The “50-year-old shoulder”

In Chinese and Japanese, the “50 Shoulder”, or sometimes also called the “40 shoulder” refers to pain and stiffness of the shoulder occurring without any apparent cause. It is not confined to the 50 year old. and may occur typically in the 35-65 age group. This is also known as the Frozen Shoulder (or Adhesive Capsulitis in medical terms). However some of these patients may have Rotator Cuff Disease or even Osteoarthritis, both of which also present as pain and stiffness. In many of these cases, the symptoms overlap with the frozen shoulder and some form of imaging (X-rays, Ultrasound or MRI scans) may be needed to differentiate them.

 

Frozen Shoulder

The Frozen Shoulder is a problem involving the shoulder capsule. This is basically a balloon that surrounds the joint, the primary function of which is to hold in the joint fluid. This balloon gets thickened and inflamed in a frozen shoulder resulting in the pain and stiffness. The Rotator Cuff is actually a number of muscles which surround the shoulder ball, sitting just outside the capsult. It is commonly inflamed (tendonitis) or even torn in this age group. Arthritis is damage to the joint cartilage itself.

Usually, the pain starts gradually. In some cases, there may some form of mild injury or overuse, but in most case, the patients cannot remember any precipitating event. The shoulder becomes stiffer and more painful over the course of a few weeks to months.

The natural history of a frozen shoulder is that it eventually gets better on its own in most cases, but may take anything from 6 months to even 2-3 years. With treatment however, this period can be shortened dramatically. The primary treatment is that of a stretching programme. The majority of patients will respond to home programme of capsular stretching but there are always a few that do not.

Those who have too much pain to stretch, or do not respond, may need further intervention. This can be in the form of a simple Manipulation, under Anaesthesia or an Arthroscopic Capsular Release. This intervention is merely a way to get over the “hurdle” as the patient still needs to continue stretching for 2-3 months after this.

Rotator cuff disease is a spectrum of disease, ranging  from Tendonitis, to Partial Thickness Tears, known as Cuff Tear Arthropathy. The patient with a rotator cuff problem sometimes in a similar way to a frozen shoulder. In others it is due to an injury such as a fall or overuse injury. The symptoms are slightly different, as the pain is more pain on exertion or they may have a painful arc.

The rotator cuff is a set of muscles, surrounding the shoulder capsule. The most commonly involved muscle is Supraspinatus. The treatment depends very much on the patient symptoms, size of tear etc.

For example if the symptoms are just a painful arc (Impingement Syndrome) and the scans are negative for a tear, then non operative treatment is often successful. This may involve a stretching programme, rest, anti-inflammatory medication or even steroid injections. If surgery is needed, it is relatively simple Day Surgery Arthroscopic Surgery in which some bone may be removed to reduce the friction and rubbing on the rotator cuff from the adjacent bone.

On the other hand if there is full thickness tear, the symptoms may be more of weakness and pain on overhead activity. In this case, a Surgical Repair of the Torn Supraspinatus Tendon may be needed. Steroid injections are not recommended as they mask the symptoms only and also may compromise the results of surgical repair.

In come cases, a patient may have both a Rotator Cuff Tear, as well as a form of Frozen Shoulder which occurs secondarily to the Rotator Cuff Disease. This complicates the treatment and usually results in slower recovery.

Call +65 6471 2674 (24 Hour) to fix an appointment with our doctor to treat Rotator Cuff Tears or Frozen Shoulder today.

Brief Outline of Frozen Shoulder (Adhesive Capsulitis)

Frozen shoulder or adhesive capsulitis causes severe restriction of shoulder movement due to pain. The condition results from abnormal bands of tissue that form between joints, thereby restricting their motion and producing pain. Synovial fluid – which usually serves to lubricate the space between the capsule and ball of the humerus in the shoulder, allowing smooth motion – is often lacking in this condition. It is more common in females.

Frozen Shoulder

 

Anatomy and physiology

Frozen shoulder involves injury and accompanying loss of movement in the shoulder or glenohumeral joint. The joint consists of a ball (formed by the humeral head) and socket (the glenoid cavity). While the glenohumeral joint is normally one of the body’s most mobile joints, it is inherently unstable due to the gleonoid cavity being only approximately one-third the size of the humeral head, (although it is slightly deepened by a rim of fibrocartilage called the glenoid labrum). The joint capsule appears to be a major cause of movement limitation in this condition. Adhesions of scar tissue forming in joint spaces can restrict movement, causing the shoulder to freeze up, with severely limited range of motion.

Frozen Shoulder Range of Movement Limited

 

Cause of Frozen Shoulder

Scar tissue formation following shoulder injury. Formation of adhesions following shoulder surgery. Repeated tearing of soft tissue surrounding the glenohumeral joint.

Signs and symptoms

Dull, aching pain in the shoulder region, often worsening at night. Restricted movement of the shoulder. Pain and ache when lifting the affected arm.

Complication if left unattended

Frozen shoulder has a tendency to worsen over time without adequate treatment and proper recovery period. Attempted athletic activity, involving the affected shoulder, will likely lead to further adhesions of the joint, with further pain and restrictions of movement. Production of scar tissue may eventually require surgical removal.

