What is a Frozen Shoulder?
Adhesive capsulitis (frozen shoulder) is characterized by diffuse pain and lack of motion of the shoulder. Patients often describe the inability to sleep on the affected shoulder. Generally, adhesive capsulitis affects individuals from 40 to 70 years old. Females are also more likely to be affected than males. The most common cause of adhesive capsulitis is referred to as idiopathic (no specific cause). Various conditions have been associated with adhesive capsulitis, but the primary condition is diabetes. Diabetic patients are 10 to 20 percent more likely to have a frozen shoulder. There is also a higher frequency of both shoulders being affected. Trauma, previous surgery, hyperthyroidism, and periods of immobilization are other conditions connected to similar findings in adhesive capsulitis.
What Can I Expect?
The natural history of adhesive capsulitis consists of three phases including a painful phase, a stiff phase, and a "thawing" phase. Generally there is a gradual onset of pain initially that is diffuse in nature. The length of the painful phase may range from weeks to months in duration. The stiffening phase is defined by the loss of range of motion of the shoulder and can continue up to a year. Most patients notice a decrease in the external and internal rotation and abduction. The "thawing" phase is described as the progressive improvement of motion over the following weeks to months.
Making the Diagnosis
The practitioner will first obtain a proper history of the patient's shoulder pain or stiffness. Important information consists of the onset of the symptoms, if there was a specific injury, the duration of the symptoms, the location of the symptoms, and prior medical health conditions. Previous treatment modalities should also be discussed. This may include physical therapy, anti-inflammatory medications, trial of prednisone, or an intra-articular injection of cortisone.
Routine x-rays and MRI evaluation may be obtained to further investigate the patient's shoulder pain. Usually, x-rays appear to be normal but may show coexisting conditions and are needed to rule out severe arthritis of the shoulder because this condition could mimic symptoms of adhesive capsulitis. A MRI may be necessary to evaluate for other soft tissue injuries in the shoulder such as rotator cuff damage.
I Have a Frozen Shoulder, Now What?
Once a diagnosis of adhesive capsulitis is made, there are two choices of treatment. A conservative method involves ice, anti-inflammatory medications, gentle range of motion exercises, and to wait. Again, this condition will eventually resolve knowing the natural history (stated above) but the variable is the duration and difficulty in that course. The other option is surgical intervention for refractory cases lasting longer than 3 months with no improvements in pain or motion.
The Surgical Procedure
The surgical procedure is performed through an arthoscopic approach. This consist of viewing the shoulder joint through two to three small incision sites. Then a capsular release of the tight soft tissue is completed and motion is regained in the operating room. In addition, at the time of surgery other structures such as the rotator cuff are viewed and damage can be addressed at the time of surgery. Patients generally have impingement of the rotator cuff as well and can be managed through a decompression (opening up of the space on top of the rotator cuff) and excising the outer portion of the clavicle.
The Day of Surgery
Surgery is usually performed on an outpatient basis. After surgery, the operated shoulder is placed in an immobilizer. The type of immobilizer used depends on the surgical procedure completed. A dressing and ice are applied to the incision site. Generally, if a capsular release was the only procedure performed, then the immobilizer is worn for the first 7 to 10 days after surgery.
The patient returns home and is advised to schedule light with any activities. The patient will been seen in the office for a post-operative visit around 10 to 14 days following surgery. At this time, the incisions are checked and range of motion evaluated. Physical therapy ideally would start within 24 to 36 hours after surgery. The initiation of therapy is vital to the following recovery process.
Patients are in formal physical therapy for the next several weeks after surgery with the length depending on how quickly the patient's recovery is progressing. Initially, the patient will attend therapy 2 to 3 times a week; however, most of the shoulder rehabilitation exercises are completed on your own at home.
Once the patient is able to complete the therapy exercises on his or her own, then he or she will continue the stretching and strengthening exercises at home for the next several months.
Article by Paul A. Nitz, M.D.