Frozen Shoulder (Adhesive Capsulitis)

Frozen shoulder is a very painful condition in which the shoulder freezes up and becomes stiff. It may or may not be due to trauma. People with diabetes, thyroid dysfunction or gout are more commonly affected. While the reason this happens is unclear (many blame a virus), it is an inflammatory condition and is often due to an underlying rotator cuff problem.

Frozen shoulder may go through phases. The ‘freezing’ phase lasts roughly 3-9 months. The ‘frozen’ phase can lasat for 4-12 months or longer. Some shoulders may then ‘thaw’ over 1-4 years, during which time motion improves, but not necessarily completely. If untreated, the average amount of time for the shoulder to go through this cycle before comfort and some motion returns is 2.5 years. If untreated, 7-42% of patients will have significant permanent stiffness.

In my opinion the best way to treat the frozen shoulder is to ‘hit it early and hit it hard’. The earlier you’re seen, the better. I inject a steroid (cortisone) into the shoulder and prescribe a medrol dose pack (steroids taken by mouth) for 6 days. While long-term steroids can potentially lead to ulcers or arthritis, that is incredibly rare from a 6-day medrol dose pack. The real side effects include increased appetite and water retention, so there may be a slight weight gain. Steroids by mouth may keep some people from sleeping well at night, so I also prescribe a sleeping pill along with it.

The third mainstay of treatment is therapy, which is optimally performed 3 days/week until motion improves. The therapist will use ultrasound on the shoulder and perform stretching exercises. In addition, rotator cuff strengthening exercises with an elastic resistance are prescribed, as the rotator cuff is often involved. It is also extremely important to perform a home stretching and strengthening program. It’s best if the steroid injection, medrol dose pack and therapy all occur at the same time. The vast majority of my patients who follow these instructions improve significantly, and often attain full or near-full motion within 1-2 months. Very few patients require surgery for frozen shoulder.

However, if 3-6 months of nonoperative treatment is unsuccessful, surgery may be considered. If surgery is pursued, a manipulation under anesthesia is usually not enough. In most cases, if a manipulation is all that’s needed, then a good nonoperative management program would have been successful. The most effective surgical treatment for frozen shoulder is an arthroscopic capsular release, in which a small scissor-like instrument is used to cut the joint capsule (balloon) around the shoulder joint. In addition, any inflamed tisssue and pathologic rotator cuff tissue is removed. After the joint capsule has been released the shoulder can then be manipulated, which is less traumatic and more effective. This surgery is not especially painful. Some patients with frozen shoulder due to former surgery or fractures may also need an open incision to release additional scarred tissue planes. Post-operative therapy is critical and begins within 1-3 days. Therapy with a knowledgeable therapist is performed 5 days a week for 4 weeks, and then decreased over the next couple months depending on how motion progresses.

Manipulation following arthroscopic release leads to normal or near normal motion with minimal pain in 75-83%. The prognosis is better for patients who have experienced stiffness for less than 6 months. Patients with frozen shoulders following surgery or a shoulder fracture typically have a more complex and severe problem, with less satisfactory results. That’s one reason why the first surgical procedure performed often sets the tone for that patient’s ultimate outcome and should be done by a specialist.