Treatment

  • Injection
  • Manipulation under anaesthesia to loosen the joint and break up the scar tissue
  • Key-hole surgery to remove the scar tissue

Rehabilitation and prevention

Most heat should be accompanied by stretching exercises to gradually restore mobility. Heat therapy should be combined with doctor-supervised physical therapy. Moving the shoulder through the full range of motion several times daily, as well as strength training exercises, may help avoid frozen shoulder. Injuries to the shoulder should be given prompt medical attention to avoid formation of scar tissue, where possible.

Long-term prognosis

The length recovery time following frozen shoulder varies depending on the underlying cause as well as the age and health of the athlete, and the history of shoulder injury. If the condition fails to improve after 4-6 months, surgery may be required. Some lasting discomfort and impairment of movement is common with this injury.

Call (+65) 64712 674 (24 Hour) to fix an appointment to treat your frozen shoulder today.

You don’t have to live with it. Most shoulder injuries can be easily treated by medication, physiotherapy and surgery.

Do you feel a twinge in your shoulder when you lift up your arm? Or find that you are having trouble stretching your arms backwards? You may be suffering from a shoulder joint injury.

The shoulder joint is made up of three bones – the upper arm bone, shoulder blade and collarbone – along with a combination of muscles and tendons called the rotator cuff.

Rotator Cuff Tear

The joint is one of the most mobile in the human body and prone to injury because of the heavy use of the arm and shoulder.

There are three main causes of shoulder pain:

  • Rotator Cuff Injuries
  • Dislocated Shoulder
  • Frozen Shoulder

Rotator Cuff Injuries

Rotator cuff injuries can range from less severe inflammation or partial tears of the cuff, to a complete tear. This can be caused by wear and tear, which is why the Chinese call this type of injury the “50-year shoulder”. People most affected are those who have to constantly life their arms over 90 degrees. Larger tears are also caused by trauma, such as in sports accidents or when you use your arms to break a fall.

Inflammation and smaller tears sometimes heal by themselves without surgery, and treatment for such conditions include non-steroidal anti-inflammatory drugs to bring down the swelling and ease the pain, combines with physiotherapy to strengthen the other rotator cuff muscles. Another option is an injection of anaesthetic into the area, which gives pain relief and brings down inflammation for up to six months. Activity modification is also important in treatment and prevention. This may include physical exercise to strengthen the rotator cuff, and changing the patient’s posture during everyday activities. A cycle of non-operative treatment usually lasts about three to six months.

In more serious tears, or when non-operative treatment is ineffective, surgeries are usually performed using the keyhole procedure, and will attempt to repair any damage to the rotator cuff. “Results are usually very good and most of our patients are able to return their sport in six to seven months.”

Dislocated Shoulder

Dislocated Shoulder

A dislocated shoulder happens when your upper arm bone pops out of the socket in the shoulder that it should fit in. Patients with dislocated shoulder will be in a lot of pain and unable to move the arm. The shoulder joint will also look deformed. After reducing the dislocation, one of the first steps of diagnosis is to undergo X-rays and a scan to find out why the dislocation happened, because in young patients, the chance of it happening again is very high. “We also conduct tests to find out how ‘loose’ the joint is as that will tell us how likely another dislocation is, even if the patient undergoes surgery.”

Not getting proper treatment could lead to more serious consequences. If a dislocated shoulder is not treated properly, the bone that is left out of the joint could damage the surrounding cartilage. Bone loss can occur because of the friction between the joint and the surrounding bone. Once that happens, it will be difficult to fix the problem with just keyhole surgery. Because of this, our orthopaedic specialist, Dr. Kevin Yip encourages seeking treatment from an orthopaedic specialist for all dislocations.

Frozen Shoulder

Just like its description, a frozen shoulder occurs when a patient cannot move his shoulder in any direction. This is caused by the thickening of the capsule of connective tissue that surrounds the shoulder joint.

Frozen Shoulder

 

There are three phases:

  1. Freezing
  2. Frozen
  3. Thawing

The first phase is when the range of motion of your shoulder becomes limited and pain arises when you try to move it. In the frozen stage, the shoulder becomes stiffer but the pain decreases, while the thawing stage is when the patient slowly regains the range of motion. The thawing process can take over a year, which is when it becomes disruptive to daily life. Treatment options include physiotherapy, injections and moving the shoulder joint to the full range of motion while you are in anaesthesia to break up the scar tissue and speed up recovery, and keyhole surgery to release the thickened capsule.

Keep Your Shoulders Safe

Shoulder conditions can have a considerable impact on your everyday life, and it is possible to lessen your risk of developing them. Our best piece of advice for protecting your shoulders would be to know your limits. If you know that a certain action is causing damage to your shoulders or making them hurt, stop doing it – activity modification is very important. And for sports enthusiasts, our advice is something we tell the guys we work out with – keep your ego at home when you exercise.

And more importantly, if you are already having shoulder pain, do not ignore it. See a doctor if you have any pain in the shoulder that persists beyond two weeks. There is treatment that can help relieve the pain and prevent it from coming back again. Remember – you don’t have to live with shoulder pain!

