Frozen Shoulder: Factors, Stages, Treatments

Stiffness around the shoulder joint, debilitating pain and limited range of movement in the shoulder are all symptoms of “Frozen Shoulder” or “Adhesive Capsulitis”. The onset of this disorder is very slow and to regain the use of the shoulder, free of pain is also a slow process.

Composition of the Shoulder

The shoulder comprises of a ball and socket joint. Three bones conjoin to form this joint –

1. The shoulder blade or scapula

2. The collarbone or clavicle

3. The upper arm or humerus

The head of the humerus fits into the shallow socket of the shoulder joint, and the connective tissue also known as the shoulder capsule, envelops the joint. Synovial fluid present in the shoulder capsule, lubricates the shoulder capsule and the joint and thereby enables the shoulder to move more easily. 

When the connective tissue in the shoulder capsule becomes rigid due to the formation of tight bands of tissue or adhesions, with a simultaneous decrease in the level of synovial fluid, it causes stiffness and limits the range of motion, of the shoulder. This condition is referred to as “Frozen Shoulder”.

Stages of Adhesive Capsulitis

• First stage or Freezing Stage – it is a slow process and with time the pain increases and becomes worse, consequently leading to loss of motion in the shoulder joint. It takes anywhere from 6 weeks to 9 months for the onset of a freezing shoulder
• In stage two (4 months to 6 months), or the Frozen state, the stiffness in the joint continues, however, the pain may subside slightly. During this stage, daily activities involving the movement of the shoulder will be very difficult
• In the Thawing or third stage, the motion in the shoulder begins to improve, but to regain complete or near to normal motion in the shoulder, it may be anywhere from 6 months to 3 years

Factors

• Affects people in the age group between 40 – 70 years
• People with chronic ailments like diabetes or suffering from stroke, hypothyroidism, hyperthyroidism, Cardiac and Parkinson’s diseases
• Can be caused by surgery, such as mastectomy, or due to a fracture or any other injury

Diagnoses

The doctor will either conduct a physical examination or will request for an x-ray or MRI to rule out other causes or injuries. The Orthopedic Surgeon may also request an Ultrasound if suspecting a thickening of the broad ligament (coracohumeral ligament), which helps strengthen the capsule in the shoulder joint. Thickening of the coracohumeral ligament or CHL is another suggestive factor of adhesive capsulitis or frozen shoulder.

Treatments

The minimum time taken for a frozen shoulder to regain its normal range of motion or near normalcy, could be 3 years, if left untreated.   

The aim of treating a frozen shoulder is to curb the pain and to improve the range of motion in the shoulder and to strengthen the shoulder.

Non-Surgical Treatments

Include:

• Prescription of anti-inflammatory, non-steroidal drugs such as analgesics or ibuprofen
• Injecting Cortisone, a steroidal medication, directly into the shoulder joint
• Physiotherapy and heat treatment – In some cases heat treatment may be employed to loosen the shoulder joint, before performing the stretching and range of motion exercises, which are performed under the supervision of a physiotherapist 

Surgical Treatment

When a patient diagnosed with frozen shoulder disorder, fails to respond to any of the non-surgical treatments, listed above, then surgery will be considered. 

The aim of performing surgery is to remove the stiffness from the joint and to stretch the connective tissue. This is done either by manipulation under anesthesia (MUA) or through shoulder arthroscopy. 

MUA – This procedure is performed by the Orthopedic Surgeon. Anesthesia is administrated and while the patient is under, the Orthopedic Surgeon will manipulate the shoulder joint to move, causing the capsule and scar tissue to either tear or stretch, consequently releasing the stiffness and increasing the range of motion.

Surgical Capsular Release or Shoulder Arthroscopy – After anesthesia has been administrated, the Orthopedic Surgeon will make 2 or 3 tiny, keyhole incisions into the afflicted shoulder. An arthroscope (camera measuring 3 and half millimeter) is inserted into one of the incisions. The images from the camera are projected onto a computer screen. Through the other two incisions, microsurgical instruments are inserted to surgically release the frozen shoulder.

Sometimes, the orthopedic surgeon may use both the manipulation and arthroscopy procedures simultaneously, to get the maximum outcomes. 

