FROZEN SHOULDER

Frozen shoulder or 'Adhesive Capsulitis' is a very common cause of shoulder pain in people aged between 40 and 60, with females affected more than men. Shoulder specialist Dr Robert Codman first described 'Frozen Shoulder' in 1934, even though this painful shoulder condition had frustrated patients and doctors for centuries before. The fact that Frozen Shoulder merely describes exactly what the patient experiences, is evidence the condition was still poorly understood.
 the word Adhesive Capsulitis and described the pathology to be characterised by adhesions and contractures from the fibrous capsule that surrounds the shoulder joint. While other concerns can produce a stiff shoulder and shoulder pain, frozen shoulder is characterised by adhesions from the capsule.
To date the reason for frozen shoulder is not worked out, although it is assigned to other medical problems for example diabetes, thyroid problems along with a history of previous cardiac arrest.
The natural history of frozen shoulder
Frozen shoulder is usually thought to have three phases, using the whole course of the problem lasting up to seven years.
1. Painful phase. This phase lasts 10-36 months. The pain could be severe and unrelenting, resulting in severe problems sleeping. Sufferers often appear unhappy, and could have lost some of their feeling of humour due to the pain lasting such a long time.
2. Stiffening phase. This lasts 4-12 months, resulting in a gradual loss of motion of the shoulder. The outcome can be a very stiff joint sooner or later.
3. Recovery period. This lasts from 12-24 months. The shortest time for this problem to resolve is over 2 yrs, the longest up to seven years. Recovery is usually not complete, with mild pain and stiffness a typical long term problem, without however any significant functional disablility.

Frozen Shoulder Signs & Symptoms
Interestingly, the non-dominant shoulder seems to be affected more than the dominant shoulder. Those patients with frozen shoulder usually experience distinct phases with differing signs or symptoms.
The first phase is called the 'Freezing' phase. In this phase pain occurs slowly and creates a gradual loss in shoulder movement. Some patients might not notice anything until they fight to, say, fasten a bra or comb their head of hair. Eventually, over the space of the couple of months, the pain becomes so severe it interferes with sleep since there is an exquisite pain when trying to lie on the affected shoulder.
The 2nd phase is referred to as the 'Frozen' phase because of the continued restriction of shoulder movement, which could last for up to a year.
The ultimate phase is referred to as the 'Thawing' phase. This could take anywhere between 5 months and 2 years, although some patients may feel a more rapid recovery. During this period there is a gradual rise in shoulder range of motion.
Because it is the soft tissues, specifically the capsule, which are affected by frozen shoulder, x-rays are evident. However, they are beneficial in distinguishing the problem from shoulder arthritis and calcific tendinopathy. The primary diagnostic characteristic of Frozen Shoulder is decreased joint capsule volume (the fluid within the shoulder joint is decreased) when an arthrography is conducted (an investigation whereby a liquid medium or dye is injected in to the joint space).
The standard fluid volume of the shoulder is about 30 cubic cm, but during arthrography in frozen shoulder the joint is only going to take 10 cubic cm of dye. Another sign of frozen shoulder may be the loss of the 'axillary fold' of the capsule around the arthrograph itself. It hasn't gone anywhere; it's merely 'stuck to itself' and should not be seen as a result.
Diagnosis:
Its not all stiff or painful shoulder is really a frozen shoulder, and even there is some controversy within the criteria for diagnosing "frozen shoulder". Stiffness happens in a variety of conditions- arthritic, rheumatic, post-traumatic, and post operative. Detecting frozen shoulder is clinical sitting on two characteristic features.

• Painful restriction of motion in the presence of normal x-rays, and
• a natural progression through three successive phases.
Once the patient is seen first, numerous conditions should be excluded: infection, post traumatic stiffness, diffuse stiffness and reflex sympathetic dystrophy.
Generally, a global loss of active and passive motion exists; the loss of external rotation using the arm at the patient's side is really a hallmark of this condition. The loss of passive external rotation may be the single most important finding on physical examination that can help to differentiate diagnosing from a rotator cuff problem because problems from the rotator cuff generally don't result in a loss of passive external rotation.
Frozen shoulder Treatment
Many treatments happen to be tried and continue to be provided, with the likely outcome that frozen shoulder experiences its natural history by itself, with treatments having little effect.
Having a modern understanding of what causes frozen shoulder, treatments could be directed at stretching, rupturing or taking out the tight fibrosed tissues.
Physiotherapy
Physiotherapy for frozen shoulder focuses on passive and active exercises for the shoulder joint.
Anything else include accessory strategies to improve joint mechanics and electrical techniques for example interferential and TENS. The potency of these techniques has not been demonstrated.
Treatment may include warming up the tissues, pendulum exercises, stretching techniques with overhead pulleys, a walking stick along with a towel to simulate drying the rear. These movements force the shoulder from the restrictions and attempt to extend the contracted tissues.
Steroid injections
Injections of corticosteroid are generally given for shoulder problems, however the effectiveness of this treatment isn't clear.
Manipulation under anaesthetic (MUA)
Surgical opinion about manipulation has varied through the years, with many doctors feeling the potential risks outweighed the benefits. Modern work indicates there can be significant good things about manipulation, in both flexibility and pain relief. However, diabetic people show less benefit and thus may be less suitable for this process.
Open surgery
Ozaki described open (ie not keyhole) surgical discharge of frozen shoulder in 17 patients. Bunker showed later when the coracohumeral ligament was cut then your shoulder would release immediately, with manipulation into outward rotation sometimes being required. Afterwards, physiotherapy is indicated to keep the range of motion gained through the operation.
Arthroscopic surgery
Various surgeons have published focus on this technique, and it appears to be useful for patients who don't respond to normal treatments or manipulation.