Adhesive capsulitis

Adhesive capsulitis is a condition associated with the shoulder. It is also known as frozen shoulder. The indications for the onset of adhesive capsulitis include difficulty in performing day to day activities involving the shoulder. The articulations associated with the shoulder are complex comprising three joints and four groups of muscles which facilitate the movement of the shoulder in various directions. The range of motion of the shoulder is taken into consideration to identify the underlying cause for the onset of adhesive capsulitis. Adhesive capsulitis is also defined as the idiopathic painful restriction of the shoulder. This condition results in the global restriction of the muscles associated with glenohumeral joint. Adhesive capsulitis predominantly occurs in people belonging to the age group of 40-60. Women are prone to adhesive capsulitis than men. Adhesive capsulitis usually lasts for a period of two years and gradually subsides.

Clinical manifestations of Adhesive capsulitis

Adhesive capsulitis occurs in three stages. The first stage is called as the freezing stage where the patient experiences mild pain and discomfort with movements of the shoulder. Increased pain during sleep and muscle spasms are more predominant in this stage. The freezing stage usually occurs for a period of three to four months.

The second stage is called the adhesive or the frozen stage, in which the pain is reduced but movement of the shoulder is restricted to a greater extent leading to stiffness. The second stage is the most difficult stage which can last up to nine months and it involves the restriction of shoulder movements in many angles causing discomfort.

The third stage is the recovery stage or the thawing stage in which the movement is restored only to a certain degree but the patient continues to experience mild pain and movement restriction in certain angles of rotation.

Diagnosis of Frozen Shoulder

The predominant risk groups who are susceptible to adhesive capsulitis are patients who have underlying conditions such as diabetes, Parkinson's disease, hypothyroidism and cardiac conditions. Women are more prone to adhesive capsulitis than men. Patients who have a history associated with injuries or trauma pertaining to the shoulder may experience adhesive capsulitis.

Adhesive capsulitis diagnosis is more symptom-associated than radiological determination. X-rays and MRI do not play a significant role in identifying this condition as it is associated with muscle groups of the shoulder. The common symptoms through which the diagnosis of this condition is done is through the movements pertaining to the shoulder such as ability to reach and touch the back of the shoulder, reaching to the back pocket and also to reach behind the head. The exact cause for the occurrence of adhesive capsulitis is not known. In some cases young people experience this condition without any associated risk factors.

Treatment of Frozen Shoulder

Adhesive capsulitis can be treated upon early discovery of the condition. Patients suffering from frozen shoulder are usually treated by physical therapy for a few months followed by anti-inflammatory medication to relieve pain and restore motion. The primary objective during the physiotherapy is to strengthen the muscle groups of the shoulder to enable movement in various angles. Surgical intervention is done in case of intense pain and loss of movement.

Shoulder arthroscopy is done followed by physiotherapy to restore the motion of the shoulder. In the surgical procedure, the movement of shoulder is rectified by removing the scar tissue under anaesthesia. The range of motion associated with the shoulder is analyzed as a post-operative measure to ensure the accuracy of the procedure. Physiotherapy increases the shoulder movements by strengthening the internal muscles of the shoulder. Patients are also advised to follow few shoulder stretches and exercise patterns to prevent relapse of the respective condition.

Fibrosis

The formation of excess fibrous connective tissue between the cells of various organs or tissues as a reactive process is called fibrosis. It can cause stiffening or hardening of tissues in skin, internal organs and joints. It can be reactive, pathological or in a benign state. When fibrosis arises from a single tissue, it is called Fibroma and in response to an injury it is called scarring.

Fibrosis may occur in many tissues within the body due to damage or inflammation, examples include:

• Pulmonary Fibrosis, affecting the lung
  
• Cystic Fibrosis affecting the mucus glands
  
• Heart Fibrosis, affects the heart that is damaged post myocardial infarction
  
• Liver Cirrhosis, accumulation of tough, fibrous scar tissue in the liver
  
• Bone marrow Fibrosis, affects the bone marrow and prevents normal production of blood cells
  
• Mediastinal Fibrosis, blocks respiratory channels and blood vessels due to calcified fibrosis of the lymph nodes
  
• Skin fibrosis, due to the formation of scar tissues due to injury.