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Interventional Radiology Treatment of Acute Cholecystitis

Percutaneous Cholecystostomy is a minimally invasiver technique for the treatment of acute cholecystitis.  We recently performed the procedure for an elderly gentleman suffering with severe abdominal pain. With help of ultrasound and fluoroscopy in our cathlab, the gall bladder was punctured through the skin and liver (transhepatic approach).  A radio opaque dye was then injected into the gall bladder to confirm the position. Using modified seldinger's technique, a drainage catheter was passed into the gall bladder, draining the infected bile and sludge outside into a sterile bag.  The pain dramatically reduced and patient was discharged to home. 

Chiba Needle used to gain access into gall bladder

Dilator passed over hair wire by Seldinger Technique

Final position of drainage catheter

Illustration showing the procedure 

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Minimally invasive intervention for Liver Cancer

We recently performed superselective Trans Arterial Chemo Embolization (TACE) for liver cancer.  The patient was an elderly lady who had inoperable liver cancer. Using microcatheters (less than a millimeter diameter), we reached the arteries supplying the cancer.  The skin incision in the groin was less than 3 mm in size and no sutures were required. The chemotherapy agent(to kill cancer cells) was injected directly into the arteries supplying the cancer.  By this method, the general side effects seen with systemic chemotherapy will be markedly reduced. After the procedure, the patient needs to stay for a day or two for observation and can go back home. Regular monitoring of the cancer by CT scan is required to monitor shrinkage of the cancer. 

Hepatic Angiogram showing tumour vascularity

Selective chemo embolisation of tumour feeders

Post treatment CT showing selective uptake of agent within the tumour

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Cerebral Palsy - Management

Cerebral palsy is a non-progressive neurological disorder that affects the motor system of the child. The motor system controls the movement, muscle tone, motor skills and the fluidity of the movement of the entire body. As the name implies the non-progressive disorder doesn’t make any further injury to the brain and it is one time insult to the brain. But the one time injury makes developmental impairments with the child.

TREATMENT:

Rehabilitation team, which consists of, Physician, Surgeon, Physical therapist, Occupational therapist, Speech pathologist, Nursing care, educators and social workers should take responsibility to take care of CP children. Physician – developmental Pediatrician should evaluate and prescribe things on the physical , functional and behavioral ailments that are necessary for the development of the child.

 

Physical therapy: Physical therapy plays a vital role in the management of cerebral palsy. Therapy helps to normalize the muscle tone and there by brings the movement control, coordination, balance and skill. It mainly works to improve the gross motor skills such as sitting, standing, walking, balancing etc. Special techniques such as neurodevelopmental therapy, sensory integration etc., will be used to break the movement dysfunction. Therapist also helps to fine out the proper assisting aid for mobility.

 

Occupational therapy: This deals with the sensory- perceptual system, fine motor control and ADL (Activities of daily Life). Fine hand activities such as holding a pen, threading a needle, playing instruments etc., through which this also influences the cognition of the child. This therapy helps in handling objects, writing, vocational training to the children. An occupational therapist helps to structure the supporting and assistive aids in accordance with the impairments of the children.

 

Surgery: When the deformity and the contractures become so bad and movement is much difficult, the child will go for a surgery to lengthen the muscle and to correct the bony misalignments. This in turn followed by the therapies to gain the range and the function.

 

Speech pathologist: Due to the developmental delay, the speech and articulation of the child will be little difficult and there will be drooling of saliva from the mouth. The speech pathologist helps the child in the training of swallowing, articulation and speech training.

 

Others such as community nurses, special educators, psychologist all help in the physical and the mental betterment of the child. But the early recognition and the treatment will help the child in many ways and keep them motivated and functionally independent.

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Look at the Heels on your Shoes

You may not think about your feet that often, way down there at the ends of your legs, but they're an essential part of almost everything you do. Whether walking, running, exercising, or just standing, having feet that are comfortable and well-cared for (rather than aching or in pain) makes the experience must more pleasant. 

  

Wearing heels make look women tall and comfortable but it also imposes stress on the body and gives more pain. It completely alters the the pattern of pressure that is being put upon the feet. Usually body weight from the legs shifted to the fore foot on normal walking. But when you wear heels the pressure is concentrated on the ball of your toes and makes difficulty walking pattern.

