Frozen Shoulder

Struggling with a stiff, painful shoulder? Wondering if it might be a frozen shoulder? Read on to find out the risk factors and symptoms of a frozen shoulder—and what can be done about it.

The shoulder is a ball and socket joint that is usually extremely mobile. The shoulder (glenohumeral) joint is made up of the head of the upper arm bone (humerus), which sits in a socket made by the shoulder blade (scapula).

The joint is enveloped by a layer of tissue called the capsule. This capsule protects and controls shoulder motion. In a healthy shoulder joint, the capsule is quite loose, allowing for a wide range of motion. (Watch as Dr. Romeo explains shoulder anatomy in this video.) In some people, however, especially those with diabetes, the capsule may become thickened, shorter, and stiff. This condition is known as adhesive capsulitis—often called frozen shoulder.

“Studies show that 90% of patients who receive a diagnosis of frozen shoulder will respond to and recover from their condition with a regimen of anti-inflammatory medication, corticosteroid injection, and physical therapy-directed exercise.”

Symptoms

Adhesive capsulitis typically starts slowly. Over time—usually over a few weeks to a few months—it becomes harder to fully move the shoulder. There are typically three stages:

  • Stage 1: “The freezing stage.” This stage is painful, and the motion gradually becomes more restricted. Your pain tends to worsen as the shoulder gets stiffer. This stage usually lasts six weeks to six months.
  • Stage 2: “The frozen stage.” The pain lessens, but your shoulder remains stiff. There is a dull pain, especially in the extremes of motion such as when reaching for something on a high shelf or reaching behind your back. Patients often report persistent pain at night. This stage usually lasts four to nine months.
  • Stage 3: “The thawing stage.” The pain and shoulder range of motion begin to improve. This stage usually lasts six months to two years.

Causes

  • No known cause. Often, the reason the frozen shoulder occurred is unknown.
  • Age and gender. Adhesive capsulitis is more common in middle-aged females.
  • Injury. Some people connect the start of the condition with a shoulder strain.
  • Immobilization. It can happen after the shoulder has been immobilized to treat an arm injury.
  • Inflammation. Bursitis or rotator cuff tendonitis (inflammation of the surrounding muscles or tendons) can cause the joint to “freeze.”
  • Diabetes.
  • Thyroid disease.
  • Cardiovascular disease.
  • Parkinson’s disease.

Diagnosis

Adhesive capsulitis is diagnosed by the patient’s history, followed by a careful physical examination. Imaging (x-ray or MRI) is helpful to rule out other conditions, but may not specifically show adhesive capsulitis.

A few conditions can mimic a frozen shoulder. One such condition is arthritis, which can be diagnosed with a regular set of x-rays of the shoulder.

An MRI may be ordered to rule out any other conditions, such as early arthritis or rotator cuff disease, after the examination and x-rays. The MRI can also identify a reduced volume to the joint capsule, consistent with a frozen shoulder.

Nonsurgical treatment options

Studies show that 90% of patients who receive a diagnosis of frozen shoulder will respond to and recover from their condition with a regimen of anti-inflammatory medication, corticosteroid injection, and physical therapy-directed exercise.

People with diabetes may have a more difficult time recovering from the condition without surgery, but nonoperative treatment is always the first line of management.

Recovery takes time. The condition actually goes away without intervention in most people, but unfortunately, this can take more than two years. Using the suggestions below may help speed up that process. Cases that fail to respond to medical management may require surgery.

Exercise & physical therapy. Stretching is key. Patients use an elastic cord or overhead pulley to restore the full range of motion, leading to less pain and better function. The stretching program may be uncomfortable, so it is important to have confidence in the diagnosis and understand how movement can help.

Oral medication. Your doctor may recommend pain medications or anti-inflammatories because pain can interfere with your ability and motivation to exercise.

Cortisone injections. When a patient has severe stiffness and pain that stops them from doing physical therapy, a corticosteroid injection (also called a steroid injection) into the glenohumeral joint is strongly recommended. It is often suggested—along with physical therapy—on the very first visit as it accelerates the recovery process with few side effects.

If a patient is conscientious and committed to daily exercise and physical therapy, their range of motion may be restored in three to six months. Recovery of a full range of motion is challenging and may take up to one year. If the symptoms continue, however, surgery can be considered.

“People with diabetes may have a more difficult time recovering from the condition without surgery, but nonoperative treatment is always the first line of management.”

How surgery is performed

In more serious cases that do not respond to nonsurgical treatment, an arthroscopic procedure (sometimes called keyhole surgery) can be performed. The procedure is done as an outpatient in an ambulatory surgery center and is minimally invasive. The goal of the surgery is to release the inflamed, thickened, and stiff shoulder capsule, as well as remove any excess inflamed tissue if required.

During the procedure, a small, pencil-sized instrument (called an arthroscope), connected to a camera and light source, is inserted through a small cut in the skin. It guides the insertion of a tube and surgical instruments into the joint space. These small instruments are used to release the shoulder capsule and remove the buildup of inflamed tissue. The operation is safe and generally takes less than one hour to perform.

Surgical recovery

Since the arthroscopic procedure to treat adhesive capsulitis is minimally invasive and done on an outpatient basis (meaning you can go home after the procedure), your recovery from the effects of the anesthesia and pain of surgery should be rapid.

You will be sent home with your arm in a sling and instructed to apply ice packs to the shoulder several times a day to reduce swelling and discomfort. Dr. Romeo will give you specific instructions for pain management after surgery.

The day after surgery, you will be ready to resume physical therapy. This appointment should be set up in advance so there is no break in the treatment program. The goal of physical therapy is to reestablish your range of motion, restore flexibility, build muscle strength, and ultimately return your shoulder to its previous function. Physical therapy and daily stretching exercises prevent scar tissue from re-forming at the surgical site.

Results

Despite being fixed surgically, the problem does not go away immediately. Even after surgery, sometimes the muscles remember their previous stiffness and do not want to relax. Therefore, it is critical to push through this challenge for the first six to eight weeks, assisted by your physiotherapist, as well as to stretch two to three times per day at home.

FAQs

Does sudden limited arm movement mean that I have a frozen shoulder?

Maybe. Other possible causes are arthritis, tears in the shoulder labrum, calcium deposits, and rotator cuff tears. Bursitis or rotator cuff tendonitis may also inflame muscles or tendons, causing the joint to “freeze” or feel stiff. Dr. Romeo will make a diagnosis based on patient history, a careful physical examination, and proper x-rays.

For more information about causes and treatment of frozen shoulder, or advanced treatment options when you have already had surgery and it did not provide the result you were looking for, please request an appointment with an experienced Chicago orthopaedic surgeon, Dr. Anthony Romeo. Call or email our office today to schedule your visit.

Anthony Romeo, MD
Dr. Anthony Romeo is one of the nation’s leading orthopaedic surgeons specializing in the management and surgical treatment of shoulder and elbow conditions. His state-of-the-art practice employs minimally-invasive arthroscopic techniques to accelerate the recovery process for a range of challenging conditions.

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