Frozen Shoulder

Frozen Shoulder New York, Knee Surgery Specialist Dr Glashow

Overview

Frozen shoulder, or adhesive capsulitis, is a condition that begins with a gradual onset of pain and a limitation of shoulder motion. The discomfort and loss of movement can become so severe that even simple daily activities become difficult. Although much is known about this condition, there continues to be considerable controversy about its causes and the best ways to treat it.

What does the inside of the shoulder look like?

The shoulder is the most mobile joint in the human body, with a complex arrangement of structures working together to provide the movement necessary for daily life. Unfortunately, this great mobility comes at the expense of stability. Several bones and a network of soft tissue structures (ligaments, tendons, and muscles), work together to produce shoulder movement. They interact to keep the joint in place while it moves through extreme ranges of motion. Each of these structures makes an important contribution to shoulder movement and stability. Certain work or sports activities can put great demands upon the shoulder, and injury can occur when the limits of movement are exceeded and/or the individual structures are overloaded.

What is frozen shoulder?

Frozen shoulder, also called adhesive capsulitis, is a thickening and tightening of the soft tissue capsule that surrounds the glenohumeral joint, the ball and socket joint of the shoulder. When the capsule becomes inflamed, scarring occurs and adhesions are formed. This scar formation greatly intrudes upon the space needed for movement inside the joint. Pain and severely limited motion often occur as the result of the tightening of capsular tissue.

There are two types of frozen shoulder: primary adhesive capsulitis and secondary adhesive capsulitis.

Primary adhesive capsulitis is a subject of much debate. The specific causes of this condition are not yet known. Possible causes include changes in the immune system, or biochemical and hormonal imbalances. Diseases such as diabetes mellitus, and some cardiovascular and neurological disorders may also be contributing factors. In fact, patients with diabetes have a three times higher risk of developing adhesive capsulitis than the general population. Primary adhesive capsulitis may affect both shoulders (although this may not happen at the same time) and may be resistant to most forms of treatment.
Secondary (or acquired) adhesive capsulitis develops from a known cause, such as stiffness following a shoulder injury, surgery, or a prolonged period of immobilization.

With no treatment, the condition tends to last from one to three years. Many patients are unwilling to endure the pain and limitations of this problem while waiting for it to run its natural course. Even after many years, some patients will continue to have some stiffness, but no serious pain or functional limitations.

Symptoms

What are the signs and symptoms of frozen shoulder?

The major symptoms of frozen shoulder are pain andloss of motion

The onset of symptoms may be gradual or sudden, depending on the cause of the condition. With primary adhesive capsulitis, the onset of symptoms is usually gradual. A sudden onset of symptoms may follow an injury to the shoulder.
The pain and loss of function associated with this condition can become so severe that it can significantly affect the quality of life, and prevent some patients from sleeping well or working.

Diagnosis

How is frozen shoulder diagnosed?

The diagnosis of frozen shoulder is made only after a careful history and physical examination is performed. Pain and loss of motion can be symptoms of many shoulder conditions, so a detailed assessment of the shoulder’s full range of motion is important. A history of surgery or injury, or the presence of illnesses such as diabetes, is information the physician needs in order to make the correct diagnosis.

It is important to recognize the different patterns of motion loss. Primary adhesive capsulitis is usually associated with loss of motion in all directions. Secondary adhesive capsulitis more often has more defined loss of motion; affecting some movements, but not others.

In most cases, the history and examination are sufficient to determine the presence or absence of frozen shoulder. Imaging may occasionally be necessary to confirm the diagnosis and to identify other underlying problems.

X-rays cannot reveal the cause of shoulder stiffness in most cases of primary adhesive capsulitis. However, in secondary adhesive capsulitis, X-rays can show signs of arthritis, fractures, or metallic plates that may be contributing to motion loss.
An MRI (Magnetic Resonance Image) shows soft tissue and may be used in cases in which another disorder is suspected, such as a rotator cuff tear.
An arthrogram may be used with an MRI to provide further information about structures in the shoulder. A dye is injected into the shoulder and images are obtained. The dye creates a contrast on the image, making the specific location of adhesions and the reduced space typical of frozen shoulder more visible.

Treatment

How are impingement and rotator cuff tears treated?

Impingement and rotator cuff tears can be treated non-operatively or with surgery.

Treatment for both injuries usually begins with a non-operative treatment plan. More than 2/3 of impingement patients can expect significant improvement in their symptoms with a physical therapy program alone. These results are lower in older patients and in those with large bone spurs.

When trauma causes a tear in younger patients, surgery is often the first choice of treatment. Patients with this type of injury recover best if surgery is done early. Generally, this pertains to those patients under the age of fifty with tears less than four weeks old.

Non-Operative Treatment

Non-operative treatment is similar for both impingement and rotator cuff tears. A vast majority of patients improve with this primary treatment alone. The goals of a physical therapy program include:

strengthening the rotator cuff tendons.
stretching and regaining lost motion caused by pain and inflammation.

allowing the humerus to be better positioned under the acromion, thus reducing compression of the bursa.

