Frozen shoulder, or adhesive capsulitis, is one of the most misunderstood and misdiagnosed conditions of the shoulder. Patients often present after several months of progressive shoulder pain and loss of movement. There is usually no injury or overuse that started the symptoms. There are currently no known causes for a frozen shoulder. This condition usually affects middle-aged people between the ages of 40 and 65 years. It is twice as likely to occur in women as in men. There may be some hormonal influence as it often affects the postmenopausal years. It is also more common in diabetics. In fact, frozen shoulder can be seen in up to 20% of these patients. Other hormone abnormalities such as thyroid disease may also be a risk factor. An injury to the shoulder, especially if followed by prolonged immobilization, can also incite the development of a frozen shoulder joint. Other, less common risk factors can be cardiac disease, cardiac bypass surgery and Parkinson's disease.
Other shoulder conditions can cause pain and difficulty with movement of the shoulder. This explains why a frozen shoulder is frequently misdiagnosed. Treatment of these other shoulder conditions will not improve the symptoms from a frozen shoulder. It it is important that you see a physician experienced with frozen shoulder to make the correct diagnosis. When diagnosed early, frozen shoulder is often easily treated with significant improvement in symptoms. If the diagnosis is missed or delayed, the recovery will take much longer.
What is frozen shoulder?
As noted above, we do not understand what specifically causes of frozen shoulder. However, we do understand the changes that take place within the shoulder joint that are causing the pain and stiffness. We also have a good understanding of the best treatment options.
Surrounding all joints there is a tissue lining called the capsule. This tissue helps to hold the fluid inside the joint and may also contain thickened bands or ligaments that help stabilized the joint. The shoulder capsule is typically loose which allows the shoulder to have the most significant range of motion of any joint in the body. However, in frozen shoulder, this capsule becomes very inflamed and contracts. The inflammation of the capsule produces pain and the contracture causes shoulder stiffness. Bands of scar tissue, called adhesions, may form which cause the capsule to become thicker and the shoulder stiffer. Interestingly, this type of inflammation and scar tissue development without prior trauma is unique to the shoulder joint.
Arthroscopic image of the bright red inflammation of the
shoulder capsule seen with adhesive capsulitis
The natural tendency with any pain is to limit the use of the area that is painful. Many patients with a frozen shoulder have stopped using the arm. As a result, the adhesions tighten further and the shoulder becomes stiffer. This creates additional inflammation and scar tissue. It becomes a continual cycle of persistent pain, further stiffness and reduced use of the arm. What began as mild soreness in the shoulder when the arm was stretched in an awkward position can become a debilitating problem where many patients cannot lift their arm overhead, out to the side, or to their back.
How do I know if I have a frozen shoulder?
Most patients with a frozen shoulder can use their arm for everyday activities as long as the shoulder is not stretched out to the side or moved quickly. Women will often notice difficulty reaching there back to fasten a bra. There may be pain trying to reach out a car window at a toll or ATM. Any sudden movement that requires reaching quickly can produce severe pain that brings them to their knees. The restricted motion may not be noticeable because the pain limits their movement. The shoulder pain is usually felt through the entire shoulder area. There may be pain at night like many other shoulder conditions. Anti-inflammatory medication typically only provides limited benefit. Evaluation by a shoulder specialist is helpful to detect the stiffness and make the appropriate diagnosis.
Frozen shoulder has been described as going through 3 stages:
1. Stage I is described as the "freezing" stage and is the most painful. This stage has been described as lasting from several months to a year. The shoulder joint becomes inflamed which produces pain. Then, stiffness starts to develop. As the shoulder continues to become more painful, most patients limit the use of the arm and further stiffness occurs.
2. Stage 2 is known as the "frozen" stage. There is a slow improvement in pain but the stiffness persists and there is further limitation of range of motion. This stage has been described as lasting from 3 months to a year.
3. Stage 3 is the final "thawing" stage. By this time, the pain is usually better and the shoulder range of motion slowly starts to return. It may take several years before the range of motion has returned.
Diagnosis of frozen shoulder
For physicians experienced in diagnosing shoulder pathology, a frozen shoulder can often be diagnosed with just a history and physical examination. Since most shoulder problems cause pain with overhead movement, one of the simplest test for a frozen shoulder is to measure rotation of the arm at the side. With the elbows against the side and the arms rotated outwardly, the external rotation of the shoulder can be compared to the opposite side. It is unusual for frozen shoulder to affect both sides simultaneously. The painful shoulder will often have less than half of the rotation of the opposite side. Only a few other conditions, such as arthritis, will cause this limitation. X-rays are helpful to exclude arthritis as a possibility. An MRI is usually not necessary unless there is some concern for other problems such as a posttraumatic tear.
