Frozen Shoulder or Intrinsic Capsular Stiffness (ICS) or Adhesive Capsulitis.
This is a condition in which the shoulder may become increasingly stiff and painful. There has been some argument regarding the appropriate term for this condition. Adhesive capsulitis, although in common use, is a misnomer as the process does not involve any sticking together or adhesion and it is not a capsulitis as it is not an inflammatory process.
Structures involved:
The capsule, or lining of the shoulder joint, is normally relatively loose, allowing the shoulder to have the greatest range of movement of any joint in the body. When a Frozen shoulder or Intrinsic Capsular Stiffness (ICS) develops the lining of the joint contracts and becomes thickened. As a consequence both the active and passive range of movement is reduced, that is shoulder movement is restricted when either the patient or examiner attempt to move the shoulder.
The muscles, which would normally move the shoulder, are typically unaffected but cannot move the joint normally because of the physical limitation of the capsule.
The other joints that make up the shoulder complex are unaffected.
Symptoms:
Pain.
Pain is normally the first issue that is noted. The pain may be severe and is typically felt over the upper arm or deltoid rather than necessarily the shoulder itself. The pain is often noted on movement such as reaching up to say a top shelf (abduction) or reaching back to reach the back seat of a car (external rotation) and reaching behind the back to tuck in a shirt or fasten a bra (internal rotation). The pain may be particularly troublesome at night and disturb sleep. Lying on either shoulder may be uncomfortable. Pain is often particularly marked on sudden unanticipated movements.
Secondary pain may develop over the back, shoulder blade and neck (Parascapular and Trapezial regions). This is often a consequence of the extra strain on the scapular stabilising muscles and neck as the Shoulder (Gleno-Humeral Joint) stiffens.
In the early stages when stiffness is not marked it may be very difficult to distinguish an ICS or frozen shoulder from an impingement syndrome as the pain on abduction may be similar and the impingement tests may appear positive.
The marked pain associated with the Gleno-Humeral joint typically subsides over a period of 6 months, although the neck and back pain may persist.
A small proportion of patients may continue to have some ongoing discomfort in the long term but this is uncommon.
Stiffness.
The stiffness or loss of active and passive movement, in the presence of normal structural imaging is the cardinal feature of ICS or a frozen shoulder. The stiffness is often progressive and may become increasingly disabling. The stiffness may reach a point where there is essentially no significant movement at the Gleno-Humeral joint and all apparent movement takes place as a consequence of scapula-thoracic movement (shoulder blade). This Scapluo-thoracic movement may compensate to a remarkable degree but may result in secondary pain around the scapula and neck.
The stiffness typically subsides over 12-24 months. Complete range of movement may not return but significant restriction or functional impairment is uncommon.
Causes:
A Frozen shoulder or ICS typically occurs for no clear reason. However, it may be associated with an injury, such as a trip and fall, or as a complication of surgery or possibly as a consequence of repeated activities at the extreme range of movement, such as painting the ceiling.
There are some conditions that appear related to a frozen shoulder or ICS, these include Diabetes, Dupytren’s Disease and Plantar Fibrosis. If you have had a frozen shoulder before you have an increased risk of developing a frozen shoulder in the other shoulder.
Diagnosis and investigations:
The diagnosis is likely to be made on the basis of the history and examination. However, investigations are important to exclude alternative causes of shoulder stiffness and identify co-existing issues.
X-Rays (plain radiographs).
These are particularly important to exclude alternative causes of stiffness including arthritis and rarely, a missed dislocation of the Gleno-Humeral Joint.
Magnetic Resonance Imaging scan (MRI).
Stiffness in the shoulder may make physical assessment of other structures such as the rotator cuff difficult. An MRI scan may be particularly useful for identifying associated structural damage, particularly if the stiffness has come on following a fall. It is not uncommon in this situation to have co-existing Rotator Cuff tears and a Frozen shoulder or ICS.
Ultrasound scan (USS).
An ultrasound scan can be a rapid way of assessing associated structural damage, particularly of the rotator cuff.
Treatment:
The majority of cases of Frozen shoulder or ICS will settle without any intervention. However, it is often an extremely painful and disabling condition. There are a number of treatments available that may relieve symptoms or potentially alter the course or rate of recovery. The evidence to support many treatments that are commonly offered is limited.
Analgesia (Painkillers).
Treatment with simple painkillers and anti-inflammatories may be particularly useful and all that is required to make the condition manageable.
Physiotherapy and rehabilitation.
Physiotherapy may be useful for symptomatic relief and to maintain as much range of movement as possible. Physiotherapy, including acupuncture and Tissue massage may be particularly useful for addressing secondary pain in the Parascapular and Trapezial regions.
Injections.
An injection of steroid and local anaesthetic may be provided into the Gleno-Humeral Joint itself. The injection may be useful from a diagnostic standpoint, confirming the articular nature of the pathology. The injection may also produce symptomatic relief in the short or long term as well as potentially modifying the course of the condition.
Surgical intervention.
Occasionally the shoulder continues to cause pain and functional impairment despite initial treatment. In this situation surgical intervention may be considered.
Manipulation Under Anaesthetic (MUA).
The traditional surgical intervention is a Manipulation Under Anaesthetic (MUA). This involves a general anaesthetic (being fully asleep). The shoulder is then carefully stretched to release the capsule and break down the thickened contractures. The shoulder is then mobilised as soon as possible with focused physiotherapy to limit or prevent recurrence of stiffness.
Arthroscopic Capsular Release.
In this situation and arthroscopic (keyhole) examination of the shoulder is undertaken. This is typically undertaken under a General anaesthetic (fully asleep) with a nerve block above the clavicle (collarbone) to numb the arm and allow early pain free movement following the procedure. The diagnosis is confirmed by the visualisation of the abnormal capsule (lining) of the Gleno-Humeral Joint. Additional damage can be confirmed and or treated. The thickened contracted tissue can then be divided under direct vision. It is not normally necessary to circumferentially release the capsule. Once the capsule has been released sufficiently the shoulder is then carefully manipulated to release any residual limitation of movement. An injection of steroid and local anaesthetic is then typically provided to the Gleno-Humeral joint. The shoulder is then mobilised as soon as possible with focused physiotherapy.
Preventing further stiffness:
Continuing rehabilitation is important to limit or prevent recurrence of stiffness. Despite this a small number of patients will have a relapse in the degree of stiffness. Very rarely repeat arthroscopic release is indicated. Those with associated conditions such as Diabetes or Dupytren’s Disease may be most at risk.
