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Frozen Shoulder

Symptoms

‍Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. The condition affects the glenohumeral joint (ball and socket joint) and occurs in about 2% of the population and most commonly affects mid-aged people. The hallmark is a normal joint with inability move the shoulder due to adhesions. Most people have a very painful shoulder and report constant pain, inability to sleep on the shoulder, and loss of motion, particularly with reaching behind and overhead.

Causes

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. Most cases occur without an injury.

A few factors that may put you more at risk for developing frozen shoulder are:

‍Diabetes: Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

‍Other Conditions: Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson’s disease, and cardiac disease.

‍Injury: Frozen shoulder can sometimes develop after a shoulder injury such as a fall with or without a fracture.

Treatment

In the majority of cases (>80%) frozen shoulder resolves with conservative treatment. Without treatment it can take 1-2 years to resolve and while motion typically returns in some chronic cases permanent motion loss can occur. Once frozen shoulder occurs in a shoulder it typically does not come back. However, it can occur in the other shoulder and even occasionally affects both shoulders at the same time. In most cases the rotator cuff is intact. Because of this an MRI is rarely needed and is not ordered unless symptoms are not improving.

Treatment options include:

Medications: Anti-inflammatories such as ibuprofen (Motrin or Advil) and naproxen (Aleve) are used to reduce pain and inflammation. Occasionally, oral steroids such as prednisone can also be used. The max does for ibuprofen is 800 mg three times per day. The max does for naproxen is 500 mg twice daily. Prolonged usage should be avoided and these should be taken with food since they can affect the stomach lining. If one experiences an upset stomach these should be stopped.

‍Injection: Studies show that injection of steroid (cortisone) into the glenohumeral joint shortens recovery and lead to a better outcome at 1 year compared to stretching alone. One of the keys is the location of the injection. Most non-orthopaedic providers place an injection into the subacromial space between the rotator cuff and acromion bone when they do an injection. However, the proper location of an injection for frozen shoulder is into the shoulder joint itself which lies beneath the rotator cuff. I perform glenohumeral joint injections with an ultrasound machine. This allows direct visualization of the joint and improved accuracy of the injection. Up to 3 injections are performed at monthly intervals, but often less than 3 are required.

‍Stretching: The mainstay of treatment is daily stretching. Consistency is the key with stretching 2 to 3 times per day. The most essential stretches are provided at the end of this document.

‍Surgery: In the event that frozen shoulder does not resolve with conservative care, surgery is an option. This is typically considered if symptoms are not improving after 4 to 6 months of conservative treatment. I perform a direct release of the adhesions with a shoulder arthroscopy. This procedure requires general anesthesia, takes about 30 minutes to perform, and patients go home the same day. Two to three small incisions are made in the shoulder, a scope is inserted, and the adhesions are directly released. The long-term outcome of this procedure is very good and the risk of complication is very low. While immediate gain in motion occurs, full recovery still takes 4 to 6 months. Physical therapy should be started immediately after the procedure and I ask my patients to attend PT three times per week for three weeks in addition to daily stretching.

Some surgeons perform a “manipulation under anesthesia” alone. The problem with this approach is iatrogenic injury may occur such as fracture or rotator cuff tear. I believe it is safer to perform a direct release with a scope.

Rotator Cuff Tear Symptoms

The rotator cuff is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor). The rotator cuff surrounds the ball and socket joint (glenohumeral joint) and provides stability to the joint as well as movement. Because the shoulder is a shallow joint and the most mobile joint in the body, it requires the rotator cuff for stability. If let untreated tears can lead to arthritis of the shoulder (rotator cuff arthropathy). This doesn’t mean that good function can’t be maintained with a tear. In fact, many people are able to maintain function despite a tear because the shoulder remains balanced with the remaining rotator cuff and other muscles that control shoulder movement.

Muscle inserts into bone via tendon. In the vast majority of cases, when a tear occurs the tendon pulls away from the bone. Broadly speaking, tears are classified as partial or full-thickness. Partial tears go part way through the tendon while full-thickness tears represent complete detachment. Frequently, an MRI will report “partial-tearing.” Since most people over the age of 40 to 50 have some changes within the rotator cuff, partial tears usually not a problem. The distinction with partial tears is when the tears are considered “high-grade,” meaning that they go almost all the way through the tendon.

