Adhesive capsulitis, more commonly known as Frozen Shoulder Syndrome (FSS), is a commonly encountered musculoskeletal problem. It is a condition that causes shoulder pain and restricts the mobility of the shoulder joint. Seen in 2-5% of the general population, it is more common in diabetics with a prevalence of 10-20%. Females are affected more often and it usually is seen in the age group of 40 to 60 years. Patients generally complain of difficulty in raising the arm, dressing, washing hair or sleeping on the side as the shoulder pain.
There may not be a precipitating factor for FSS, in which case, it is called as primary or idiopathic. Secondary causes of FSS are more commonly seen, being most prevalent in diabetes. Thyroid disorders, Parkinson’s disease, prolonged immobilization, stroke or any muscle, ligament or bony injury around the shoulder joint can lead to this condition.
This condition is chronic, meaning it may take months to years to recover completely. FSS has three stages. In the first stage, called the ‘Freezing stage’ or ‘Painful phase’, the patient generally complaints of severe disabling and diffuse shoulder pain that is worse at night. This is due to inflammatory fluid in the shoulder joint. It can last for 2 to 9 months. Following this stage, the ‘Frozen stage’ or ‘Stiffening phase’ ensues, which is characterized by reduction in the pain but persistent stiffness. Patient may experience pain at the extremes of motion, but is still unable to carry out all movements at the joint. Stiffness may worsen at this stage. This is caused due to thickening and shrinkage of the shoulder joint capsule, with adhesion formation. This phase may last for 4 months to a year. The last phase called the ‘Thawing stage’ or ‘Resolution phase’ can take for up to 2 years and is characterized by gradual increase in range of motion and return to normal state.
Generally only one shoulder is involved, but patients who have suffered this condition are prone to develop FFS in the other shoulder in future. This condition is diagnosed clinically, however, Ultrasound or MRI of the shoulder may be done to rule out any underlying cause. Blood sugar test to rule out diabetes is done in suspected patients.
Treatment of FSS involves treating the underlying condition. This condition is, in most cases, self-limiting. Symptomatic treatment in the form of analgesics, or painkillers can be given in the initial phase when pain is severe. Heat application in the form of hot packs is useful, especially before physical therapy. Injections of anesthetics and steroids are also given into the shoulder joint, which relieves pain temporarily. Physiotherapy (PT) is an important modality of treatment in FSS and the type of therapy differs according to the phase of the disease. In the initial phase, any activities that cause pain are avoided and the patient is encouraged to do simple pain free exercises rather than intensive physical therapy. During the Frozen stage, the focus of PT should be to improve the range of movement of the shoulder by aggressive stretching exercises. Low load and prolonged stretches are recommended. During the third stage, the PT should be progressed by increasing the frequency and duration of stretches while maintaining the same intensity, as tolerated by the patient. Manual techniques and ultrasound application is also done, but needs the help of a physiotherapist. If all options fail, there is a place for surgical interventions in certain conditions.
In conclusion, it is necessary to remember that FSS is a common condition, especially in diabetes; can last for months to years, and is mostly self-limiting. It is thus, necessary, to be patient, continue physiotherapy and not give a cold shoulder to this problem.
MD (Medicine), DNB (Rheumatology)
Consultant: Arthritis, Joint Pain & Rheumatology Clinic