Frozen shoulder, or adhesive capsulitis, is one of the most common problems that we see in clinic. The anatomic problem with frozen shoulder has to do with a structure deep in the shoulder called the capsule. Think of the capsule like a balloon. Inside the balloon are structures like the joint cartilage, joint fluid, and the biceps tendon attachment. In frozen shoulder, that balloon is very inflamed and very thick. Normally, the capsule is the thickness of a balloon. In frozen shoulder, the capsule can be the thickness of a leather belt.
The hallmark symptoms of frozen shoulder include pain and restricted range of motion. Often, this pain occurs for no good reason and most people cannot pinpoint a particular time or injury in which the pain began. We call this an insidious onset. Over time, patients begin to feel more pain as their shoulder gets stiffer. Patients will typically report pain at the extreme of motion, or end-range pain. This pain occurs because the capsule (balloon) is stretched at the extreme of motion. The balloon is where all the pain fibers are. Therefore, when the balloon gets stretched, it causes so much pain.
When we see patients in the clinic, the first thing we need to determine is whether the pain is from frozen shoulder or if the pain is rotator cuff tendon-based pain. There are minor differences which are critical to differentiate as the treatment is different. On physical examination, patients with frozen shoulder will have varying degrees of loss of motion. Some have significant limitations in their movement, while others will only have mild restriction in their range of motion. The classic physical exam finding is loss of external rotation movement (rotation out away from the body).
The most common reason for frozen shoulder is – no good reason at all. We call this idiopathic adhesive capsulitis. There are risk factors which place patients at higher risk for getting frozen shoulder which include diabetes, thyroid disease, and cardiac disease. However, we do not know why frozen shoulder occurs in the first place. Other causes of frozen shoulder include post-traumatic (after an injury) or post-surgical (after a shoulder surgery has been performed).
The good news is that very few people need surgery for frozen shoulder. In fact, less than 10% need surgery for frozen shoulder. The mainstay of treatment is physical therapy. Regaining full range of motion is essential for pain relief. Unfortunately, this can take quite some time. Sometimes it takes weeks, but more commonly many months. However, as the range of motion improves, so does the pain. To help with the pain from physical therapy, we typically recommend a cortisone injection into the shoulder joint (into the “balloon”). This is the fastest way to get pain relief, as it typically takes the sharpness of the pain away. In addition, it really helps with night pain to allow patients to sleep better. We also often recommend an anti-inflammatory, such as Advil, Aleve, meloxicam, Celebrex, etc. However, these oral anti-inflammatories are not as effective in relieving the pain as a cortisone injection. Furthermore, heat is also helpful before stretching, and ice can be applied after stretching therapy.
Overall, frozen shoulder can be a very frustrating diagnosis and treatment plan for patients. However, we encourage them to be consistent in their daily stretching program as it will be effective most of the time. If you have shoulder pain that is been going on for 3 or 4 weeks and not getting better, you should make an appointment to have an orthopedic surgeon evaluate it.
Dr. Mitchell Fagelman is an orthopedic surgeon and OrthoTexas and he specializes in diagnosing and treating shoulder and elbow pain in athletes and adults. He often sees 5 and 10 patients a week with frozen shoulder. However, on average, less than 10 of these individuals need surgery for this condition each year.
