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Frozen Shoulder

Frozen shoulder is a debilitating condition that causes acute shoulder pain and gradually increasing stiffness and loss of function that can last in excess of 18 months. The great majority of patients with frozen shoulder have no known cause. There is an increased frequency in middle aged women and in people with diabetes. Frozen shoulder can also complicate other conditions such as shoulder fractures and shoulder surgery.

Frozen shoulder is caused by an inflammation and thickening of the ligaments and capsule of the shoulder. The ligaments normally stabilize the shoulder but when inflamed and thickened, can cause severe pain on rapid movement and globally restrict movement in all planes. This makes it impossible for ladies to reach their bra strap with the affected arm.

Frozen shoulder is commonly divided into 3 phases: painful, stiffening and thawing. These occur over 18-24 months. Not all patients follow the classical presentation.

The painful phase describes the chronic background ache from the capsular inflammation. This can make sleeping very difficult. Without obvious stiffness this can present like many other painful shoulder conditions such as impingement. The chronic background ache may last for 6 months. Pain control can include simple pain killers, anti-inflammatories and an image guided steroid injection into the glenohumeral joint. The joint injection will provide most benefit the earlier it is given in the inflammatory painful phase. Rarely oral opiate medications, oral corticosteroids and sleeping tablets may be required. Due to the difficulty in controlling the pain, people try multiple options such as massage, acupuncture and electrical stimulation. These generally provide short-term relief.

The stiffening phase is marked by loss of movement in all planes. This movement is not helped even if forced with your good arm. The chronic background ache slowly resolves but other pains persist. Rapid stretching of the shortened, thickened ligaments can cause extreme pain (such as trying to catch a fallen object). Slow stretches like rolling onto your shoulder while sleeping will also cause you to wake. With the ball and socket of the shoulder being stiff and painful most people compensate by using the shoulder blade to lift the arm. This extra strain on the neck and upper back muscles causes an end of the day, fatigue pain.

The thawing phase spontaneously occurs greater than 12 months after the original onset of pain with slowly improving range of motion. Most people regain a functional range of motion. Diabetics have greater residual stiffness.

The diagnosis is made on history and examination. Investigations (plain Xray +/- ultrasound) help exclude arthritis or tumour as rare alternate diagnoses. MRI is very rarely required.

MRI findings include a thickening of the shoulder joint capsule.

With the natural history being recovery of a functional painless shoulder, treatment is generally non-operative. Treatment includes pain management (see painful phase), minimising stiffness and maintaining strength. Movement should be maintained while in the shower daily in all planes. Patients should maintain functional use and strength within the pain-free zone of movement. Painful stretching should be avoided as this has been shown to increase the duration of the painful phase and lengthen the time to resolution.

Rarely surgery is required for frozen shoulder. In patients with severe functional loss, no family support and the threat of financial ruin an arthroscopic capsular release can be considered at 6 months after onset. If the thawing phase has not commenced beyond normal natural history time frames (18 months) and the functional loss is interfering with quality of life a delayed capsular release can be performed. The keyhole procedure removes a segment of the thickened joint capsule and ligaments to restore range of motion.

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