External Rotation

Cross Arm Push

Standing parallel to an elastic resistance cord, the elbow should be bent 90 degrees at the side. The hand should slowly rotate away from the body, using the elbow as a hinge. Rotation should continue until the arm is in a neutral position.

The hand is placed on the opposite shoulder. The other hand is used to pull the elbow across the body until a good stretch is felt on the back of the shoulder.

Anti-inflammatory medication may be prescribed to help reduce pain and inflammation. Many patients with rotator cuff tears can function quite well if pain and inflammation are controlled with medication and physical therapy. This is especially true for the elderly and those with low demands on the shoulder.

If symptoms have not improved with this program, the doctor may recommend a steroid injection into the bursa. Cortisone, or a similar steroid, is often combined with a local anesthetic to help control the pain and inflammation of the bursa. Steroid injections are used with caution. Damage to the rotator cuff tendons may occur with more than two or three injections over several months. Patients with diabetes are generally not good candidates for steroid injections because of problems with glucose control.

Operative Treatment

Impingement

A non-operative treatment plan is often all that is necessary for most patients with impingement syndrome. However, the small percentage of patients whose symptoms have not improved after 6 months of dedicated physical therapy may be candidates for surgery. The shoulder should be reevaluated to make sure no other problems exist.

Subacromial decompression expands the space between the acromion and rotator cuff tendons. This can be done either arthroscopically or with open incisions, depending on the preference of the surgeon. During an arthroscopy, a tiny fiberoptic instrument is inserted into the joint. In many cases, the doctor can assess and repair the damage through this scope without making large incisions. Scar tissue or bone spurs can successfully be removed with either technique. If a rotator cuff tear is found at the time of surgery, it can also be repaired if necessary.

Rotator cuff tear

Not all rotator cuff tears require surgery. Many patients are content with their progress following a non-operative treatment plan. Patients who have been unable to regain lost motion and strengthen the surrounding muscles sufficiently may need a rotator cuff repair. This is often the case for the younger, more active patients who want to address continued weakness following physical therapy.

Rotator cuff repairs can be performed either arthroscopically or with open incisions. Arthroscopic techniques are new and limited to specific types of tears. An open repair that secures the rotator cuff tendons back to the humerus remains the surgical treatment of choice.

What types of complications may occur?

Complication rates after surgery are generally low. Pre-operative antibiotics are given to reduce the slight risk of infection after surgery. Infection tends to occur a little less often when arthroscopic techniques are used. Risks of major bleeding or nerve damage are extremely small. Postoperative stiffness is the major complication of both impingement and rotator cuff tears.

Recovery

Non-Operative

The recovery from non-operative treatment of frozen shoulder can take one to three years. It is important for patients with frozen shoulder to understand the natural course of the disease and how long it can persist. A home stretching program, combined with a supervised program with a skilled therapist, can speed the recovery rocess in many cases.

Operative

Following surgery:

Patients usually remain in the hospital for one to two days. During this time, pain medication is delivered directly to the joint through a catheter.
While in the hospital, patients begin an aggressive shoulder motion program supervised by a physical therapist.
Patients are encouraged to use the treated arm for daily activities. A sling is not worn.
Patients are put on a home stretching program that is to be done between structured therapy appointments.
Surgical incisions are to be kept clean, dry, and covered until the doctor sees the patient at the follow-up visit, normally about ten days after surgery. Stitches are usually removed at this time.
Progress is closely monitored with regular office visits. Specific weaknesses or motion limitations are addressed during these visits.
The strengthening phase of a rehabilitation program begins after the patient has achieved a full, pain-free arc of motion. This generally takes at least three months.

FAQ

1. Why did I develop a frozen shoulder?

We do not have a good explanation for the development of frozen shoulder in most patients.The majority of cases seem to be more prevalent in women, diabetics, and those with hypothyroidism. Others who develop frozen shoulder are those who have sustained an injury and developed stiffness as a result. The trauma can be quite mild or severe, and the body’s response to the event is probably more important than the event itself.

2. How can frozen shoulder be treated?

The resolution of a frozen shoulder can be very slow, but physical therapy can speed up the healing process. Frozen shoulder begins with pain followed by the rapid development of stiffness. Usually when the pain starts to subside physical therapy can be effective in stretching the capsule back out. Occasionally in unmanageable cases surgery is indicated. This is true only in cases in which the pain has subsided and the residual capsular contracture has not responded to six months or more of physical therapy. Early surgery in the face of frozen shoulder will lead to more problems with stiffness after surgery.

I have been diagnosed with a rotator cuff tear in addition to frozen shoulder; why won’t the surgeon repair the rotator cuff now?

Surgery in the face of a frozen shoulder is not recommended because of the immobilization required after a rotator cuff repair. The shoulder becomes more inflamed after the surgery and the immobilization required to heal the cuff repair leads to increased stiffness. The only way to deal with this combination of problems is to allow physical therapy to stretch out the frozen shoulder. Once that has been accomplished, the rotator cuff repair can be performed. The shoulder will probably be stiffer than the average cuff repair after the immobilization period ends, but research has shown that physical therapy can help regain lost motion.