Brrrrrrrrrrrrrr….

are you getting the cold shoulder?

by Alejandro Badia, MD

The shoulder loses range of motion, and deep pain is a common component of this troublesome malady

Frozen shoulder, or adhesive capsulitis, is a common but poorly understood condition that can affect the shoulder in a variety of patients. Its name suggests the fact that the shoulder loses range of motion, and deep pain is a common component of this troublesome malady. Very frequently, the condition develops because of trauma to the shoulder, which includes prior surgical intervention; however, many patients development this condition spontaneously for unknown reasons. It is commonly seen in older woman as well as patients with certain metabolic conditions including diabetes, thyroid hormone imbalances, and even Parkinson’s disease.

Three stages

Adhesive capsulitis generally presents in a series of three stages. The first is known as a painful stage where deep persistent pain develops and often does not allow the patient to sleep well. The range of motion is not as affected until the second stage, known as the freezing stage. In this stage, the shoulder loses a significant amount of its motion capability. In the third stage, known as the thawing stage, the patient begins to incrementally regain much of the range of motion, but during this stage pain can also reappear.

 Therapy is crucial

While many patients go through all stages and sequence, and eventually regain a near normal range of motion, it is important to monitor the progress and be ready to intervene because some of this motion loss can be permanent. It is particularly true in patients, who have had a fracture or even a surgical procedure, whose recovery needs to be monitored closely so that capsulitis does not limit the return of function. Frequently this cascade of events worsens and then resolves within a one or two year period. During that time, anti-inflammatories, such as ibuprofen and even a corticosteroid injection introduced into  the shoulder joint can offer some relief. This cortisone-type preparation can be very beneficial to reduce pain and deep swelling, but it can be detrimental to normal tissues in the long run and should not be abused. Other conservative measures include acupuncture, as well as TENS (transcutaneous electrical nerve stimulation), which has a similar effect as acupuncture in creating the release of endogenous opioids, or the body’s analgesic chemicals, which provide relief of pain. Throughout this time, particular exercises instituted by a physical or occupational therapist are crucial in order to maintain range of motion and stimulate recovery.

While the causes of frozen shoulder are not well understood, the pathology is typically characterized by thickening of the joint capsule. This thickening leads to a loss in tissue mobility and consequently inhibits the shoulder range of motion.

When the range of motion does not respond to conservative measures and pain magnifies, surgical treatment may be indicated. Traditional treatment involves manipulating the shoulder while under an anesthetic, which can lead to an improvement in motion that might be only temporary.

The reason is that manipulation itself can cause tearing of the soft tissue structures that often heal by forming additional scar tissue; therefore, it is often best to perform manipulation in conjunction with an arthroscopic procedure where the tissues are released during the surgery (arthroscopic capsulectomy).

What is arthroscopic?

Arthroscopy is a minimally invasive procedure in which a tiny camera is inserted into the joint so that the joint capsule can be visualized from the inside allowing the release of the tissue using either mechanical instruments or even radiofrequency probes in a traumatic fashion. During arthroscopy, fluid is pumped into the joint expanding the joint and helping improve the range of motion. Once motion is restored, it is important to maintain it and for this reason…postoperative pain management is a key factor. Maintaining motion may include the use of a continuous passive motion (CPM) machine, which the patient will often use at home in order to maintain the arc of motion that the surgeon obtains intraoperatively. The patient should be ready to concentrate on the rehabilitation during this immediate postoperative period in order to maximize its effectiveness. It is important that the patient seek an orthopedic surgeon with ample experience in shoulder problems because certain cases of adhesive capsulitis can be particularly difficult to treat. Regardless, one should be optimistic because most cases of frozen shoulder spontaneously resolve over time with supportive care. To resolve frozen shoulder, a team approach is necessary. Being well motivated and having an understanding of the condition and its natural history can help patients through a frustrating series of events.

Other conservative measures include acupuncture, as well as TENS (transcutaneous electrical nerve stimulation)

During arthroscopy, fluid is pumped into the joint expanding the joint and helping improve the range of motion

Dr. Alejandro Badia dedicates his practice to the surgical and medical management of hand, elbow and shoulder problems, including acute injury. Learn more about Dr. Badia at www.radthemag.com