The shoulder (the humeral head – or ball – and glenoid – the cup) are surrounded by robust ligaments and capsules (you can almost think of it like a balloon) that provide stability to the shoulder and are normally, very elastic. These allow a huge range of motion in the shoulder that is unparalleled elsewhere in the body.
When this becomes inflamed the balloon effectively shrinks, thus limiting motion and because it is inflamed it is very painful for the patient. This creates a veritable “catch 22” where the shoulder’s capsule is contracted, which produces pain and inflammation, which prevents shoulder motion, which causes capsular contraction / pain / inflammation / immobility. The cycle will continue unless broken. This immobility is what describes a “frozen shoulder” however doctors call it “adhesive capsulitis”. The name is easy to dissect however, adhesive means sticky or stuck, capsule is the shoulder capsule, and doctors place the term “-itis” on the end of anything to denote inflammation. Therefore adhesive capsulitis is a sticky or stuck shoulder capsule that is inflamed.
We do not understand why this occurs exactly, but we do know it is slightly more common in women then men, shows no race predilection, is common in diabetics, and patients with other autoimmune disorders. Additionally, patients with other endocrine abnormalities (like hypothyroidism) may have this disorder as well. There is often a genetic predilection or history of this within a family. It is common in Northern European families, and families of Scandinavian descent which is reasonably common in Ballard at least. Many patients may state that they know of no previous history in their families; and this may be true because no one was ever able to physically examine the shoulder of your ancestors! There were not many shoulder surgeons around fifty to sixty years ago; however, the idea of a family member having a tight painful shoulder that gradually improved is consistent with the diagnosis.
It usually presents with an insidious onset of pain (along the Deltoid insertion, or outside of your arm) which some may attribute to an injury. Loss of active and passive range of motion will be noted with pain at the end of range of motion, pain with activity, and especially pain at night. Some common complaints are:
- “My shoulder is stiffening up.”
- “I can’t reach over my head.”
- “I can’t reach back to fasten my bra.”
- “It’s getting harder to put on my coat.”
- “I can’t reach my wallet.”
It is important to differentiate a rotator cuff tear, which may have decreased active ROM but still full passive ROM (meaning I can still move your shoulder even though you may be unable), rotator cuff surgery, and arthritis, which can lead to shoulder replacement surgery (which is why every initial visit I will order X-rays if you do not present with them). The cornerstone to diagnosing a frozen shoulder, or as physicians call it “adhesive capsulitis”, is via physical examination. Every new patient to my practice will have an exhaustive physical examination of the shoulder in part to help rule out this problem as it is a common cause to shoulder pain.
Non-operative treatment is similar to other conditions with NSAIDS, physical therapy, and cortisone injections comprising the main stay of treatments. I prefer to start with an intra-articular cortisone injection and then see you back in follow up in 6 weeks to check your clinical progress. As explained earlier, it is extremely important to break the cycle of inflammation causing pain causing the inability to move the shoulder, so however we can do this is important: whether it be through physical therapy and NSAIDs like naproxen or ibuprofen or corticosteroid injections. Most of the time, if caught early enough, this will alleviate your symptoms. Some chronic cases can last for several months to years; in most of these cases more invasive options such as surgery need to be considered to expedite resolution of symptoms.
If necessary, frozen shoulder surgery is a quick 20 minute arthroscopic surgery that will release the capsule in your shoulder (effectively increasing the size of the balloon) which is seldom indicated due to the success of non-operative management. This surgery requires two or three small incisions about the size of a pinkie finger around your shoulder. An electro-cautery device is used to safely cut the capsule of the shoulder. Patients routinely leave the operating room with the entirety of their range of motion restored. Patients will be immobilized for less than twenty four hours while the nerve block (given to help with postoperative pain control) wears off. Once the block has worn off, immediate shoulder range of motion is strongly encouraged with immediate home exercises, and preferably next day (or very soon afterwards) visits pre-planned with a physical therapist. Rehabilitation after surgery is quick, as the goal is motion not immobilization which is why immediate therapy is preferable. In terms of shoulder surgery, the recovery is much faster for this operation. While gains are made intraoperatively, it is incredibly important to keep the shoulder moving to prevent recurrence.