Adhesive Capsulitis: "Frozen Shoulder"

Adhesive Capsulitis: AKA 'Frozen Shoulder Syndrome'

Doctor, do I have Frozen Shoulder?

What is Frozen Shoulder?

Adhesive Capsulitis also known as "Frozen Shoulder", presents as a gradual loss of movement in the shoulder (Glenohumeral) joint. The Glenohumeral joint is commonly seen in an x-ray as a golfball on a tee consisting of the humeral head (ball) and the glenoid (socket).


What symptoms should I experience?

The development of Frozen Shoulder is a slow and steady process divided into three stages that can take months to years. The Freezing stage (2-9 months) is the first stage where the movement of the shoulder will cause pain, overtime the pain will intensify and may be present at night, and range of motion will decrease. The Frozen stage (4-12 months) is the second stage where the pain might decrease while the stiffness of the shoulder will increase; you will experience limitation on your activities of daily living. The Thawing stage (6-24 months) is the third and final stage where the range of motion in the shoulder slowly begins to improve.


What causes Frozen Shoulder?

The shoulder joint is composed of bones, ligaments, and tendons that are encased in a capsule of connective tissue that will become swollen, irritated and painful. The inflammation that has developed in the capsule will lead to the formation of scar tissue which is called adhesions. The formation of adhesions will cause the shoulder movement to become restricted and movement becomes painful.


What are the risk factors for the development of Frozen Shoulder?

Adults between the ages of 40's - 60's, particularly women have an increased risk for developing Frozen Shoulder. People who have reduced mobility or immobility of the shoulder due to a rotator cuff injury, arm fracture, stroke, recovery from surgery without physical therapy are at increased risk. Patients with a past medical history of Diabetes, Hyperparathyroidism (overactive thyroid), Hypothyroidism (underactive thyroid), Cardiovascular disease, Tuberculosis, or Parkinson's disease have an increased risk for developing Frozen Shoulder compared to the general population.


How is Frozen Shoulder diagnosed?

The first step is a complete history and physical examination by your physician. During the physical exam the active and passive range of motion is tested on the uninjured shoulder to have an idea of your normal baseline. During the active range of motion examination, the physician will allow you to move your shoulder on your own. During passive range of motion, the physician will ask you to relax and move the shoulder for you. The active and passive range of motion in the injured shoulder will be decreased. The decreased passive range of motion is what will favor the diagnosis of Frozen shoulder over Rotator cuff tear (passive range of motion is intact). The final diagnosis can usually be achieved from history, signs and symptoms alone, but the physician will also order and x-ray or MRI to rule out other problems such as arthritis or rotator cuff tear that will limit the movement of the shoulder similar to Frozen Shoulder.


What are the treatment options for Frozen Shoulder?

The first approach to the treatment of Frozen Shoulder is the use of over the counter medications such as aspirin, ibuprofen (Motrin IB, Advil) or Aleve to decrease inflammation and pain. If the over the counter medication is not effective, the physician will prescribe stronger pain relief / anti-inflammatory medication. The medication should also go along with physical therapy prescribed by your physician. The purpose of physical therapy is to stretch the capsule and provide home exercises that promote increase motion and decrease pain. Hot and cold compresses will help reduce the pain and swelling. If the over the counter medication and prescribed medication has failed, the physician can prescibe a steroid oral dose pack or a steroid injection during the early stages of the process to increase the positive results of physical therapy. The 3:1 steroid injection is made of 3cc of lidocaine HCl 1% and 1cc of Triamcinolone Acetonide Suspension directed into the shoulder joint.

The physical therapy can take up to six weeks and visits will range from one to three times per week. It is very important for the patient to engage in home exercises once or twice daily in combination with physical therapy to increase the positive outcome. The process of recovery to baseline can take on average six to nine months. Internal rotation (moving the arm to touch the lower back and reaching the inferior border of the scapula) is usually the motion that takes the longest to recover. 

If the first approach has failed the physician will determine appropriate to perform surgery. The surgery is performed under general anesthesia where the shoulder joint is manipulated to separate the scarring and achieve the most approximate range of motion as the uninjured shoulder. Then, arthroscopy (a small instrument with an attached camera and bipolar ablator through small incisions) is used to separate the capsular adhesions.


When can I resume activities of daily living?

Returning to activities of daily living will vary between patients and how soon the Frozen Shoulder has been treated. How soon a patient will resume activities will depend on whether the shoulder has recovered; not on how many days or weeks since the injury or surgery. The shoulder is considered recovered only if full range of motion and strength is achieved without experiencing pain and is similar to the uninjured shoulder.


Can Frozen Shoulder be prevented?

Preventing the development of a Frozen Shoulder or at least lessening the stiffness of a shoulder can be achieved by early physical therapy. If you have experienced an injury that has caused you to limit the range of motion of the shoulder, it is important to see a physician early to develop an exercise program that will prevent a Frozen Shoulder.

Luis G. Colon Gonzalez MS3 Third year medical student at University of Medicine and Health Sciences (UMHS)

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