Frozen Shoulder

Have you ever experienced pain in your shoulder associated with stiffness that makes your daily activities difficult? Then you might be suffering from a condition called ‘frozen shoulder’, also known in medical terms as ‘adhesive capsulitis’.

It’s a common but often misunderstood condition that can seriously affect your daily activities, right from combing your hair, changing clothes to reaching out for something high on the shelf. With right treatment at right time, most of the patients recover rapidly and achieve a complete recovery. Let’s try to understand in simple words what frozen shoulder is all about, how to recognize it, and what can be done to get back to your routine faster.

What is frozen shoulder?

Frozen shoulder is an inflammatory condition that causes swelling of the outer envelope of shoulder joint (capsule), with eventual thickening and tightness of the same (adhesion), hence the name ‘adhesive capsulitis’. It starts with a dull aching pain in the shoulder, which may worsen with extreme movements and at night. Pain gradually builds up followed by the stiffness.

What does it happen?

Frozen shoulder typically affects people between 30 to 60 years, and it's more common in women.

Based on the etiology (cause), it is classified into following two types:

A) Primary:

• It is idiopathic (without any cause)

• Pre-disposing factors: diabetes mellitus, thyroid disorder, high cholesterol, Parkinson’s disease

• Up to 20% of people with type 2 diabetes mellitus develop frozen shoulder at least once in their lifetime. At times both the shoulders are affected simultaneously or in succession.

• Has a relatively slower onset

B) Secondary:

• Typically starts after an inciting event: fall over shoulder, jerk while lifting weight, surgery, prolonged immobilisation (e.g. in ICU)

• Has a faster onset

What are various stages of frozen shoulder?

Understanding the natural course of frozen shoulder helps you set the right expectations during the treatment. It progresses through three stages:

1. Freezing Stage (6 weeks to 9 months)

• Gradual onset of shoulder

• Pain radiates towards the neck & the arm

• Movements start getting restricted

• Pain worsens at night, causing sleep disturbances

• Sharp pain on sudden jerky movements

2. Frozen Stage (4 to 12 months)

• Pain becomes less intense

• Stiffness further increases

• Daily activities such as combing hair, wearing clothes are affected due to restricted movements

3. Thawing Stage (6 months to 2 years)

• No pain

• Slow improvement in range of motion

• Shoulder gradually returns to normal function

Signs and Symptoms

If you’re wondering whether you might be developing frozen shoulder, look for these common symptoms:

• Dull aching pain in the outer shoulder or upper arm

• Pain that worsens with movements or at night

• Decreased ability to reach overhead, behind your back, or across your body

• Difficulty with everyday activities like dressing, grooming, or driving

It’s important to note that symptoms can mimic other shoulder conditions like rotator cuff tears or arthritis, so reaching a final diagnosis is the key.

How is it diagnosed?

Clinical examination is the mainstay method for reaching the diagnosis. Restriction of both active (doing movements yourself) and passive (someone else trying to move your joint) movements is the hallmark.

Radiological tests such as X-rays or MRI are used to rule out other pathological conditions. Xray rules out arthritis, calcific tendinitis, while MRI might be required to rule out rotator cuff tear, confirm the changes of adhesive capsulitis, especially after a traumatic event.

What are the treatment options?

The goal of treatment is to reduce pain and restore normal joint mobility. The approach varies depending on how severe your symptoms are and what stage you’re in. The treatment is essentially non-surgical.

1. Medications

Medications don’t change the course of the disease but help to alleviate symptoms. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) reduce the inflammation and manage severe pain in early stages. Nerve mediations such as pregabalin help in reducing the nocturnal pain. Primary role of medications is to reduce the severity of pain, so that rehabilitation can be started earlier.

2. Physical therapy

It is the cornerstone of treatment, although when it should be started is debatable. Pain controlling modalities such as TENS can be used in the initial stages. Stretching exercises ideally should be started once the night pain and pain with jerky movements has completely subsided. A supervised rehabilitation by a physical therapist helps to improve joint flexibility and regain the movements faster.

3. Intra-articular injections

In patients with no response to the medications and physiotherapy modalities, injections within the joint can reduce inflammation and provide rapid pain relief, especially in the early stages. This injection contains a mixture of corticosteroid (Triamcinolone) and a local anaesthetic agent (Bupivacaine) and are administered by the orthopaedic surgeon on out-patient basis. The benefits are variable, usually temporary but can be a useful part of a comprehensive plan.

4. Surgery (Arthroscopy + Manipulation)

Quite rarely when the conservative treatments fails to relieve the symptoms even after 8 to 12 months, the last resort is an arthroscopic capsular release, followed by manipulation of the joint.

It is a minimally invasive key-hole procedure where the tight joint capsule is released and loosened to restore the mobility. It is performed under general plus regional anaesthesia and needs hospitalisation for a day. Shoulder movements and rehabilitation are immediately resumed from the next day. It is very effective treatment modality but mostly reserved as a last resort for the rare refractory cases.

Recovery timeline: How long does it take?

Frozen shoulder management is like a marathon rather than a sprint and complete recovery is the rule. Understanding the condition thoroughly and its timeline are crucial for the patients to have the patience. Timely diagnosis and treatment are crucial as the long course of symptoms can be quite frustrating Most patients return to complete normalcy within 12 to 18 months. While it may sound like a long time, remember: recovery is usually steady and leads to a full return to function.

How can patients help themselves at home?

Here are a few simple strategies to support your recovery:

- Apply heat: A warm compress before stretching can loosen the joint & hence the pain

- Stay active: Avoid complete rest. Gentle movements helps prevent further stiffness.

- Sleep smart: Use pillows to support your arm in a comfortable position.

- Be patient: Progress can be slow, but timely treatment is the key to faster recovery.

To summarise..

Frozen shoulder can be frustrating, painful, and interfere with daily life, but it’s also a condition with a high recovery rate when treated appropriately. If you suspect you might have frozen shoulder, don’t wait. Early treatment and guided physical therapy can shorten the recovery time and ease out the discomfort.