Physician Blog by Edward J. Bieber, MD
Shoulder Pain – Frozen Shoulder
What is a Frozen Shoulder?
Frozen shoulder (adhesive capsulitis) is a loss of both active and passive motion of the shoulder with a gradual onset without a clear underlying cause. This condition is separated from other painful conditions of the shoulder that result in tightness due to the fact that there is a loss of motion in all planes. The good news is that you should not need surgery. The bad news is that you will be uncomfortable for some time.
Patients can get stiff shoulders after a traumatic event or shoulder surgery but, although these may resemble adhesive capsulitis, they are very different entities. True adhesive capsulitis is much more common in women and usually occurs between 40 and 60 years of age.
It is an inflammatory process with thickening of the shoulder joint capsule, fibrous scar tissue formation and adherence of the capsule to the humerus (upper arm bone) and formation of abundant Type III collagen which leads to a mechanical block. It has a higher association with diabetes, Dupuytren’s contracture, heart disease and autoimmune disorders, specifically autoimmune thyroid disease. It can also occur after an injury or surgery. Typically, it will not recur in the same shoulder. Rarely, some patients develop frozen shoulder at some time in the future in the opposite shoulder. The diagnosis is often one of exclusion since it is often confused with other sources of shoulder pain, making it very important to be evaluated by an experienced shoulder surgeon.
Frozen shoulder is a biologic problem. What I mean by this is that it changes the nature of the capsule, or shrink-wrap around the shoulder joint. Typically, the shoulder capsule is thin and somewhat elastic allowing for a great range of motion. In the case of frozen shoulder, the capsule becomes many times thicker than normal. Think of the capsule as a rubber band. A thin rubber band – the normal shoulder capsule – is easier to stretch than a thicker rubber band – the capsule in a patient with frozen shoulder.
What to Expect
There are typically three stages to a frozen shoulder. Initially, there is pain with all ranges of motion. Over the course of days to weeks the shoulder becomes tighter and tighter. Ultimately the pain improves but the shoulder remains stiff. This can last weeks or even months. No matter how much you try to stretch, it doesn’t seem to release. Finally, the thawing phase starts. Gradually over the course of a year or two your motion should return to near normal.
The structures that are most affected are the capsule and multiple ligaments of the shoulder. It is divided into 3 stages:
1. Freezing/Painful – diffuse pain for 6 weeks to 9 months
2. Frozen/Stiff or Plateau – pain diminishes but movement limitation persists for 4-9 months
3. Thawing – Gradual return of motion at 5-26 months but possibly not back to normal
The most common symptoms are pain that varies in intensity and stiffness.
The evaluation begins with a careful history and physical exam to rule out other sources of the patient’s symptoms. Laboratory studies, including testing for diabetes and inflammatory conditions, are part of the initial work up. A complete x-ray series is also recommended. MRI or MRA (MRI with a dye injection) is useful to rule out other problems but is not considered diagnostic for this problem.
Treatment is primarily non-surgical using NSAIDs (non-steroidal anti-inflammatory drugs such as Advil or Aleve), steroid injections and heat. The timing of starting physical therapy is controversial and many surgeons feel that it should wait until late stage 2 or stage 3 since starting too early may increase the inflammation. Other treatments such as manipulation under anesthesia and arthroscopic releases are reserved for cases that are not showing progress in a reasonable period of time.
The overwhelming majority of patients can rehabilitate on their own with a series of gentle stretches. I often find that over-stretching causes an increase in pain without a significant improvement in range of motion. In rare cases, more common in patients with diabetes mellitus, if after six months or so the motion is not improved you and your surgeon may consider a visit to the operating room. This is where you undergo manipulation under anesthesia which may be combined with an arthroscopic release of the thickened capsule. You will then undergo physical therapy to maintain the motion that is regained in the operating room. Fortunately, most people with frozen shoulder are able to regain nearly normal motion and function in time.
For more information or treatment, please make an appointment.
– Edward Bieber, M.D.
Dr. Edward Bieber of OrthoBethesda is the area’s most experienced total shoulder surgeon.
He has been performing anatomic total shoulders since 1986 and reverse total shoulders since 2007. He employs an integrated program of state of the art surgery with the OrthoBethesda physical therapy team to achieve superior results with both types of shoulder replacements. He has extensive experience with computer assisted directional devices and custom made devices for patients with significant bone deformity. Read more here and make an appointment with Dr. Bieber today.