Most of the pain around the shoulder is thought to be frozen shoulder. So I think it is time we demystify or rather defreeze the myth behind frozen shoulder. Frozen Shoulder is a very vague term, which was coined about a hundred years ago for any form of painful shoulder that was stiff. The reason believed then was that the capsule or the covering of the shoulder joint becomes frozen. However, with modern research we know that this is not entirely true. So what exactly is frozen shoulder?
The shoulder joint, like any other joint, has a thick covering called as the joint capsule. For some unknown reason, there triggers off a series of events in which this capsule becomes thickened because of uncontrolled multiplication of the cells within it. What follows thereafter is a series of stages in which this capsule will contract and thereby cause limitation of the movement of the shoulder along with pain. Though we do not know as to how it was triggered, we know for sure what are the predisposing factors. Definitely diabetics are more likely to suffer from this problem. Diabetics are four times more likely to get stiff shoulder than non-diabetics. Similarly, if a diabetic has stiff shoulder on one side, it is likely that he will get one on the other side as well, the risk of which is calculated to be about approximately 40 per cent. Patients who suffer for hypo-thyroidism may also be predisposed to stiff shoulder. Stiff shoulder may also occur after injuries around the shoulder since they may cause micro damage not only to the muscle but to also to the capsule.
The natural history of stiff shoulder is that of a long-drawn process. If left untreated, most of the stiff shoulders will heal themselves eventually, but may take upto 18 months. In the classic form, a stiff shoulder will pass through three stages each lasting for about six months. The first stage is the painful stage in which there is intense pain around the shoulder joint due to inflammation of the capsule. The shoulder movements are only restricted towards the end range. The second stage is the frozen stage in which the stiffness becomes more marked and the pain slowly and gradually starts lowering down but never ceases completely. The last stage is that of the thawing phase in which the movements slowly warm up or return to be normal again and the pain starts disappearing gradually. Many a times a sudden jerk sustained by the patient may cause resolution of symptoms. I have heard this happen one too many times when a patient was travelling in a bus and holding on the grab bar above him. With sudden breaking action, he got pushed ahead and whilst holding on to the grab bar, there was a sudden snap in the shoulder and to the patient’s surprise; a “natural act” released the stiff shoulder.
It is necessary to start treatment in the early stages, since by instituting the appropriate treatment, the duration of the disease can be shortened immensely. The first stage of treatment essentially consists of taking medication as well as doing exercises. These exercises – usually to be taught by the physical therapist – consist of a variety of stretches of the shoulder joint. These exercises should be repeated frequently, say four to five times a day and one should do a minimum of 10 reputations each. It is useful to use hot fermentation around the joint before doing the exercises and then follow it up with ice packs afterwards which help decrease the inflammation. The use of anti-inflammatory medication as well as the occasional pain-relieving medicine and/ or a muscle relaxant is also advised. About 85 per cent of all patients will be benefited by this simple regime.
In those patients, for whom the symptoms do not settle or resolve, an injection may be done in the shoulder. The technique is that of “capsular distention”. What essentially we do in capsular distention is to place a needle inside the shoulder joint and then distend the shoulder joint with about 30 to 40 ccs of saline. This causes distention and in some cases minor rupturing of the capsule, which helps, alleviate the pain and decrease the stiffness. Manipulation under anaesthesia or forcibly moving the shoulder joint under the effect of anaesthesia was a treatment that was practised very widely in the yesteryears. Though it is useful, it definitely carries the risk of creating fractures and tears of the muscle because of undue blind force that may be applied. A manipulation is best avoided and should be done only by a skilled practitioner.
In about 5 per cent patients, none of these techniques work and then what needs to be done is to do a release of the capsule of the shoulder joint using keyhole arthroscopic techniques. All said and done it is important for the patient to realise that this problem may take a couple of months to resolve and there is no quick-fix solution. Doing regular stretching and proper exercises would be the key in prevention of this problem.
In my next column, I will discuss the issue of tears of the tendon of the shoulder and how we can prevent them. Till then, happy reading!
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