Self-care and Frequent movement to Thaw the Frozen Shoulder

The normal shoulder is one of the most mobile joints, and permits us to place our hands where we need it, and helps us make the master of the environment that we live in.

One of the common problems that are being faced these days by many people is that of a frozen shoulder. Frozen shoulder is referred to the condition in which the shoulder joint becomes painful, and develops stiffness gradually over time.

The Shoulder Joint is a complex ball-and-socket joint where the ball shaped upper end of the arm bone (humerus) articulates with the cup shaped socket in the shoulder blade (scapula). Strong connective tissue, called the shoulder capsule, surrounds the ball and socket joint. The capsule and ligaments surrounding the shoulder joint holds the bones together and permits movements is a safe manner. The muscles around the shoulder help move it in such a beautiful and well-coordinated manner. The capsule is lined with special cells that make the joint fluid, that lubricates the joint, keeping the movements friction free and smooth.

Frozen shoulder is thought to be a result of inflammation of the shoulder joint capsule, resulting in stiffening of the shoulder. The shoulder joint capsule becomes thickened and stiff. The shoulder becomes very painful and movements at the shoulder become reduced over time.

The inflammatory process in the shoulder may be triggered off by a minor illness such as a viral fever, a trivial injury to the shoulder, or sometimes situations where the shoulder was left immobile for some time. This painful and stiff shoulder problem is more common in Diabetics, although it is not clear as to why Diabetes makes our shoulders more susceptible to this inflammatory process. The long working hours, irregular dietary habits, stressful and sedentary lifeclass along with lack of regular exercise is often blamed for leading onto such problems. Most often Frozen shoulder is seen in people older than 40 years, however, the problem is gradually becoming more common in younger people. This urges us to try and prevent such problems.

The symptoms of a frozen shoulder are dull aching shoulder pain, with the patient complaining of severe pain with shoulder movements. Over time, it is noticed that the movements at the shoulder gradually become reduced. Often, the pain is worse during the night, disturbing sleep.

Frozen shoulder usually progresses through stages:

• Freezing stage: This is when any movement in the shoulder initiates pain and the shoulder’s range of motion gradually becomes limited.
• Frozen stage: Even though the constant dull pain may reduce, the shoulder becomes stiffer and extremely difficult to move.
• Thawing stage: This is when the limit of the shoulder’s motion starts improving

It can take a year to three years or so for a frozen shoulder to go through these stages and resolve.

While frozen shoulder can be severely painful and disrupting, becoming a hurdle in everyday routine activities, it is something that can be resolved with a few simple steps, most of which involves self-care.

Diagnosis & Investigations
The diagnosis is most often made based on a detailed evaluation of the patient & clinical examination. Your orthopaedic surgeon may sometimes take an X-Ray to rule out other potential problems that may cause a painful, stiff shoulder. Sometimes, an MRI is used to evaluate the shoulder in greater detail.

Preventive measures
For any other reason, such as after an illness, or an injury to that upper limb, due to which the shoulder movements are reduced may lead onto a frozen shoulder. Early active mobilisation of the shoulder would help prevent the onset of this problem.

In people who are diabetic, and those with hyperthyroidism or hypothyroidism, it is recommended to seek treatment to maintain these conditions under good control. This is thought to reduce the chances of frozen shoulder.

Remedies for a frozen shoulder:

• Lifeclass plays a major role in deciding the severety of frozen shoulder and the time it takes to heal. Maintaining good control on Diabetes, thyroid problems if present, is thought to help hasten recovery.
• Actively use the involved shoulder frequently as much as possible to eventually improve the pain and range-of-motion. However, it is recommended to avoid heavy weights & strenuous use of the shoulder.
• Warm packs or Ice packs can also be applied to relieve the shoulder pain. Warm water fomentation is commonly used to reduce pain & permit more movement at the shoulder.
• A visit to the Orthopaedic Surgeon to confirm the diagnosis, and then work with the physiotherapist to learn range-of-motion exercises goes a long way in bringing this shoulder back to its normal self. These exercises will aid in recovering the mobility in the shoulder to a large extent. The patient can choose to regularly visit the therapist for exercises or learn them and consistently follow up at home with discipline.
• With determination, self-care and regular exercises, there is gradual improvement in the shoulder

In more severe painful shoulders, the following may help:

• The initial pain and inflammation can also be reduced with certain regular pain relievers but, it is always advised to take it after consulting your orthopaedic surgeon.
• Alternative medicines like acupuncture works quite well as if done properly, especially to assist in relieving pain.
• Transcutaneous electrical nerve stimulation (TENS) is also one of the physiotherapy treatments that can help in control of pain.

Occasionally, further treatment may be indicated:

• Steroid injections into the affected shoulder joint to bring down the pain and improve the mobility of the shoulder especially in the early stages.

• Injecting sterile water into the joint capsule is sometimes done to help the tight capsular tissue to stretch, thereby reducing the stiffness and ease movement.
• A shoulder manipulation under anaesthesia might also be done by the orthopaedic surgeon to help regain movements in the shoulder. In this process, the patient is given general anesthesia. and the doctor then moves the joint very carefully in various directions.
• Frozen shoulder requiring surgery is extremely rare. Sometimes, if it does not resolve and X-Rays and MRI scans reveal tight, thickened capsule tissue that is adherent and limits movements. Occasionally, this needs surgical release by arthroscopic surgery to remove adhesions and scar tissue from inside the joint, and assist in restoring movements to the shoulder

Key Points:

• Frozen shoulder is a result of a type of inflammation of the shoulder joint capsule, causing thickening of the capsule, making it stiff.
• The shoulder becomes Painful & stiff, with reduced movements.
• Some health conditions may increase chances of this problem – Diabetes, Hypothyroidism
• 3 Phases – Freezing à Frozen à Thawing. The whole process takes between 1-3 years.
• Prevent prolonged immobility of the shoulder. Even if the shoulder is rested due to other illness or injury, the shoulder can very often be mobilized within safe limits.
• A few patients may need injections into the shoulder or manipulation under anaesthesia, and very occasionally, some may need arthroscopic surgery
• The vast majority of patients improve with self-help - doing active exercises regularly to restore movements, and physical methods such as ice packs or warm water fomentation to reduce pain.

Dr. Shankar Kurpad, Consultant Orthopedics, Columbia Asia Referral Hospital Yeshwanthpur