It has been reported that, if left untreated, frozen shoulder symptoms will resolve after several years. However, given the pain and functional limitations, patients do not want to wait that long. When diagnosed early, frozen shoulder treatment without surgery can significantly improve pain and restore function in much less time. Over 90% of patients with a frozen shoulder that developed spontaneously (without trauma or surgery) can be managed without surgery. Patients who have had prior trauma or surgery usually have more extensive scar tissue present and are therefore more difficult to treat. Also, diabetics have a higher likelihood of failure to respond to nonoperative management and a higher likelihood of recurrence. In the absence of diabetes, recurrence of a frozen shoulder is rare. Patients are much more likely to develop frozen shoulder on the opposite side within several years after onset in the original shoulder. In diabetics, this can approach 50% probability.
The initial management of frozen shoulder is anti-inflammatories to decrease the inflammation in the shoulder joint and home exercises to restore motion. While this may be beneficial within the first month or two after the onset of symptoms, by the time most patients have seen a physician, these measures are no longer effective. I will usually recommend an injection of anti-inflammatory medication into the frozen shoulder joint. A steroid (cortisone) injection has been shown to provide short-term benefit in pain relief. After the pain has been decreased with the injection, focused physical therapy to stretch the shoulder adhesions is beneficial. I have found that many patients are unable to stretch the shoulder sufficiently on there own to restore adequate movement. The critical key to the successful treatment of a frozen shoulder is restoring full range of motion. As long as some stiffness is present, there will still be pain and likelihood of recurrence. Home exercises for shoulder stretching will be necessary when they are not seeing a physical therapist. Some form of physical therapy may be required for several months.
The primary goal in treating a frozen shoulder is to restore full range of motion. When the motion has returned, the pain will improve. Manipulation of the shoulder under anesthesia has been shown to be very effective. Over 90% of patients were satisfied with the procedure and close to two thirds of the patients had no or mild disability within 3 months. A manipulation simply means a stretching of the shoulder to break up the adhesions. No incisions are made. However, anesthesia in the form of a nerve block or general anesthesia is necessary to provide sufficient pain relief and relaxation to allow this stretching. Physical therapy is required afterwards to maintain the motion. When performed by an experienced shoulder surgeon in patients with no prior trauma or previous surgery, the risks of a manipulation (tearing or fracture) are minimal. While I prefer to start with nonoperative management, many patients, having had a manipulation, return to me requesting an immediate manipulation of a frozen shoulder on the opposite side.
In patients having had prior surgery or trauma, other shoulder problems such as a tear, or patients not responding to manipulation (especially diabetics), an arthroscopic capsular release is beneficial. This procedure involves placing a small camera or arthroscope into the shoulder joint where the shoulder adhesions are identified and surgically incised. Scar tissue can be removed. Inflammation in the capsule (synovitis) can also be excised. The remaining pathology within the shoulder joint is also addressed. While this procedure allows precise release of the scar tissue and adhesions, additional scar tissue may be created by the surgical invasion into the joint. Aggressive physical therapy is still required to maintain the mobility achieved during the operation. It will require several months of therapy to improve mobility. Studies have demonstrated that pain relief and range of motion are significantly improved in the great majority of patients at an average of 3 months after the procedure.
Key points to treating frozen shoulder:
1. Seek early treatment from a specialist in diagnosing shoulder pain. A frozen shoulder is often misdiagnosed and aggressive early treatment often results in quick resolution of the symptoms.
2. The key to treatment of a frozen shoulder is to restore range of motion. This usually requires physical therapy to stretch the shoulder or surgical intervention to release the bands of scar tissue (adhesions). As the motion improves, so will the pain.
3. There is a high likelihood of developing a frozen shoulder on the opposite side at some point in the future. Start stretching the shoulder if it becomes painful.
4. Diabetic frozen shoulder treatment is often more difficult. Seeking early treatment can significantly improve results.
5. Dr. Payne is a specialist in treating shoulder conditions and has managed hundreds of patients with frozen shoulder. He is an expert in both the nonoperative and operative treatment options.