What’s frozen shoulder and how is it treated?

 

I typically see several cases of frozen shoulder each week. Also known as adhesive capsulitis, frozen shoulder’s an extremely painful condition with three distinct phases that eventually resolve. Some patients come to see me for a second opinion after a diagnosis. Some patients want an explanation for the pain they’re experiencing without a definitive MRI finding. Your MRI will look fairly normal, with thickening in the shoulder capsule. You may have been told there’s nothing wrong except age-related changes. General practitioners or family doctors might be unfamiliar with the stages of frozen shoulder and will refer patients to me because they’re just not sure what’s going on. In some cases, if a patient is in the early stages of frozen shoulder, the condition may not be obvious.

 

I think frozen shoulder is one of the most frustrating problems for my patients. The pain and stiffness impact your sleep, your daily routine, and can leave you at wits’ end. I know of a patient who’d experienced childbirth, a torn hamstring, and abdominal surgery, and said the pain from her shoulder was far worse than any of those. At the same time, it’s a benign condition. You’ll get better eventually, and surgery won’t resolve the pain—in fact, it could make the pain worse. 

The first phase in frozen shoulder is pain caused by inflammation. What might confuse you is the pain may start on the outside of your upper arm. This is a referral pattern of pain that is coming from the shoulder. The shoulder joint capsule refers to the group of ligaments that encapsulate the shoulder's ball-and-socket joint, which connect the upper arm bone to the shoulder's socket, and stabilize the joint.

 

As the inflammation worsens, stiffness set in. At this point, we can diagnose your condition as frozen shoulder. Gradually, mobility decreases as inflammatory pain worsens. This phase can last for several months. The second phase is stiffness. The pain begins to improve, but you have little to no mobility in your shoulder. The third phase is thawing—a gradual improvement of movement after the pain is gone. 

I recommend over-the-counter anti-inflammatory pain medications like ibuprofen to treat frozen shoulder. In some cases, we’ll try a cortisone injection in the joint to help reduce inflammation. Sometimes massage therapy may improve your pain by increasing blood flow to the area, helping your muscles relax and improving inflammation. No physical therapy is recommended at this stage because it’s just too painful. During the second and third phases, when pain diminishes, massage and physical therapy are great tools for getting your mobility back faster.

Some people pass in and out of the phases in a year. More often, patients regain full mobility in about three years. Typically, the tissues around the joint are very pliable and elastic with more mobility than any other joint but I’ve had a few extremely rare cases in which the capsule around the shoulder muscle remained stiff and we had to perform surgery for them to regain mobility. The procedure is called a capsular release. This is an arthroscopic, minimally invasive surgery through small incisions called portals using a camera placed into the joint. These are performed only after your pain is completely gone and you can’t get your mobility back. It allows the shoulder to move and you have to work hard in physical therapy to regain full motion. 

 

During the first two phases, please don’t think surgery will help. You then interfere with the frozen shoulder process and surgery makes it worse. At times the pain is so severe that patients hope and believe there is a surgery to alleviate this pain. But please trust me, surgery could make this worse. I want to emphasize that a bit. I’m a shoulder specialist and a surgeon. If a shoulder surgeon tells you that you don’t need surgery, you should believe them. 

Generally, frozen shoulder is classified as idiopathic, which means we don’t really know what causes it. Anecdotally, I’ve seen patients who experience a minor trauma, like a fall with no serious injury, or their dog jerked on its leash while walking, and then they develop frozen shoulder. I’ve seen it in patients who are post-chemotherapy, those with endocrine problems—insulin dependent diabetes in particular—and following a mastectomy. The lack of movement might trigger the response, or something about a disease process could cause it, but I’ve also seen patients with no other risk factors except they’re female. Men have a lower risk for frozen shoulder, and I rarely see it in patients over age 65. Again, this is all anecdotal. We just don’t know what causes it. That doesn’t usually comfort my patients who are in severe pain. 

Once the syndrome begins, there is nothing we can do to stop it. Hopefully, if you know what to expect, you can cope better. During the initial phase, avoid being startled, for example. Involuntary motion like jumping back is painful. Likewise, don’t suddenly reach for things. Your limited motion will cause a hard stop, like running into a brick wall. 

The best things I can tell you about frozen shoulder are first, you can’t make the disease process worse; and second, you’re going to get better. Sometimes, patients fear that making an inadvertent movement that causes a sudden increase in pain will set back their recovery. They’re happy to hear that’s not the case. You only move forward. The pain just hurts; you didn’t add more recovery time. You move through the stages whether you do anything or not. We intervene with injections, physical therapy and massage just to make you more comfortable and bring back range of motion a bit sooner.