OVERVIEW
Frozen shoulder is also known as adhesive capsulitis. This can be broken down into components to better understand what is happening.
- Adhesive: meaning sticky, or in this case stuck together or stiff
- Capsule: is the lining of the joint and where the ligaments are
- -itis: referring to inflammation
A frozen shoulder occurs as a result of inflammation of the lining of the shoulder joint; such that when motion is attempted, the ligaments need to stretch to allow the motion which causes pain that limits motion. Over time inflammation resolves by forming scar tissue within and around the ligaments of the shoulder resulting in loss of motion.
CAUSES
Many factors can influence the development of a frozen shoulder. The initial cause of the inflammation can be the result of an obvious trauma, major or minor, or the result of repetitive microtrauma. It can be the result of surgery or immobilization of the arm due to another injury. It can also result from no apparent cause but just "come on" as progressive pain and stiffness. It may occur in certain patient populations for reasons that are unclear. For example, there is a much higher risk of frozen shoulder in patients with diabetes, thyroid disorders and cardiac disease.
CLINICAL PICTURE
The average patient with a frozen shoulder will complain of pain with reaching. The pain is experienced most frequently when reaching behind their backs, behind their heads and also over head and away from their bodies. They have pain with putting on coats or shirts and women have difficulty hooking and unhooking their bras. Pain is also present at night and can interfere with sleep. It can go on for months with the expectation that it "will get better." But as the pain continues patients reflexively avoid the painful end ranges of motion. Over time, the functional range of the shoulder decreases until the scarring begins and there is true loss of motion.
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Loss of elevation and external rotation
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Frozen shoulder is often confused with tendonitis, bursitis or other rotator cuff problems. Treatment, which would be appropriate for these other problems, is sometimes started but is typically not successful and physical therapy can be very painful. Additionally, if steroid injections are given, they are often given in the wrong part of the shoulder with limited success. MRI scans are often done when the patient fails to improve. The MRI scans are typically inconclusive because with a frozen shoulder, the rotator cuff is not torn but may show age-related changes that can be interpreted as partial tears.
DIAGNOSIS
A good thorough physical exam is imperative to accurate diagnosis. Limited rotation of the shoulder joint is the key. There is very little difference between active and passive range of motion and it is often found that passive rotation of the shoulder is more painful than active firing of the rotator cuff muscles (another key). Obtaining X-rays is an important step because osteoarthritis can cause the same symptoms as a frozen shoulder and will be evident on an X-ray whereas X-rays of a frozen shoulder are negative for osteoarthritis. As mentioned above in the clinical picture section, an MRI is not necessary to diagnose a frozen shoulder.
TREATMENT
To successfully treat a frozen shoulder all components of the problem need to be addressed. The "itis" or inflammation needs to be treated with anti-inflammatories. If nonsteroidal anti-inflammatories such as ibuprofen or naproxen are not successful, then an injection of corticosteroids is usually very effective. It has to be put where the problem is and that is directly into the shoulder joint where the capsule is and where the inflammation is. Once the inflammation is under control, a course of physical therapy is much better tolerated and often effective in restoring motion.
If this is not successful then procedures such as Manipulation under Anesthesia, or shoulder arthroscopy with cutting of the adhesions can be performed.
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Manipulation under anesthesia
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It should be noted that the natural history of adhesive capsulitis is that it usually will get better by itself, but that can take many months to several years. This course can be significantly shortened, however with appropriate recognition and treatment.
If you have questions or wish to schedule an evaluation by one of Cascade Orthopaedics' specialists, please call us at (253) 833-7750.
This material presented is for educational and informational purposes only. You should consult a physician or health care provider for actual evaluation, diagnosis, and individual treatment recommendations or advice.
