar bone. The shoulder is a very mobile joint which relies on control from muscles and ligaments for stability.
Four rotator cuff muscles are very important for the shoulder movements. All four connect from the shoulder blade to the humerus (arm bone).
The shoulder joint capsule (connective tissue surrounding the shoulder joint) is normally a loose structure allowing a large range of movement in the shoulder joint. With a frozen shoulder the capsule becomes inflamed and stiff. Abnormal bands of tissue (adhesions) form between the joint surfaces, restricting movement. There is also a lack of synovial fluid which lubricates the shoulder joint. The space in the shoulder joint is reduced.
Muscles become very tight and can feel as if they are going into spasm. Tight nodules can be felt in the muscles around the shoulder and co-ordination of contraction to produce movement is affected.
Why have you got a frozen shoulder?
If you have diabetes or a history of stroke, lung disease, overactive thyroid, rheumatoid arthritis or heart problems then you are at a higher risk of developing frozen shoulder. The condition can also develop following surgery (not only to the shoulder), or a fall, or injury to the shoulder.
In the general population 2-5% of people will have a frozen shoulder during their lifetime but amongst people with diabetes that rises to 10-20%. It is even higher for insulin-dependent diabetes at 36%. With diabetes frozen shoulder often affects both shoulders and is more severe. Recovery time is prolonged, extending to an average of 3 – 5 years.
You may not fall into any of the categories mentioned above. For some patients frozen shoulder develops for no apparent reason - there is no history of illness, or trauma. In these patients we commonly find there is an emotional link. There may have been a recent bereavement or other major change or event - changing jobs, moving house etc. Although in these cases physical symptoms have an emotional cause, there is still a good response to physical treatment.
The actual reason why a frozen shoulder develops is not known. There are many theories including an autoimmune link, a viral agent and hormonal theories.
How can your frozen shoulder be treated?
Medication
Non-steroidal anti-inflammatory (NSAIDs) medications include aspirin, ibuprofen, diclofenac and naproxen. This is the first line of defence with persistent shoulder pain. A single dose will reduce pain but to reduce inflammation it is necessary to take the medication daily. It can take up to 3 weeks of regular medication to achieve a significant reduction in inflammation. NSAIDs are also available as creams and gels which can be applied directly to the shoulder, these are particularly useful for people who have a sensitive stomach and are unable to take medication.
Side-effects sometimes occur with anti-inflammatory medications. Always read the leaflet that comes with the medication for a full list of cautions and possible side-effects.
Injections
Corticosteroid injections can be administered into the shoulder to reduce inflammation. Doctors may need to give up to three injections to have a lasting effect. The injections can have a dramatic effect on the pain of a frozen shoulder but do not treat the cause, which is necessary to restore full movement
Physical therapy
A course of physiotherapy may be prescribed. This will usually involve developing an exercise programme for you to carry out at home. Techniques will be used to work on the shoulder including stretching, ultrasound, heat and cold therapy or TENs.
Osteopathy – see below
Surgery
Surgery should only be considered after at least 3 months of more conservative therapies with minimal improvement in pain and movement. There are two main surgical procedures for frozen shoulder:
a) Manipulation under Anaesthesia
The surgeon manipulates the shoulder to move it through the full range of movement and break through adhesions. The aim is to free the shoulder and increase range of motion. There may be complications from this surgery including fracture of the arm bone, tearing of the rotator cuff muscles, or possible dislocation of the shoulde. Aggressive rehabilitation with physiotherapy or osteopathy is needed after this procedure.
b) Arthroscopic Capsular Release
A fibre optic camera is inserted into the shoulder joint so the surgeon can examine the soft-tissues of the shoulder joint. Any adhesions are cut away to free the joint. Generally there are faster results with this surgery and it can be repeated if inflammation persists.
Recovery from surgery ranges from 6 weeks to a year. Rehabilitation with exercises and physical therapy is still needed after surgery. The longer symptoms are present before surgery, the longer it takes to recover.
How osteopaths treat frozen shoulder using the Niel-Asher technique®
Diagnosis
Our first priority in taking care of you is to diagnose your shoulder condition, as frozen shoulder is frequently incorrectly diagnosed. We take a full case history and physically assess the condition of your shoulder to determine what is causing your symptoms.
