Frozen Shoulder (Adhesive Capulitis)

Cause

Although many shoulder conditions involve pain and loss of motion, frozen shoulder is most often caused by inflammation (swelling, pain, and irritation) of the tissues surrounding the joint. The tissue that surrounds the joint and holds it together is called the capsule.  Normally the capsule has folds that can expand and contract as the arm moves into various positions. In a frozen shoulder, the capsule has become inflamed and scarring develops. This scar formation is called adhesions. As the capsule's folds become scarred and tightened, shoulder movement becomes restricted and moving the joint becomes painful.  This condition is called adhesive (scarring) capsulitis (inflammation of the capsule).  It is not known exactly what causes this condition.  Immobilization of the shoulder, such as after an injury or surgery, can lead to a frozen shoulder.  Inflammation of the muscles and/or tendons, as with rotator cuff tendonitis or bursitis, can also cause the shoulder joint to become frozen. 

Progression

Although the process is often self-limited, the problem of a frozen shoulder occurs in 3 phases.  Each phase is approximately 4 months in length.  Initially, a "freezing phase" occurs.  This is followed by a "frozen phase" and is completed by a "thawing phase".  The entire time frame of a frozen shoulder may last as long as a year.  While it is extremely rare for this problem to last longer than a year, it may last as long as 3 years, causing stiffness and discomfort for that period of time.  Fortunately, it is very rare for the disorder to recur. 

Surprisingly, the non-dominant shoulder is affected more than the dominant one.  This disorder usually occurs between the ages of 40 and 60, and 70% of the cases occur in women.  It is not normally associated with calcium deposits or rotator cuff injuries, and often x-rays are completely normal.  Initially pain may occur with activities, as well as at rest.  This often prevents sleep or may cause considerable pain during sleep with difficulty in finding a comfortable position in bed.  Pain is progressive over a period of weeks and often results in loss of motion in the shoulder as the patient attempts to limit the pain by voluntarily decreasing the amount of use and motion in the shoulder.  Many people are able to retain enough motion to allow for some function.  However, the loss of motion with respect to raising and rotation of the arm often significantly limits the activities of daily living such as placing the arm behind the back or tucking in a shirt. 

Treatment

Treatment is generally based on the time period when the patient is seen first by their doctor.   Frozen shoulders that are first treated in the "freezing stage" or when the shoulder becomes stiff are very difficult to treat because this phase is very resistant to the standard methods of treatment including physical therapy, injections, and medication.  Patients become frustrated during the "freezing phase" which typically lasts about four months, because it is often resistant to treatment.  However, the period of time when the shoulder is actually frozen or quite stiff, which is usually 3-4 months after the shoulder becomes painful and progressively loses motion, is often responsive to treatment.  The methods of treatment include physical therapy, medication and nerve blocks.  The "thawing phase", which is approximately 3-4 months following the "frozen phase", and a total of six months after the initial problem starts, is the time when therapy is most important and can often greatly improve the motion and use of the shoulder.  Other treatments such as manipulating the shoulder and arthroscopy may be necessary.  These treatments aid in treating the frozen shoulder since they may allow for an earlier recovery by stretching out the capsule, which has tightened in the shoulder.  Surgical treatment such as manipulating the shoulder, or even arthroscopy, should be approached with substantial caution since the frozen shoulder itself is often a self-limiting process. 

The two main goals of treatment are to increase motion and to decrease pain.  To increase motion, physical therapy is usually prescribed. The physical therapist moves the patient's arm to stretch the capsule and teaches the patient home exercises that may include use of a wand or overhead pulley. He or she may also use ice, heat, ultrasound or electrical stimulation. The therapist will demonstrate a stretching program that you should do at least once or twice a day.  To decrease pain, physicians frequently recommend anti-inflammatory medications such as aspirin, ibuprofen (Motrin, Advil), Naprosyn, or Aleve. Pain pills such as Tylenol or narcotics may be prescribed to decrease the pain after therapy or to help with sleep at night. Occasionally, steroid injections of the joint or the bursa may be indicated. 

Supervised physical therapy usually lasts from one to six weeks, with the frequency of visits ranging from one to three times per week. The patient should engage in home exercises and stretching throughout the healing process. The stretching exercises should be done at home at least once or twice daily, as noted above. In general, frozen shoulder will resolve almost completely with time and consistent compliance with the prescribed treatment program. This process can take up to six to nine months, or longer for some patients, although it may take only a few months for others. Internal rotation (moving the hand to the back pocket or up the middle of your back) is usually the motion that takes the longest to regain. 

The frozen shoulder is a curious and perplexing problem that often causes substantial frustration for patients, therapists and physicians.  Fortunately, it is a self-limited process and often improves with the time and conservative treatment.