Adhesive Capsulitis (Frozen Shoulder)

Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time,the shoulder becomes very hard to move.

After a period of worsening symptoms, frozen shoulder tends to get better, although full recovery may take up to 3 years. Physical therapy, with a focus on shoulder flexibility, is the primarytreatment recommendation for frozen shoulder.

Frozen shoulder most commonly affects people between the ages of 40 and 60, and occurs in women more often than men. In addition, people with diabetes are at an increased risk for developing frozen shoulder.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

Description

In frozen shoulder, the shoulder capsule thickens and becomes stiff and tight. Thick bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint. The hallmark signs of this condition are severe pain and being unable to move your shoulder --either on your own or with the help of someone else. It develops in three stages:

Stage 1: Freezing

In the "freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

Stage 2: Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

Stage 3: Thawing

Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

Cause

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes. The reason for this is not known. In addition, diabetic patients with frozen shoulder tend to have a greater degree of stiffness that continues for a longer time before "thawing."

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Symptoms

Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Imaging Tests

Other tests that may help your doctor rule out other causes of stiffness and pain include: X-rays. Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of soft tissues. They are not required to diagnose frozen shoulder, however, they may help to identify other problems in your shoulder, such as a torn rotator cuff.

Treatment

Frozen shoulder generally gets better over time, although it may take up to 3 years. The focus of treatment is to control pain and restore motion and strength through physical therapy.

Nonsurgical Treatment

Most people with frozen shoulder improve with relatively simple treatments to control pain and restore motion.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.

Physical therapy. Specific exercises will help restore motion. These may be done under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before stretching. Below are examples of some of the exercises that might be recommended.

External rotation — passive stretch. Stand in a doorway and bend your affected arm's elbow to 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.

Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

Surgical Treatment

If your symptoms are not relieved by therapy and other conservative methods, you and your doctor may discuss surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments, and the risks involved with surgery.

Surgery for frozen shoulder is typically offered during "Stage 2: Frozen." The goal of surgery is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

Manipulation under anesthesia. During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.

Shoulder arthroscopy. In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.

In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have good outcomes with these procedures.

Recovery. After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to 3 months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy. Long-term outcomes after surgery are generally good, with most patients having reduced or no pain improved range of motion. In some cases, however, even after several years, the motion does not return completely, and some degree of stiffness remains. Diabetic patients often have some degree of continued shoulder stiffness after surgery. Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.

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