When you wear heels the toes are encroached in toe box of your shoes and it causes discomfort all over the foot. The hazards are not only over the feet but it extends all over the body. On the feet the person will develop Hammer toes, Bunions, Stress fractures, Ingrowing nails, Morton's Neuroma and solemnly the result will depict as foot pain during walking. The effects above the foot are sprains and strains at the ankle, Tightness of the calf muscles (tendo achilles) and strain to the knee joint as well. The total posture has been altered and there is an increase at the lumbar arch and induces a low back pain.

The height if the heel will alter the pressure on the fore feet, when the heel is at 1''- the stress will be 22%, at 2''- 57%, at 3'' – 76%. It also increases the pressure by 26%over the knee cap.

If you ask, Does heel alone gives pain on the feet? The answer will be -NO. Even the complete flats also impose strain on the foot. With Complete flats or ballet shoes, the body weight over the foot stretches the muscles on the foot and collapses the arch. It also imposes the foot into pronation and over stretches the deep calf muscles.

So the ideal shoes that should have a heel height of less than an inch will keep the arch intact and prevent us from being suffer with lots of aches and pain in the body.

For Further Information, Contact:

Ms. P. Pughana Ambhigai B.P.T, M.P.T, Physiotherapist, Kauvery hospital, Chennai. 044 4000 6000

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Dengue Fever Alert!

Suspect dengue when a high fever (40°C/ 104°F) is accompanied by two of the following symptoms:

• Severe headache
• Pain behind the eyes
• Nausea, Vomiting
• Swollen glands
• Muscle and joint pains
• Rash

Severe dengue is a potentially deadly complication due to plasma leaking, fluid accumulation, respiratory distress, severe bleeding, or organ impairment. The warning signs to look out for occur 3-7 days after the first symptoms in conjunction with a decrease in temperature (below 38°C/ 100°F) include:

• Severe abdominal pain
• Persistent vomiting
• Rapid breathing
• Bleeding gums
• Blood in vomit
• Fatigue, restlessness

Treatment:
 
Being a virus, antibiotics are not effective against Dengue. Patients should seek medical advice, take rest and drink plenty of fluids. Paracetamol can be taken to bring down fever and reduce joint pains. However, aspirin or ibuprofen should not be taken since they can increase the risk of bleeding.
For severe dengue, medical care by doctors can frequently save lives. Maintenance of the patient's circulating fluid volume is critical.
 
Contact Kauvery Hospital, Chennai at 044 4000 6000 if you suspect having Dengue Fever.

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The Role of the Anaesthesiologist — from Surgical Anaesthesia to Critical Care Medicine and Pain Medicine

Care of the Surgical Patient

The anaesthesiologist is the perioperative physician (“peri-” meaning “all-around”) providing medical care to each patient through his or her surgical experience.

This includes medically evaluating the patient before surgery (preoperative), consulting with the surgical team, providing pain control and supporting life functions during surgery (intraoperative), supervising care after surgery (postoperative) discharging the patient from the recovery unit.

Critical Care and Trauma Medicine

Anaesthesiologists are uniquely qualified to coordinate the care of patients in the intensive care unit because of their extensive training in clinical physiology/pharmacology and resuscitation. Some anaesthesiologists pursue advanced fellowship training to subspecialize in critical care medicine. In the intensive care unit, they direct the complete medical care for the sickest patients. The role of the anaesthesiologist in this setting includes the provision of medical assessment and diagnosis, respiratory and cardiovascular support, and infection control.

Anaesthesiologists also possess the medical knowledge and technical expertise to deal with many emergency and trauma situations. They provide airway management, cardiac and pulmonary resuscitation, advanced life support and pain control. As consultants, they play an active role in stabilizing and preparing the patient for emergency surgery.

Pain Medicine

Because of their specialty training and vast experience in controlling pain during surgery, anaesthesiologists are uniquely qualified to prescribe and administer drug therapies or perform special techniques for acute, chronic and cancer pain. Here are two of the most common areas in which anaesthesiologists treat pain:

Acute Pain Management

Includes preoperative pain relief in trauma,postoperative pain relief,labour analgesia i.e painless labour.

Chronic and Cancer Pain Management

Anaesthesiologists are the vanguard of those who are developing new therapies for chronic pain syndromes and cancer-related pain. Anaesthesiologists who specialize in the treatment of chronic pain often dedicate their practices exclusively to a multidisciplinary approach to pain medicine, working collaboratively with other medical specialists in a pain clinic. 

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