Sunday January 6, 2013
Shoulder pain in the elderly
By Dr SHAMSUL ISKANDAR HUSSEIN & Prof Dr PHILIP POI
Frozen shoulder is a common, sometimes painful, self-limiting condition that can be adequately managed in the primary care setting.
SHOULDER pain commonly affects daily activities, and subsequently, the quality of life of our Malaysian seniors.
While elderly people are more likely to experience pain than the general population, in many instances, they are under-treated. Many older adults feel that pain is just a natural part of the ageing process and do not seek medical treatment until the condition has worsened.
A common cause of shoulder pain is what your general practitioner would call a “frozen shoulder”. Dr Robert Codman first described this in 1934, as a painful shoulder condition of inconspicuous onset that is associated with stiffness and difficulty sleeping on the affected side.
The hallmark of a frozen shoulder is a marked limitation when one tries to raise the arm forward, as well as difficulty in external rotation of the shoulder joint – an action we commonly do when we open the newspapers to read.
People in the mid-50s usually represent the majority who are diagnosed with frozen shoulder.
The condition occurs slightly more often in women than men. Within five years, the other shoulder will also be affected in less than 20% of the patients, after the first has resolved.
Fortunately, it is unusual for the condition to recur.
Why does it happen?
Frozen shoulder can be of unknown origin (idiopathic) or it may be associated with another systemic illness such as diabetes mellitus.
Unfortunately, frozen shoulder in diabetes is often more severe and is more resistant to treatment. People with some hormonal deficiencies, or those suffering from Parkinson’s disease, stroke, heart or lung disease are also more likely to have this condition.
A painful shoulder can be caused by sports injuries, such as rotator cuff tears, which is sometimes seen in racquet sports, impingement (of the nerves in the neck) syndrome, dislocation of the acromioclavicular (collarbone) joint, and also arthritis of the shoulder joint.
No one is really clear about how a frozen shoulder develops, although there is strong evidence of inflammation of the joint lining (called synovium) with subsequent reactive scarring and thickening (fibrosis) of the capsule that envelops the shoulder joint. The joint becomes fibrosed and the protective joint capsule contracts, leading to a reduction of the range of movements in the affected shoulder.
What happens if I have a frozen shoulder?
A person who has a frozen shoulder usually progresses through three phases that generally overlap:
The painful phase: This can last between three to nine months in duration. There will be pain and stiffness around the shoulder without a history of injury, which is worse at night with little response to the common painkillers.
The adhesive phase: At around four to 12 months, the pain gradually subsides, but stiffness remains. The shoulder continues to hurt, often only at extremes of movement. Movement of the shoulder joint is grossly reduced with near absence of external rotation.
The resolution phase: This is when there is spontaneous improvement in the range of motion.
What will the doctor do?
Most doctors would not investigate a frozen shoulder beyond plain x-rays of the shoulder. This may show low density of the bone, which is most likely due to disuse of the limb.
A bone scan may show increased uptake of contrast media at the affected side, while magnetic resonance imaging (MRI) may show thickening of the tissue, which surrounds the joint (capsular tissue) and its adjoining ligament, the coraco-humeral ligament.
Having developed a frozen shoulder is frustrating and can disrupt or curtail some physical activities. A sufferer should seek correct advice from an orthopaedic or rheumatology specialist if they are concerned.
Often, there is a gradual and spontaneous improvement, but the range of motion in the affected shoulder may never recover completely.
The management and treatment of a frozen shoulder should ideally depend on the stage of the disease at the time of presentation to the doctor. In certain situations, your doctor may consider an injection of steroids into the shoulder joint to provide pain relief by reducing the inflammatory process.
Some will require referral to a specialist when the condition warrants further treatment or surgical intervention.
Treatment in the painful phase
At this initial phase, treatment is directed at pain relief. You are allowed to perform all types of pain-free activities. Taking painkillers will reduce the symptoms due to the underlying inflammatory processes, and when necessary, other stronger painkillers can be used sparingly and with consultation with your doctor.
Physiotherapy is useful to maintain the range of motion of the affected shoulder, and sometimes, to reduce pain. Regional pain control such as steroid injections or a suprascapular nerve block may be the only way to achieve adequate pain relief.
Treatment during adhesive phase
Stretching exercises are advocated as the focus of treatment with the aim of regaining the range of motion. Prolonged stretches under low loads will produce the desired effect. This is best done under the supervision of a trained physiotherapist.
In those who are unable to tolerate the pain and disability due to this condition, shoulder manipulation under anaesthesia is indicated. It is a reliable way to improve range of motion in frozen shoulder.
Currently, minimally invasive shoulder surgical technique (shoulder arthroscopy) has been proposed for the treatment of frozen shoulder. It allows the surgeon to have a controlled release of the contracted capsular tissue. Arthroscopic release avoids complications such as bone fracture and injury to the sensitive structures within the shoulder joint.
Frozen shoulder is a common, sometimes painful, self-limiting condition that can be adequately managed in the primary care setting. It is a clinical diagnosis, and when identified early, recovery can be accelerated with simple measures such as adequate pain relief and physiotherapy.
In certain circumstances, manipulation under anaesthesia and arthroscopic capsular release of the shoulder joint are required to provide functional improvement.
> Dr Shamsul Iskandar Hussein is a senior lecturer in orthopaedics, and Prof Dr Philip Poi is a senior consultant geriatrician. This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail email@example.com. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.