What is Frozen Shoulder?

Frozen Shoulder is also known as Idiopathic Adhesive Capsulitis

Symptoms

The symptoms of idiopathic adhesive capsulitis include, in varying combinations, pain, stiffness, sleep disturbance and weakness.

The pain is generally a deep aching pain felt in the vicinity of the ball of the shoulder, but also commonly felt in the chest area and further down the arm to a point about midway between the shoulder and the elbow. The pain will often be present at rest and is generally more intense when one is using the arm and shoulder.

Stiffness will vary from very mild to extremely severe. An example would be stiffness so severe that one has difficulty reaching the middle belt loop on a pair of pants.

Sleep disturbance is a very common feature of idiopathic adhesive capsulitis. People find that they often awaken from sleep due to pain; they can generally return to sleep but are awakened again before their normal waking time. Sometimes changing position, using over-the-counter medication, or using ice will lessen the pain that is disturbing sleep.

Diagnosis

Diagnosing idiopathic adhesive capsulitis (frozen shoulder) requires a careful history. Certain features of the history as volunteered by the patient are very useful clues for the examiner. Does the shoulder hurt with sudden movements? Is the shoulder stiff? Have the symptoms been getting worse over the course of several weeks? These are all useful clues an examiner will seek.

Another important basic tool is a careful physical examination of both shoulders conducted by an experienced examiner. By combining the elements of a careful history, along with the findings of the physical exam, an examiner can narrow the possible causes of the patient’s shoulder pain and stiffness. It is often possible to reach a presumptive diagnosis of idiopathic adhesive capsulitis without sophisticated imaging studies.

Causes

The cause of adhesive capsulitis is unknown. There is a form of frozen shoulder that is associated with diabetes. If you are not a diabetic, please focus any research you may undertake on non-diabetic diagnosis of frozen shoulder.

It is common for patients to associate their early memories of shoulder pain with a specific task or event. This task may be an arm movement during a sporting event or a hard day of working in the yard. It is my belief that these memories are representative of symptoms present in a long evolution of frozen shoulder. The event remembered is probably not the actual cause of the frozen shoulder.

Treatment

Exercise is very effective at lessening the pain and stiffness of idiopathic adhesive capsulitis (frozen shoulder). It seems counterintuitive, but a lot of evidence shows that using a frozen shoulder helps it, and not using a frozen shoulder delays its recovery. Therefore, try to continue with your normal activities, like gardening or sports, as your tolerance allows. The intensity of your activity should be based on the level of pain you are able to tolerate.

Physical therapy is often employed in the treatment of idiopathic adhesive capsulitis. It may consist of a home exercise regimen and can also involve supervised physical therapy in combination with a home regimen.

A few patients will notice a decrease in stiffness and pain by treating frozen shoulder with cortisone injection; however, most patients do not notice substantial lasting relief. This is a treatment that I sometimes—but not generally—employ.

Over-the-counter pain medications designed to fight inflammation, such as Aleve or Advil, will sometimes lessen the pain and stiffness of frozen shoulder. I recommend that one try a seven to 10 day trial of over-the-counter anti-inflammatory medicines. If no relief is gained from this trial, I recommend that the patient stop using anti-inflammatory drugs for treatment of their frozen shoulder.

There is a role for surgery in patients with frozen shoulder who have failed to gain satisfactory relief of their pain or stiffness despite an adequate trial of nonoperative treatment. Surgery can include manipulation under anesthesia or arthroscopic frozen shoulder surgery. There are many important details to understand before making a decision about surgery for frozen shoulder.

What is Diabetic Frozen Shoulder?

Diabetic Frozen Shoulder is also known as Diabetic Adhesive Capsulitis

There is an association between diabetes and frozen shoulder, but the cause of frozen shoulder

in diabetics is unknown. Treatment of diabetic frozen shoulder begins with the same treatment that is employed for a non-diabetic frozen shoulder. Diabetic frozen shoulder generally requires a longer recovery, and diabetic frozen shoulder is more likely to require surgery.

In addition to the treatment methods employed for a non-diabetic frozen shoulder, it is important that a diabetic with a frozen shoulder also manage their diabetes well. That means closely monitoring their blood sugar. Exercise, blood sugar control, and prudent dosing of medication will all help a diabetic frozen shoulder recover more quickly.

Symptoms

The symptoms of diabetic adhesive capsulitis include, in varying combinations, pain, stiffness, sleep disturbance and weakness. The pain is generally a deep aching pain felt in the vicinity of the ball of the shoulder, but also commonly felt in the chest area and further down the arm to a point about midway between the shoulder and the elbow. The pain will often be present at rest and is generally more intense when one is using the arm and shoulder.

Stiffness and soreness vary from very mild to extremely severe. People find that they often awaken from sleep due to pain and generally can return to sleep—but are awakened again before their normal waking time. Sometimes change of position, over-the-counter medication or ice will lessen pain that is disturbing sleep.

Diagnosis

The diagnosis of diabetic adhesive capsulitis (frozen shoulder) requires a careful history. Certain features of the history as volunteered by the patient are very useful clues for the examiner. Does the shoulder hurt with sudden movement? Is the shoulder stiff? Have the symptoms been getting worse over the course of several weeks? These are all useful clues an examiner will seek.

Another important basic tool is a careful physical examination of both shoulders conducted by an experienced examiner. By combining the elements of a careful history, along with the findings of the physical exam, an examiner can narrow the possible causes of the patient’s shoulder pain. It is often possible to reach a presumptive diagnosis of diabetic adhesive capsulitis without sophisticated imaging studies.