Call (+65) 6471 2674 (24 Hour) to make an appointment to see our doctor for your shoulder pain treatment today.

Frozen Shoulder

The term “frozen shoulder” is used to describe a condition characterised by pain and gradual loss of range of motion of shoulder. It occurs in up to 5% of the population and is more common in females. Frozen shoulder affects patients between ages of 40 and 60 years and the non-dominant shoulder is more commonly affected. Up to a third of patients who have a frozen shoulder will develop the same condition in the opposite shoulder.

Frozen Shoulder

Pain and stiffness in frozen shoulder is due to inflammation and progressive fibrosis (or scarring) of the capsule of the shoulder joint.

This disorder can be subdivided into primary or secondary frozen shoulder.

Primary Frozen Shoulder

This is a frozen shoulder condition which develops in the absence of any other shoulder condition. There is, however, an association with diabetes and thyroid disease. This is more common than the secondary frozen shoulder.

Secondary Frozen Shoulder

The frozen shoulder progresses through four stages before it starts to improve.

Stage 1

Gradual onset of pain typically referred to the middle of the upper arm. Aching pain is experienced at rest and sharp pain on movement. Patient is unable to sleep on the affected side. This stage lasts less than three months.

Stage 2

“Freezing” stage characterised by increasing pain, especially at night, together with gradual limitation of shoulder motion.

Stage 3

“Frozen” stage where the predominant complaint is stiffness and pain is diminished. Symptoms have been present between 9 to 15 months at this point.

Stage 4

“Thawing” stage where pain is a minimal and gradual improvement is seen in the range of motion.

Treatment for Frozen Shoulder

Before treatment can be instituted, the diagnosis has to be confirmed and secondary frozen shoulder has to be excluded. This involves a history suggestive of the disorder with a physical examination by a healthcare professional to exclude other causes of shoulder pain and stiffness.

The physical examination may also be able to pick up causes of secondary frozen shoulder. Finally X-ray images, and in cases where other associated condition are suspected, an ultrasound scan or MRI scan may be obtained.

The treatment of a frozen shoulder involves several possible modalities.

Physiotherapy

This is the mainstay of treatment. Mobilisation exercises within the limits of pain improve symptoms and function while aggressive stretching is associated with a poorer outcome. The exercises recommended are dependent on the stage of the condition. In the later stages, strengthening exercises are also incorporated.

Oral Anti-inflammatory Medication

Because of the inflammation process involved in this disorder, this class of medication is useful to alleviate the pain component of symptoms and is routinely given.

Manipulation Under Anaesthesia

This procedure also known as MUA. In this procedure, you will be under general anaesthesia while the orthopaedic surgeon tries to move your shoulder to the full range of motion.

By doing this, the scar tissue around the shoulder capsule will break up and release your shoulder capsule. This procedure has a high success rate and many patients has high satisfaction with the result. The advantages of MUA is that it only requires half an hour’s time and there is no cut or wound to your skin.

Surgery

Surgery is an alternative for the patient who has failed non-operative measures. As a guideline, physiotherapy should be instituted for at least four to six months before it can be concluded that the patient has failed this modality of treatment. Surgery involved is an arthroscopic (keyhole surgery) release of the shoulder capsule.

Dos and Don’ts for Frozen Shoulder

Do

  • Seek medical opinion even if you are sure you have a frozen shoulder as a secondary frozen shoulder possibility needs to be excluded. The outcome of a secondary frozen shoulder, if left neglected, can be quite different from that of a primary frozen shoulder.

Don’t

  • Ignore a stiff and painful shoulder as appropriate early intervention results in a shorter duration of discomfort and inconvenience.
  • Aggressively stretch a stiff shoulder as it can result in worsening of the frozen shoulder.

Let our orthopaedic surgeon advise you personally on treatments to frozen shoulder.

Call +65 64712674 (24 hr) for an appointment today.

Frozen Shoulder

What is Shoulder Pain due to Frozen Shoulder?

Frozen shoulder is a disorder where the connective tissue surrounding the glenohumeral joint of the shoulder becomes inflamed and stiff and abnormal bands of tissue form restricting motion and causing chronic pain.

The joint becomes so tight and stiff that it is nearly impossible to carry out simple movements for example raising the arm. The range of movement is severely restricted.

Frozen Shoulder
Frozen Shoulder

What are the Causes of Frozen Shoulder?

The cause for frozen shoulder is unknown. Nonetheless, there are a number of risk factors which includes diabetes, stroke, accidents, lung disease, connective tissue disorders, and heart disease.

 

Shoulder Adhesive Capsulitis
Shoulder Adhesive Capsulitis

How to Prevent Shoulder Pain due to Frozen Shoulder?

To prevent shoulder pain due to frozen shoulder, a common recommendation is to keep the shoulder joint fully moving. Often a shoulder will hurt when it begins to freeze.

What are the Treatments?

The treatment is a combination of medication, physiotherapy and home exercise. Some patients require manipulation of the shoulder joint under anaesthesia to break down the abnormal tissue bands. Arthroscopic debridement of the scar tissue may be necessary for more severe cases.