Treatment
Successful treatment of frozen shoulder is based on trigger point therapy. A trigger point is a tender area in muscle which can be felt as a nodule in tight bands of muscle fibres. Compression of a trigger point can cause local tenderness or pain in a more distant area, e.g. compressing a trigger point in the shoulder area may be felt as pain in the elbow.
Our treatment involves working on trigger points particularly in the rotator cuff muscles around your shoulder. By releasing the trigger points your shoulder movement increases. Treatment involves working deep into the soft-tissues and can be tender at the time. Most patients describe this as a 'nice discomfort', quite different to the pain of the frozen shoulder. Movement of your shoulder is assessed at the beginning and end of each treatment session and there is usually a marked improvement.
The number of treatments needed varies, depending on the severity and stage of the frozen shoulder. If you come when you are in stage 1 then it can take 12 - 15 sessions to full recovery. Fewer sessions will be needed if you are in the later stages. Success of treatment is dependent on how well you follow advice and look after your shoulder between sessions.
If there are complications with your frozen shoulder such as tendonitis, or if you are diabetic, or both shoulders are affected, treatment can take longer. It is usually possible to see progress after each session whether that be reduction of pain or increased movement in your shoulder.
How can you avoid developing a Frozen Shoulder?
It is important to keep your shoulder moving after an injury or at the initial onset of pain. Unfortunately pain discourages movement, but further development of adhesions that restrict movement will occur unless your shoulder is kept moving in all directions. Osteopathy can help to encourage movement and prevent adhesions and frozen shoulder from developing.
Prognosis
Although, at the time, it may seem impossible the majority of frozen shoulders return to full mobility. Occasionally some stiffness at extremes of movement remains. In 15% of cases a second frozen shoulder occurs affecting the opposite side. The good news is that frozen shoulder is not known to occur twice in the same shoulder so you should never get it again in that shoulder.
How you can help your shoulder
Ensure that your shoulder condition is a frozen shoulder by seeing your doctor or an osteopath or physiotherapist before following this advice.
Keep moving
It is very important to keep using your shoulder within the limitations of the pain. Holding your shoulder in a protected position without moving only worsens the condition. It is true that ‘if you don't use it you lose it’, so use the full movement you have available. Do not try to force your shoulder to move beyond the limitations of the pain as you will find this aggravates your symptoms.
Cold packs
During the painful stages putting a cold pack on your shoulder may help to reduce pain and inflammation. Take a cold pack, or bag of frozen peas, wrap it in a tea towel and place it over your shoulder for 10 minutes only. Never put ice directly on the skin as it will cause an ice burn. The cold pack can be reapplied every hour but should only be left on your shoulder for 10 minutes at a time. Three applications per day can make a significant difference to pain and inflammation in your shoulder.
Exercises
You should not perform any stretching or strengthening exercises until the pain subsides and you just have restricted movement. The exercises below are appropriate for the painful stages.
- Let the arm hang freely by your side with a weight, e.g. a can of food, in your hand to weigh down through your shoulder. Gently allow the hand to move in a small circle within the constraints of the pain. Continue for up to 30 seconds, stop if your arm begins to ache.
- Stand facing a wall, an arm’s length away. Lift your arm forwards as far as it will go, keeping the elbow straight. Gradually walk your fingers up the wall - two or three steps. Hold for 20 seconds in this position, then walk your fingers up the wall a little further. Repeat 3 times.
- Repeat the same exercise standing side-on to the wall and lifting your arm away from the side of your body and walking your fingers up the wall.
More exercises can be introduced under instruction from an osteopath or physiotherapist.
Sleeping
Night-time can be the most difficult time and lack of sleep affects every aspect of your life. It may help to support your arm with a pillow. Lying on your back place the pillow underneath the back of your arm, not your shoulder, to give support. On your side with the upper shoulder being the affected one, you can support the arm by tucking a pillow between the arm and your side or bringing the arm forward to rest on a supporting pillow. You may get a longer period of sleep if you apply a cold pack to your shoulder before you go to bed – as described above.
These simple measures should help you to manage your condition better.
Further help
Frozen shoulder is such a painful and restricting condition you are probably despairing by now. If you would like to have an assessment of your shoulder or a course of treatment, or if you have any questions then please do not hesitate to contact a Frozen Shoulder clinic.
|