Cause

The cause of diabetic adhesive capsulitis is unknown.

Treatment

Exercise is very effective at lessening the pain and stiffness of diabetic adhesive capsulitis (frozen shoulder). It seems counterintuitive, but a lot of evidence shows that using a frozen shoulder helps it, and not using a frozen shoulder delays its recovery. Therefore, try to continue with your normal activities, like gardening or sports, as your tolerance allows. The intensity of your activity should be based on the level of pain you are able to tolerate.

Physical therapy is often employed in the treatment of diabetic adhesive capsulitis. It may consist of a home exercise regimen and can also involve supervised physical therapy in combination with a home regimen.

A few patients will notice a decrease in stiffness and pain by treating frozen shoulder with cortisone injection; however, most patients do not notice substantial lasting relief. This is a treatment that I sometimes—but not generally—employ.

Over-the-counter pain medications designed to fight inflammation, such as Aleve or Advil, will sometimes lessen the pain and stiffness of frozen shoulder. I recommend that one try a seven to 10 day trial of over-the-counter anti-inflammatory medicines. If no relief is gained from this trial, I recommend that the patient stop using anti-inflammatory drugs for treatment of their frozen shoulder.

There is a role for surgery in patients with frozen shoulder who have failed to gain satisfactory relief of their pain or stiffness despite an adequate trial of nonoperative treatment. Surgery can include manipulation under anesthesia or arthroscopic frozen shoulder surgery. There are many important details to understand before making a decision about surgery for frozen shoulder.

Manipulation Under Anesthesia FAQs

What surgery are you suggesting?

I am suggesting that you undergo a procedure during which I stretch your tight shoulder.

Is it done in an operating room?

No. I usually do this in the recovery room of the operating room. This affords sufficient monitoring capability to do the procedure safely.

Will I be anesthetized?

Yes. The surgery is usually done with the shoulder anesthetized. That method involves numbing nerves to the shoulder during a procedure called an interscalene block. It is common to be sedated if the surgery is done with an interscalene block. The sedation is such that most patients will take a nap during the procedure. It is also possible to do this with sedation alone, but it is quite sore afterwards.

Do I have to stay in the hospital?

No. This procedure is done on an outpatient basis.

What are the alternatives to surgery?

This surgery is done to improve function and decrease pain. Your shoulder will become flexible much, much sooner with manipulation. If you find that your pain and function are acceptable, it is reasonable to decline surgery. Almost all frozen shoulders will become flexible if enough time passes.

About Your Doctor

How many of these have you done?

I do not have an exact total. I have been performing surgery since 1981. I would estimate that I have done about 300 manipulations of the type I have suggested to you. I am a Board Certified Orthopaedic Surgeon. I have been in practice at Piedmont Orthopaedics since 1986. I subspecialize in my practice, and most of what I take care of relates to problems of the shoulder.

Risks

What are some of the things that could go wrong?

The anesthesia carries risks with it. The person who evaluates you for your anesthetic will discuss those risks with you. In general, complications from anesthesia are very, very, rare but they do exist.

How often does an infection occur?

Probably less than 1 in 10,000, since there are no incisions made.

Could I die?

No surgery is absolutely safe. It is possible that one could die from any type of operation. The death rate from this surgery is profoundly low. I would estimate that it is less than 1 in 100,000. Other major events such as heart attack or stroke are extremely rare following this type of surgery.

Will it relieve my pain satisfactorily?

I find that about 95% of patients are very happy with the result after they have completely recovered from this type of surgery.

Will I have limitations on what I can do after it is healed?

No. It is safe to pursue all activities without restriction once completely healed.

A Common Sequence of Recovery

What is involved in this type of surgery?

In preparation of surgery, you will be asked to not eat or drink for at least 8 hours prior to surgery. Specific times to stop all food and drink will be given to you by your anesthesia professional. If you are on a drug that causes blood thinning such as Plavix, Coumadin, or Xarelto, be sure to mention that to me and your anesthesiologist. It may be important that those drugs be stopped well in advance of surgery. If you have rheumatoid arthritis or lupus and are on certain drugs for those conditions, they too may need to be stopped prior to surgery.

The anesthesia personnel who evaluate you for surgery will determine what lab work, if any, is needed. On the day of your surgery, you will be asked to arrive about 2 ½ hours prior to your surgery time. After surgery is over, you will need to remain at the facility for at least 1 hour. It is okay to eat or drink as soon you feel like it after surgery. Your pain can be controlled by using the pain medication pills that I will prescribe for you. Pills will not eliminate all of the pain, but they will make it tolerable. Pain may be severe in the first few days. Pain can also be helped by the use of ice on the shoulder, sitting in an upright position as in a recliner and resting the arm in a position of maximal comfort to the side. I will probably recommend that exercises to your shoulder begin almost immediately after surgery.

What about the overall recovery from this operation? How long does it take to completely recover?

Approximately 3 months is common, but recovery times vary widely.

Will I be hurting that long?

No. Generally, within a week or two a person notices a significant diminution in their pain. They continue to gain further improvement steadily after that.

How long will I need prescription pain medication?

Most patients will use it regularly in the first week and periodically until about 3 weeks following surgery. Often by week 3, it is only used at night.

Will I have to wear a sling?

Yes. A sling is provided at the time of surgery, and the patient is instructed to use it as he or she desires for pain relief. You may stop using it as soon as you’d like.