Shoulder

Frozen Shoulder (Adhesive Capsulitis)

Anatomy

The shoulder is a complex, ball-and-socket joint made up of three bones: the upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The ball, or head, of the upper arm bone fits into a rounded socket (glenoid) in the shoulder blade. A combination of muscles and tendons (rotator cuff) keeps the arm bone centered in the shoulder socket.

The shoulder capsule is made up of bands of strong, connective tissue (ligaments) that surround the shoulder joint and hold it together. The undersurface of the shoulder capsule is lined by a thin membrane (synovium) that releases synovial fluid to lubricate the joint and eliminate friction, helping the shoulder to move more easily.

Description

In frozen shoulder, also called adhesive capsulitis, the tissues of the shoulder capsule become thick, stiff and inflamed. Stiff bands of tissue (adhesions) develop and, in many cases, there is a decrease in the synovial fluid needed to lubricate the joint properly. Over time the shoulder becomes extremely difficult to move, even with assistance. Frozen shoulder generally improves over time, however it may take up to 3 years. The focus of treatment is to control pain and restore motion and strength through physical therapy. Frozen shoulder develops in three stages:

• Freezing—Pain worsens and range of motion decreases; typically lasts 6 weeks to 9 months.
• Frozen—Painful symptoms may improve, but stiffness remains, making daily activities very difficult; lasts 4 to 6 months.
• Thawing—Shoulder motion slowly improves, however it usually requires 6 months to 2 years to regain a near-normal range of motion.

Symptoms

In addition to the shoulder becoming stiff and difficult to move, symptoms of frozen shoulder include a dull or aching pain located over the outer shoulder area, or at times, the upper arm. Painful symptoms are typically most severe in the early course of the disease, or when moving the arm, especially when movement is sudden.

Risk Factors

Although the causes of frozen shoulder are not fully understood, there are several factors that may increase the risk for developing this condition.

• Diabetes—Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.
• Other diseases—Additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease and cardiac disease.
• Immobilization—Immobilizing the shoulder for a period of time following surgery, fracture or other injury may result in frozen shoulder.

Nonsurgical Treatment

More than 90% of patients improve with relatively simple treatments to control pain and restore motion.

• Nonsteroidal anti-inflammatory medication (NSAIDS)—Drugs such as aspirin, ibuprofen or naproxen can help relieve pain and swelling. Whether in over-the-counter or prescription-strengths, these medications must be used carefully. Taking them for more than one month should be reviewed with your primary care physician. If you develop acid reflux or stomach pains while taking an anti-inflammatory, be sure to talk to your doctor.
• Steroid injections—Steroids, such as cortisone, are very effective anti-inflammatory medicines that can be injected directly into the shoulder joint to relieve pain. Your doctor will use these cautiously.
• Physical therapy—Specific exercises or a shoulder conditioning program will help restore range of motion. Physical therapy may be used under the supervision of a physical therapist or a home program.

Surgery

If symptoms are not relieved by medication and physical therapy, your doctor may recommend surgery to stretch and release the stiffened shoulder joint capsule. The most common surgical methods are manipulation under anesthesia and shoulder arthroscopy. In many cases, they are used in combination to obtain maximum results. Most patients have very good outcomes with these procedures.

• Manipulation under anesthesia—Typically performed under general anesthesia (you are put to sleep), the orthopaedic surgeon forces the shoulder to move. This causes the capsule and scar tissue to stretch or tear, releasing the tightening and increasing range of motion.
• Shoulder arthroscopy—During this minimally invasive procedure, the orthopaedic surgeon cuts through tight portions of the joint capsule using pencil-sized instruments that are inserted through small incisions around the shoulder.

With any surgery there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. Your orthopaedic surgeon will speak to you prior to surgery to explain any potential risks and complications that may be associated with your procedure.