Adhesive Capsulitis (Frozen Shoulder)
Adhesive capsulitis is a problem that involved the lining of the shoulder joint. It tends to affect middle aged people. This is a disease process that goes through three distinct phases. In the first phase which is the inflammatory phase the lining of the shoulder joint becomes very aggressively inflamed. As a result the patient usually feels a great deal of pain, worse at night and as a result they are reluctant to move their shoulder. After roughly 6 months the inflammation “burns out” and the patient then moves into the scarring phase. During this phase the cells that make scar tissue behave in the same irrational way they the cells that control the inflammatory reponse do during the first phase. During this phase the lining of the joint becomes scarred. The patient no longer has the same severe pain but when they attempt to move their shoulder they experience sharp pains as they stretch on the newly formed scar tissue. This too lasts about 6 months and thereafter the patient moves into the “recovery phase” during which time the scarring is gradually broken down and the movement slowly returns. This process is said to take about 12 months.
We have no idea why people develop this problem. There are many theories including the most popular one that a viral infection triggers this reaction. We do know that people with diabetes are more prone to suffering from this condition and often take longer to recover.
Traditionally it has been said that left alone the condition gets better after 2 years. Despite what has been believed and taught for many years, this is not necessarily always the case. In many cases patients probably stop coming back to their doctor after two years or learn to live with the condition but in some cases patients do make a full recovery.
Despite the known phasic process of this disease, each patients experience will be slightly different. Some patients inflammatory phase is so severe that it compromises their lives while others pass through this phase without any significant disruption.
Depending upon the stage at which you see your specialist the treatment may vary. Invariably patients will be sent for physiotherapy to try and maintain their range of movement. This is often a futile exercise as the pain is too severe to allow adequate movement (if in the inflammatory phase) or the scar tissue is too severe to allow movement (if in the scarring phase). Injection of a steroid into the glenohumeral joint often helps a great deal and will also allow the physiotherapist the opportunity to move the shoulder more. This injection is most helpful if given during the inflammatory phase. Sadly many patients only seek specialist opinion once they are well through this phase.
When physiotherapy fails, the traditional treatment for this has been a manipulation under anaesthesia. This is essentially putting the patient to sleep and then moving the shoulder through its range to tear the scar tissue that is formed. Depending upon which phase the patient is at the time of the manipulation this can either improved things dramatically (If they just have scar tissue present) or aggravate the situation (If they have a very inflamed lining of the joint).
Many surgeons have moved away from always doing just an MUA and carry out a capsular release and synovectomy. This involves inserting the arthroscope into the joint and “dissolving” the inflamed lining and “melting” the scar tissue. This is done using a radiofrequency wand. (The radiofrequency wand is the same wand that is used to “shrink” the capsule when it is lax. However when shrinking the capsule the setting is on very low and when melting or ablating the capsule it is set on a higher setting.)
(Click here to see video of capsular ablation.)
