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Frozen shoulder

Frozen shoulder or adhesive capsulitis is known as a ‘syndrome of middle years’. This is because this nasty condition usually occurs between the ages of 40 to 60 years. Figures suggest that it affects 2-5% of the population in this age range, so up to one in twenty middle aged adults experience this thankfully self-limiting shoulder condition with more women than men experiencing it.

What is frozen shoulder? Usually occurring only in one shoulder, it is a three stage condition that lasts approximately 18 to 24 months. It is characterised by an initial phase of intense pain in the shoulder, followed by a middle phase of severe joint stiffness, finally leading to gradual recovery.

In stage one the shoulder joint becomes gradually painful over a couple of weeks or months, often without reason. Typically the first sign of trouble is intermittent pain on performing specific movements: putting on a jacket, reaching across to open a car door or turning off a bedside light. Then the pain becomes stronger and more constant, with a deep ache present even at rest. Most often pain is felt in the middle of the upper arm rather than over the actual shoulder joint. The pain which was gradual at the start becomes almost unbearable on any movement of the sore joint. At this stage most people respond by unconsciously using that shoulder and arm less and less to prevent pain. Over time lying on the shoulder at night is impossible. This ‘full blown’ stage can take 3 to 4 months to develop, though occasionally and frighteningly it occurs very rapidly.

The second stage takes over from acute pain to a point where the joint stiffens or ‘freezes’, hence the name, ‘frozen shoulder’. The only advantage of this stage is that while pain is not as prominent, function is badly compromised. Almost every activity of daily living requires freely moving shoulders. In this phase you cannot raise the arm above the level of the ear, cannot get a jumper on or take it off, cannot wash, brush or dry hair, etc. This distressing stage can last for nine months or more.

Recovery occurs gradually. Research shows that 80% of people recover fully over the following year, eventually being able to use the arm fully again. Unfortunately some 5-10% never regains full painfree movement in the affected shoulder.

So, if diagnosed with frozen shoulder is there any way to speed up recovery?
Evidence based research worldwide now shows that a four pronged approach is the only effective way to address this painful syndrome. The first step is to seek accurate diagnosis (some other shoulder problems can give sharp pain also, but present completely differently). Diagnosis is made entirely on clinical findings. As yet there is no consistent blood test or x-ray that can diagnose frozen shoulder.

After diagnosis, a combination of oral pain and anti-inflammatory medication, steroid injections into the joint in conjunction with intensive physiotherapy and backed up by specific home exercises is the only way to shorten the timeframe and improve outcome. Any single one of these gives less good results than all three together. The timing of each intervention is critical and requires that G.P. and chartered physiotherapist work in tandem to free up the painful stiff joint.

Just recently, significant improvements are being seen after one or two steroid injections into the joint very early in the painful stage, backed up by highly specific manual therapy to the tight joint, in the form of joint mobilisations. In this case the recovery process needs to be actively managed. Movement must be encouraged while avoiding any increase in pain. This delicate balance is not as easy to achieve as you would think. Usually the chartered physiotherapist will monitor this period closely, arranging subsequent injections if symptoms suggest.
Compliance with an exercise programme is crucial during recovery to ensure that gains achieved in each treatment sessions are carried over. Again it is important to perform any exercises exactly as prescribed by the physiotherapist. Either over doing or under performing exercises will impact negatively on progress.

With this approach we have seen several frozen shoulder presentations recover in 4-6 months rather than the documented 18-24 months.

Unfortunately if you are slow to seek medical assistance with frozen shoulder symptoms this early ‘window of opportunity’ passes by. Even so rehabilitation remains the cornerstone of treatment, though if the joint has become really stiff before treatment starts therapy effects occur much more slowly.

One final point: once recovered from frozen shoulder, the chance of it coming back to the same shoulder is almost unheard of, but in about 10% of cases the other shoulder gets the same syndrome some years later. As we now know what treatment works, the advice is to seek therapy as soon as possible. Whatever else, ignoring a painful stiffening shoulder is not wise.
Mairead O’Riordan, MSc, MISCP is a senior Chartered Physiotherapist & CEO of TherapyXperts, an allied health network dedicated to clinical excellence.
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