What is Frozen Shoulder?
"Frozen Shoulder," is a term used to describe a common painful shoulder condition that is manifested by severe pain and stiffness, or loss of motion. Another term for frozen shoulder is adhesive capsulitis. It more commonly affects women (9 out of 10 times), and generally develops in individuals in their forties and fifties. Although it can occur after trauma such as fractures or dislocations, it more commonly occurs with only minor precipitating events such as a slight pinched nerve in the neck or mild tendonitis from overuse. In many cases there is no identifiable cause and it simply begins unexpectedly. Individuals with diabetes seem to develop the condition more often and are prone to form much more scarring and stiffness.
In this condition the inner lining of the shoulder becomes progressively more and more inflamed. If one were to look into the shoulder early in the development of this condition you would see significant inflammation (redness) of the joint lining. As the condition progresses the lining of the joint begins to shrink or contract, resulting in a progressive loss of motion in the shoulder joint. The loss of motion prevents individuals from combing their hair, reaching overhead, throwing, reaching out to the side or into their back pockets and women have great difficulty fastening and unfastening their bras in back.
Patients often complain of severe pain, which occurs not only with use of the arm but also with rest. Pain at night is a common complaint and sleeping in many cases is very difficult.
During the early, or 'inflammatory', stage the condition generally progressively worsens often in spite of therapy, injections and medications. Supervised physical therapy, however, is generally recommended during this time to minimize the severity of stiffness. Occasionally an injection of cortisone may decrease some of the pain in individuals who also have some mild to moderate bursitis or tendonitis in addition to the frozen shoulder.
The average condition seems to progressively worsen over a four to six month period, after which time the progression, or worsening, of pain and stiffness seems to plateau. Usually, the pain then gradually decreases. The average condition seems to resolve over a one and one-half year period, although many patients may never regain normal motion.
Manipulation Under Anesthesia and/or Arthroscopy
In those individuals who have progressive and unacceptable pain, in spite of time and therapy, a 'manipulation under anesthesia' may be suggested or offered. This should be after the condition has been present for approximately four to six months, when the inflammatory stage has begun to calm down. If a manipulation is performed too early in the condition, (during the acute inflammatory stage), the success rate of the procedure is much less favorable and scar tissue may continue to form after the procedure.
A manipulation is a procedure that is performed at the hospital, on an outpatient basis. An anesthesiologist will generally provide a very strong sedative intravenously or a general anesthetic for the procedure. We generally then inject cortisone and a local anesthetic into the shoulder to diminish pain and further development of scar tissue. Next the surgeon will forcibly move or manipulate the shoulder to release the tight capsule and scar tissue. After the manipulation an aggressive, daily course of physical therapy is prescribed to maintain the amount of motion obtained while the patient was 'under anesthesia'. Also, in severe cases we will occassionally prescribe a 'continuous passive motion machine'- a device that will be used by the patient at home to passively move the arm and shoulder.
Open surgery to cut out the tight and scarred capsule is rarely necessary to treat this condition although occasionally an arthroscopic surgical procedure will be performed instead of the more simple manipulation under anesthesia. An arthroscopic release, as opposed to a manipulation, is commonly recommended for patients who have diabetes as well as those who have undergone prior surgery on the shoulder and therefore will have formed more significant scarring. The surgery is performed under a general anesthetic, as an outpatient, and often is followed by the use of a CPM (Continuous Passive Motion) machine at home as well as daily outpatient physical therapy.
Adhesive capsulitis (frozen shoulder) is a frustrating and painful condition for our patients; however, there is no simple cure or treatment for this condition. We prefer to initially recommend therapy and observation, allowing nature to take its course before resorting to a manipulation or surgery. Rarely individuals with severe osteoporosis have been reported to sustain a fracture of the arm with a manipulation, and individuals with diabetes, as well as those who develop a frozen shoulder after a surgical procedure, have been shown to form more scar and respond less favorably than other patients to all forms of treatment. Also, those individuals with pinched nerves, arthritis, tendonitis, rotator cuff tears and other coexisting conditions may still continue to have problems with their shoulders as a result of these other conditions. For these reasons and because all surgical procedures have risks, we prefer to try all other forms of treatment before resorting to a manipulation or arthroscopy.