Abate Adhesive Capsulitis

Your shoulder is painful, so much so that it is hard to move. You have taken ibuprofen but it doesn’t seem to work. You could have adhesive capsulitis or frozen shoulder.

Frozen shoulder happens when the lining that goes around the shoulder joint gets inflamed, possibly the result of a small injury. It thickens over time, forming scar tissue.

Frozen shoulder may occur after trauma, surgery or prolonged immobilization, but it often arises without any apparent precipitating event. It commonly affects middle-aged females and risk factors include diabetes, thyroid problems and coronary artery disease.

The long-term prognosis for frozen shoulder is thought to be good, with people passing through three stages and ultimately resolving within 12-24 months, regardless of treatment. These three stages include:

·       A freezing stage, where pain dominates and range of motion slowly decreases.

·       A frozen stage, where the pain gradually subsides but the stiffness remains.

·       A thawing stage, where range of motion gradually returns.

Not everyone with frozen shoulder will move through all three stages and spontaneously recover as anticipated. In fact, some research indicates that up to 50 percent of people are left with a loss of shoulder motion that persists beyond the expected time frame for recovery.

To combat this confusion, the terminology surrounding frozen shoulder is shifting towards two stages, indicated by whether pain or stiffness is the main feature. Characterizing frozen shoulder as “pain predominant” or “stiffness predominant” is helpful from a management perspective, as each stage requires unique interventions that serve a different purpose.

Before frozen shoulder can be treated, however, it must be specialized from conditions that are more rapidly correctable, as well as those referred from the spine. Even though these presentations can mimic frozen shoulder, their handling is much different.

Once frozen shoulder is ruled in, one must determine whether pain or stiffness is the dominating feature. The pain-predominant stage is first, followed by the stiffness-predominant stage, and although there can be some overlap between the two, the essential qualities of each are relatively specific.

In the pain-predominant stage, patients will complain of constant symptoms that are irritated by all shoulder movements. Inflammation is the primary pain generator, and every attempt should be made to not bother the shoulder with vigorous activities or therapy during this time. The goal of treatment during this pain-predominant stage of frozen shoulder is symptom reduction and inflammation control. Movement is still beneficial in order to retain as much range of motion as possible, since it will reduce as the condition progresses. A good rule of thumb is any increase in pain with movement should settle down quickly afterward.

Some research indicates that there is strong evidence for injections in the right patients with frozen shoulder. Ideal candidates for this intervention would be those in the pain-predominant stage, where symptoms are constant and easily aggravated.

Once someone is out of the pain-predominant stage (which can take several months) and stiffness becomes the overarching feature, the aim of treatment is to recover the lost range of motion. By this time, the shoulder capsule, which holds the shoulder joint together, has undergone structural changes that render it short and tight.

This loss of motion, which can be severe, is very consistent during the stiffness-predominant stage. Someone wouldn’t have days where they could move a lot farther than others. In addition, people tend to complain of pain only when the shortened shoulder capsule is stretched to its capacity. When they move away from the limit of their motion, pain should subside.

The ideal way to restore restricted range during this stage is through remodeling of the shortened tissue. Remodeling is best achieved through specific movements performed several times per day, with enough force to provide adequate stimulus for change. Pain should be produced at the end range of these movements but should stop shortly after the stress is released. If pain persists long after stretching is completed, it’s a sign that overloading has taken place. Restoring range of motion is slow and can take months, but compared to natural history, it greatly speeds up the process of recovery.

People often go wrong in treating frozen shoulder because they don’t adhere to the stages. They are either too aggressive in the pain-predominant stage or don’t fully understand how to remodel tissue in the stiffness-predominant stage. It is for this reason that some research has shown people who attend therapy for frozen shoulder have the same outcomes as those who don’t.

Successful management of frozen shoulder starts with an accurate diagnosis, and then applying the correct intervention depending on whether pain or stiffness is predominant.

Initial treatment is generally with over-the-counter nonsteroidal anti-inflammatories (NSAIDs) such as acetaminophen or ibuprofen. This is often followed with physical therapy, hot and/or cold treatments, prescription corticosteroids, arthroscopy, shoulder manipulation and electronic stimulation.