Dr. RAS Naidu, PhDIntroduction:
Frozen shoulder (FS) also known as adhesive capsulitis shoulder (ACS), involves stiffness and pain in the shoulder joint. Affected individuals struggle with daily activities, and sleep disturbances. FS may develop as a primary condition or secondarily following surgery or trauma. In FS, the shoulder joint capsule undergoes several pathological changes that lead to stiffness and restricted movement. Treatment for ACS remains a challenge today, placing a significant burden on healthcare systems as well as the wider economy, with patients unable to work for prolonged periods of time. It progresses through three stages: freezing, frozen, and thawing, each with varying degrees of pain and reduced range of motion. Causes of adhesive capsulitis of shoulder (ACS) include trauma, previous shoulder surgery, prolonged immobilization, diabetes, thyroid disorders (TDs), age and gender, cardiovascular disease (CVD), Parkinson’s disease (PD), rheumatoid arthritis (RA), and other autoimmune disorders. The treatment of FS is phase-specific and involves a combination of pain management, physical therapy, and in some cases, invasive procedures. Early intervention and a tailored approach to each phase can help minimize symptoms and expedite recovery.
FD progresses through three distinct phases, each with characteristic symptoms and pathological changes.
1. Freezing Phase (Painful Phase- 6 weeks to 9 months):
Symptoms include gradual onset of shoulder pain that worsens over time, pain is often severe and can be more pronounced at night, and progressive loss of shoulder movement due to pain.
Pathological Changes: Initial inflammatory response within the shoulder joint, leading to pain and swelling. Beginning of fibrous tissue formation as the body responds to chronic inflammation. Elevated levels of pro-inflammatory cytokines (IL-1, IL-6, TNF-alpha) and fibrogenic cytokines (TGF-beta).
2. Frozen Phase (Adhesive Phase – 4 to 12 months):
Symptoms include Pain may begin to decrease, but stiffness becomes the dominant issue, significant loss of shoulder movement, with difficulty performing daily activities, and shoulder feels stiff and hard to move.
Pathological Changes: Continued thickening and stiffening of the joint capsule due to excessive fibrous tissue, development of dense, disorganized scar tissue within the joint, formation of fibrous bands (adhesions) that restrict joint movement, and persistent Inflammation.
3. Thawing Phase (Recovery Phase – 6 months to 2 years):
Symptoms include gradual improvement in shoulder movement and reduction in stiffness, pain continues to decrease, shoulder function slowly returns, although complete recovery may vary.
Pathological Changes: Decrease in inflammatory response and reduction of pro-inflammatory cytokines, gradual breakdown and reabsorption of fibrotic tissue (reduction of fibrosis), reduction of excess scar tissue, and adhesion breakdown.
Causes of adhesive capsulitis of shoulder (ACS):
Diabetes: Excessive glycosylation of collagen in diabetes may reduce elasticity, and joint mobility.
Age: With age, decreased elasticity and healing ability, increased stiffness and prolonged inflammation lead to fibrosis and frozen shoulder.
Postmenopausal women (PMW) with TDs: Low levels of estrogen, osteoporosis or musculoskeletal issues are associated with a higher risk of FS. TDs lead to changes in collagen synthesis and degradation, an accumulation of glycosaminoglycans in tissues.
CVDs: Through a combination of inflammation, impaired blood flow, metabolic changes, reduced mobility, microvascular damage, medication side effects, and stress-related hormonal changes.
PD: Through a combination of factors, including muscle rigidity, altered motor function, postural changes, neuroinflammation, reduced physical activity, altered pain perception, and autonomic dysfunction.
Injuries and Surgeries: Through immobilization, inflammation, scar tissue formation, adhesion formation (bands of scar tissue within the joint capsule).
RA: Through chronic inflammation, pain and reduced mobility, joint damage, fibrosis and scar tissue formation, autoimmune factors, muscle atrophy, and the systemic effects of the disease.
Treatment Options:
Physical Exercise: Pendulum stretch (10 revolutions in each direction once a day), towel stretch (10-20 times daily), finger walk (10-20 times daily), cross-body reach (hold the stretch for 15-20 seconds and repeat 10-20 times daily), and armpit stretch (10-20 times daily).
Medical: Ibuprofen or naproxen can help reduce pain and inflammation. Acetaminophen can be used to manage pain. Oral corticosteroids can reduce inflammation and pain in the short term.
Intra-Articular Injections:
- Corticosteroid Injections to reduce inflammation.
- Hyaluronic Acid injections to lubricate the joint, improve mobility, and reduce pain.
- Hydrodilatation injection to stretch and improve mobility.
Manipulation Under Anesthesia (MUA): The patient is put under general anesthesia, and the doctor forcibly moves the shoulder to break up adhesions and improve range of motion.
Arthroscopic Capsular Release: A minimally invasive surgery where the surgeon uses an arthroscope to cut through tight portions of the joint capsule to release adhesions.
Others: Suprascapular Nerve Block (anesthetic injection), Acupuncture, Transcutaneous Electrical Nerve Stimulation, Heat Application, Cold Therapy, Activity Modification (Avoiding activities that exacerbate pain)
Nutritional Supplements: Some evidence suggests that supplements like omega-3 fatty acids, vitamin D, and glucosamine might help with joint health and reduce inflammation.
Conclusion:
Managing blood sugar levels in diabetes may prevent or manage FS. Understanding the role of adhesions in FD is crucial for effective treatment to restore normal function. Managing PD, RA, CVD through physical therapy, medications, and lifestyle modifications can help reduce the risk of developing FS. Prevention and managing FS issues associated with injuries and surgeries is possible by initiating early mobilization, physical therapy, pain management, and structured rehabilitation. Recognizing the role of cytokines throughout the progression of FS provides insights into potential interventions and therapeutic strategies to manage the condition effectively. Scientific study reported that well-planned exercise program is better than oral corticosteroids for pain relief from frozen shoulder.
DISCLOSURE STATEMENT
Disclaimer: The information provided in this blog is for general informational purposes only and is not a substitute for professional medical advice. Always consult with a healthcare provider for any health-related concerns.