Causes

Rotator cuff tears may occur after an injury or repetitive activity over time, but most cases occur without an injury. As we age the rotator cuff tendon degenerates and age and genetics are the greatest risk factors for a tear. Studies show that about 50% of people over the age of 65 have a full-thickness rotator cuff tears. Most of these people don’t even know they have a tear!

Treatment

Treatment for rotator cuff tears is based on age, health, and response to conservative treatment. The rotator cuff tendon is not capable of repairing itself. Rather then tear will stay the same size or enlarge over time. In people under the age of 60, the risk of progression is about 50% in a two-year period. The ability to get healing with a surgical repair depends upon age, the tear size, muscle atrophy, associated arthritis, and health (smoking and diabetes for instance). One must also consider timing of repair. Traumatic tears have a better outcome if fixed within 6 months of injury. Additionally, after about six months of symptoms atrophy may occur. Unfortunately, atrophy of the rotator cuff is not considered reversible. Based on this, if someone desires repair, I typically recommend performing this within six months of beginning treatment.

Guidelines for surgery are general and must be individualized as noted above. But, as a general guideline, I recommend repair for all full-thickness tears in people under the age of 60 given the risk of increase in tear size. For people between the ages of 60 and 70, treatment is based on the above factors with health and activity expectations being the most important factors. For people over the age of 70, I nearly always recommend an attempt at conservative treatment. Surgery is then considered if one does not respond to conservative treatment.

For partial tears, conservative treatment should almost always be attempted first since these tears progress slowly or may not progress at all. Then surgery is considered if one does not respond to 4 to 6 months of conservative treatment.

Treatment options include:

Medications:

Anti-inflammatories such as ibuprofen (Motrin or Advil) and naproxen (Aleve) are used to reduce pain and inflammation. The max does for ibuprofen is 800 mg three times per day. The max does for naproxen is 500 mg twice daily. Prolonged usage should be avoided and these should be taken with food since they can affect the stomach lining. If one experiences an upset stomach these should be stopped.

Injection:

Injection of a steroid (cortisone) may be used to provide pain relief and facilitate physical therapy. I perform these injections with an ultrasound machine. This allows direct visualization of the joint and improved accuracy of the injection. Up to 3 injections over a 2 year period are allowed. Beyond this there are typically diminishing returns and excessive injections may be detrimental to the rotator cuff.

Alternative injections include Toradol (an anti-inflammatory agent similar to ibuprofen), prolotherapy, or platlet-rich plasma (PRP). ). I use Toradol in people who do not tolerate steroids. Prolotherapy involves injecting a substance such as sugar into tissue to “stimulate a healing response.” I do not perform prolotherapy as it has not been shown to improve symptoms in rotator cuff tears. PRP involves taking a small amount of blood from a patient, spinning in a centrifuge to separate the growth factors from the red blood cells, and then injecting the growth factors back into the shoulder to potentially decrease pain. While PRP has anti-inflammatory properties, it has not been shown to heal the rotator cuff. Therefore, it is not covered by insurance and is an out-of-pocket expense. Typically a series of 3 injections are performed at weekly intervals for 3 weeks.

Therapy:

‍Physical therapy with strengthening is one of the mainstays of treatment of rotator cuff tears. Long-term studies show that despite not healing the rotator cuff, therapy can lead to substantial improvements in function with good patient satisfaction. The core exercises in strengthening the rotator cuff are provided at the end of this handout. These exercises can be performed twice per day, 5 days a week.

Surgery:

Most tears, regardless of size can be repaired. I perform all my rotator cuff repairs arthroscopically. This is less invasive and therefore less painful than an open incision. It also allows a better view of the rotator cuff. This procedure requires general anesthesia, takes about 60 to 90 minutes to perform, and patients go home the same day. Small incisions are made in the shoulder, a scope is inserted, and the rotator cuff is repaired with anchors. Anchors are essentially headless screws which are placed flush with the bone. These anchors have sutures that are used to bring the tendon done to the bone so that the tendon can heal to the bone. The long-term outcome of this procedure is very good (>90% success in most cases) and the risk of complication is very low (1/5000 chance of infection). However, repair requires a long recovery period and the tendon takes about 12 weeks to heal into the bone. Therefore, a sling is worn for 6 weeks after surgery. Specific motion exercises afterwards are tailored to the tear pattern (patient-specific). The sling is removed at 6 weeks and motion is progressed. Strengthening is allowed at 12 weeks, followed by gym activities at 4 months. Full recovery takes 6 months for small tears and 12 months for large or massive tears.