What is a frozen shoulder?
A frozen shoulder (also sometimes called adhesive capsulitis) is a condition where the capsular structures (ligaments) of the shoulder have shortened and scarred and this decreases the motion of the shoulder. The normal capsule of the shoulder helps to keep the shoulder in the socket, but is only tight at the extremes of motion. However, when these structures tighten and shorten they begin to restrict motion at progressively smaller ranges of motion of the shoulder. Frozen shoulder most commonly occurs without an obvious cause. It can be seen after injuries where shoulder motion is not allowed or pain restricts motion for a period of time. It can be associated with patients who have diabetes or thyroid disorders. A frozen shoulder can come from other causes such as a fracture or after surgery of the shoulder, but this is a different condition from this description.
What are the symptoms of frozen shoulder?
Many patients with frozen shoulder report pain diffusely around the shoulder. Although they can have night pain many times the pain seems to be more pronounced when trying to perform activities. For some patients any motion can be painful and for others it is only painful when they begin to reach the end of their ability to move the shoulder. At that point it can be sharply painful to move further. Patients can be frustrated that they can’t reach objects on a shelf normally or they can’t reach behind their back to get their hand in a pocket or tuck in a shirt.
How is the diagnosis of frozen shoulder made?
The diagnosis is usually made by taking a history and doing a physical examination of the patient. X-rays taken of a frozen shoulder are typically normal. However, it becomes relatively easy on physical examination to detect a significant loss of range of motion in the ball and socket (glenohumeral) joint of the shoulder. Many patients will exaggerate motion of the shoulder blade (scapula) in order to try to move the arm. This is because the ball and socket part is restricted and the shoulder blade helps compensate.
What is the conservative management for frozen shoulder?
Frozen shoulders typically have two stages. In the first stage when the process is beginning to get worse the pain seems to be a dominant aspect for the patient in addition to diminishing motion and restricted function of the shoulder. After this there can frequently become a time where the shoulder is not as acutely painful and is more tolerable with activities with the arm at the side. However, the patient notices significant restriction of movement of the shoulder and pain at the limit at that range of motion. The key to trying to make this better conservatively is a stretching program for the shoulder. What is important is to be able to stretch the shoulder 3 to 4 times a day in multiple different positions. This is needed in order to try to stretch out the capsule to allow more normal shoulder motion. Seeing a physical therapist once or twice a week and ignoring daily stretching simply won’t help the patient get better quickly. Stretching programs are very specific and the program needs to apply a true stretching force to the shoulder. Simply trying to lift the arm up in the air or move it around to improve motion is not adequate. For some patients an injection of cortisone within the joint can help with inflammation, and make it so that a stretching program is more tolerable. Nonsteroidal medicine such as Ibuprofen or Aleve can help for those patients who can take them. Fortunately, the natural history with frozen shoulder is that most patients will improve with time and with a stretching program and won’t need further treatment. However, this can take several months to get final improvement.
What are the surgical options?
For some patients who fail to improve, a simple manipulation can be considered. This is where the patient is given an anesthetic and the shoulder is moved by the surgeon in a way so as to break up the adhesions and restrictions in the capsule in order to restore motion to the shoulder. After a manipulation when the motion is restored, it will still be important for the patient to resume the stretching program in order to try to maintain this new improved motion. For some patients a manipulation is not adequate and it is necessary to actually cut some of these capsular structures to restore motion. In this situation a shoulder arthroscopy is performed, again under anesthesia, and the tightened capsule is cut in order to release it and allow motion of the shoulder to improve. Although there is concern this could make the shoulder unstable it is actually quite rare. Again, just as with a simple manipulation, diligence on the part of the patient and a continued physical therapy program would be necessary.
What is the postoperative rehabilitation?
Rehabilitation should start right away with early motion and use of the shoulder. There are typically no restrictions put on the patient when actively using their shoulder to gain as much motion as possible. However, again, diligence with the program that was used prior to any operative intervention is important. Home therapy, as well as organized physical therapy, are typically encouraged. In spite of a manipulation or a capsular release, it may take many weeks for the patient to regain their ultimate range of motion.
What are the risks and complications of these procedures?
For a full list of potential risks and complications the surgeon should be consulted. Briefly, with a simple manipulation it is possible, although rare, that the arm could be fractured in attempting to improve range of motion. It is also possible that structures such as the rotator cuff could be torn with the manipulation, but again this is very uncommon. It is certainly also possible that in spite of the manipulation and therapy afterwards that the frozen shoulder could recur. For the arthroscopic capsular release, clearly there are issues with anesthesia and the potential for infection with an invasive procedure, but again this is rare. It is possible, but rare, that a nerve injury could occur with a capsular release. Again, recurrence of the frozen shoulder is a potential concern.