Fibrosis formation

During the early stages of Lymphedema, tissues swell with protein-rich lymph that may not drain properly. The tissues are soft to touch; this condition is known as pitting edema. There is pressure on these tissues pushing the fluid aside thus leaving an indentation. If left untreated at this stage, the lymph may become fibrotic thus forming fibrosis. As fibrosis develops, the normal tissues are replaced by the scar-like structures that cause hindrance to lymph drainage. Fibrosis can occur in slightly swollen tissues too. As the lymph cannot drain properly, it leads to accumulation of protein molecules in the tissues thus increasing formation.

Fibrosis causes

• It may be caused by a disease or while treating the disease.
  
• Other causes could include burns, injuries, chemotherapy, radiation and gene mutation.
  
• It is also possible that the causes may remain idiopathic, i.e. the cause is unknown.
  

Effects of fibrosis

Symptoms of fibrosis can vary depending on the location and severity of the condition. Common symptoms include scarring.

• Fibrosis will harden the affected tissue, at times they also swell. These changes can make the tissues incapable of functioning properly; the fluid flow through these affected tissues might be reduced. When present in the lungs, the lung is unable to expand adequately leading to shortness of breath.
  
• Fibrosis of joints can cause pain and stiffness of the affected joint.
  
• Fibrosis in the shoulder may lead to frozen shoulder.
  
• Fibrosis of the tendons may lead to deformity of fingers and hand.

Arthroplasty

Arthroplasty literally means 'formation of joint'. It refers to the surgical replacement of arthritic or destructive joint with prosthesis. During arthroplasty, the dysfunctional joint is replaced with a better remodeled joint. Osteotomy procedure used to restore or modify joint congruity is also arthroplasty. Although arthroplasty is used for construction of a new movable joint, it cannot be applied to every body joint. Its use, in practice, is confined to the shoulder, elbow, hip, knee, certain joints of the hand, metatarso-phalangeal joints in the foot.

The two main reasons for undergoing arthroplasty are pain in the joints and decreased quality of life. Some common indications for arthroplasty would include advanced osteoarthritis, rheumatoid arthritis with avascular necrosis, congenital dislocation of the hip joint, shallow hip socket, frozen shoulder, loose shoulder, traumatized joint and joint stiffness, un united fractures of the neck of the femur, and for correction of certain types of deformity.

There are three methods in general which are adopted in Arthroplasty: excision arthroplasty, half-joint replacement arthroplasty and total replacement arthroplasty. Each of these methods have their own distinct merits as well as disadvantages and special applications.

In excision arthroplasty both the articular ends of the bones are simply excised. A gap is created between them and this is filled with fibrous tissue, a pad of muscle or other soft tissue which may be sewn in between the bones. This method is applicable to all the joints other than the knee and ankle.

In half-joint replacement arthroplasty, one of the articulating surfaces is removed and this is replaced by a prosthesis of similar shape. The prosthesis is made of metal and rarely silicone rubber. This technique has its application at the hip. It has rather limited use elsewhere in the body.

As for total replacement arthroplasty, both the opposed articulating surfaces are excised and replaced by prosthetic components. Sometimes, in larger joints, one of the components is of metal and the other, a high density polyethylene. Both components are held in place by acrylic 'cement.'

The joint is fully exposed and the damaged bone and cartilage are cut away or reshaped. Prosthesis are inserted after measurements are taken to ensure proper fit. The joints are usually tested before the incision is closed. Arthroplasty is typically followed by several days of hospitalization. Medications are given to relieve the pain and prevent further infections and blood clots. Physical therapy is extensively employed to bring back the joints to near normal functioning. Occupational therapy is also prescribed to enable patient independently cope up with routine activities. Patients resume normal activities after two to three months duration.