Frozen Shoulder or Shoulder Capsulitis

Adhesive capsulitis or “frozen shoulder” is a common cause of shoulder pain and stiffness. Patients who have frozen shoulder often have pain that increases with shoulder motion. The pain can interfere with daily activity and sleep. The shoulder stiffness affects motion in all directions such as reaching up in the air or trying to place the hand behind the back.

Adhesive capsulitis begins as an inflammatory process within the shoulder. This leads to scar tissue formation and that causes stiffness.

Patients with frozen shoulder may have a hard time raising their arm in the air.

Patients may have a hard time reaching behind their back. This makes it difficult to perform daily activities such as dressing.

Adhesive capsulitis begins as an inflammatory process within the shoulder. This leads to scar tissue formation and that causes stiffness.

The symptoms of frozen shoulder usually pass through three phases before the patient gets better. These phases and their treatment are described below.

Stage 1: “Freezing Stage” (0-3 months):

The shoulder pain usually begins as a minor discomfort and gradually worsens over a period of weeks. Sometimes there is an injury that begins this process. The onset of shoulder stiffness usually begins after the pain has started.

What is happening inside my shoulder?

During the beginning stage of frozen shoulder there is a very strong inflammatory response within the shoulder joint and scar tissue is forming. The picture above is an arthroscopic image of a shoulder joint affected by frozen shoulder. The thick red tissue is inflammatory tissue within the shoulder.

Stage 2: “Frozen Stage” (3months-one year):

The symptoms of pain and stiffness are no longer getting worse. Patients often adjust to the “new normal” of shoulder stiffness and pain. Towards the end of this phase the pain starts decreasing.

What is happening inside my shoulder?

The inflammatory process inside the shoulder joint is ending as your shoulder is becoming more comfortable. However, over the past several months a thick layer of scar tissue has formed around the shoulder which makes it difficult to move.

Stage 3: “Thawing Stage” (12months-18months)

The shoulder pain has greatly improved and most patients have minimal discomfort but the shoulder is still stiff. During the next several months the shoulder will gradually stretch back out and regain motion.

What is going on inside my shoulder joint?

The scar tissue that formed is gradually stretching out and being broken up.

In general, the treatment for frozen shoulder is stretching exercises and anti-inflammatory medications such as Ibuprofen.

The stretching exercises help to loosen up the scar tissue around the shoulder and improve your shoulder motion. Patients are usually prescribed a brief course of physical therapy to learn how to do the exercises. After that, the patient must continue the stretches on their own at home as part of their daily routine. Patients are encouraged to stretch their shoulder twice per day.

Cortisone injections may also be used to treat frozen shoulder. Cortisone is a type of steroid. These are very strong anti-inflammatory medications. By injecting this into the shoulder it may decrease the inflammatory process that is causing the scar tissue to form. These injections are reserved for patients who are having severe pain that prevents them from stretching the shoulder or pain which interferes with sleep and daily activity. Often times the injection can decrease the pain enough to allow them to better stretch the shoulder. There are side effects to these injections and therefore they are not recommended if a patient is already making good progress. The major side effects of cortisone injections are that they weaken some of the tendons around the shoulder and in diabetic patients may cause blood sugar levels to rise.

Is surgery used to treat frozen shoulder?

Most patient will get better without needing surgery. However, surgery can be helpful for those patients who do not improve with the standard non-operative treatments described above. It is recommended that patients attempt at least three months of non operative treatment before considering surgery.

The goal of surgery is to break up the scar tissue that has formed around the shoulder. By loosening this scar tissue the pain is decreased and motion improved. There are two different types of surgery which can accomplish this. A manipulation under anesthesia is when the patient is put to sleep and the surgeon stretches the shoulder to tear the scar tissue. This was the standard operation in the past before the introduction of shoulder arthroscopy. This operation is still performed today by many orthopaedic surgeons and it produces good results.

The other operation is an arthroscopic capsular release. This is an arthroscopic shoulder surgery. This means the operation is done in a minimally invasive fashion using small incisions to put a camera and instruments into the shoulder. The tight shoulder capsule and scar tissue are then released.The image above demonstrates how this operation is performed. In this picture a cutting instrument is used to release the tight shoulder capsule.

This image shows the shoulder after the operation has been completed. The tight capsule has been released which allows more room for shoulder motion.