Frozen Shoulder

The ball is held in the socket by ligaments and by the rotator cuff tendons. To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

The shoulder capsule is the collective name for all of the ligaments that surround the shoulder joint. The capsule provides stability for the shoulder while allowing for an incredible range of motion of the shoulder joint.

As frozen shoulder develops, the shoulder capsule thickens and becomes stiff and tight. Stiff bands of tissue (adhesions) form, and in many cases, there is less synovial fluid in the joint. The hallmark sign of a frozen shoulder is stiffness that does not respond to stretching.

There are three stages of frozen shoulder:

1. In the freezing stage, you slowly have more and more pain. As the pain worsens, the loss of range of motion increases. Freezing usually lasts from 6 weeks to 9 months.
2. In the frozen stage, your pain symptoms may improve, but the stiffness remains. This stage typically lasts 4 to 6 months, and during this time, daily activities may be quite difficult.
3. Shoulder motion slowly improves in the thawing stage. Return to normal or close to normal motion and comfort typically takes anywhere from 6 months to 2 years.

In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

The causes of frozen shoulder are not well understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder, however, many cases of frozen shoulder occur without a known cause.

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 diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or another injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to try to prevent frozen shoulder.

Symptoms associated with frozen shoulder include:

• Dull or aching pain with shoulder or arm motion
• Pain located over the outer shoulder area and sometimes the upper arm
• Limited range of motion
• Shoulder stiffness and tightness
• Limited shoulder function and strength secondary to pain

Medical History. Dr. Jurek will review your medical history and shoulder symptoms with you.

Physical Exam. Dr. Jurek will examine your shoulder and move it carefully in different directions to see if movement is limited and if pain occurs with the motion. She’ll check if you have limited range of motion both actively and passively, which is the hallmark finding of frozen shoulder. Active range of motion refers to you moving your shoulder on your own, and passive range of motion refers to Dr. Jurek moving your shoulder for you.

Imaging Tests. Dr. Jurek may order imaging tests to help rule out other causes of stiffness and pain in your shoulder. These tests may include:

• X-Ray. X-rays show clear images of dense structures such as bone and may show other causes of limited range of motion in your shoulder, such as arthritis.
• MRI and Ultrasound. These studies provide clear images of soft tissues and may identify other problems in the shoulder, such as a torn rotator cuff.

Frozen shoulder generally resolves over time, although it may take up to 3 years.

The focus of treatment is to control pain and restore motion and strength through gentle exercises or physical therapy.

More than 95% of patients improve with time and simple treatments to help control pain and restore motion.

Non-steroidal anti-inflammatory medication. Drugs like Motrin, Aleve, and Ibuprofen help reduce pain and swelling.

Heat. A heating pad or warm shower generally helps to reduce the pain associated with a frozen shoulder.

Steroid injection. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint to help relieve the pain caused by a frozen shoulder. Dr. Jurek will discuss if this treatment is a good option for you.

Gentle exercises/physical therapy. These may be a home exercise program or exercises performed under the supervision of a physical therapist. Heat may be used to help loosen the shoulder up before the stretching exercises. Below are examples of some of the exercises.

• External rotation — passive stretch. Stand in a doorway and bend your affected arm 90 degrees to reach the door jamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

• Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.

• Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

It is rare that surgical treatment of frozen shoulder is necessary but if your symptoms persist despite time and adequate nonsurgical treatment, Dr. Jurek may discuss surgery with you. The goal of surgery for a frozen shoulder is to release the stiffened joint capsule to regain a permanent full range of motion of the shoulder.

Shoulder Arthroscopy: Capsular Release With Manipulation. In this procedure, Dr. Jurek will cut through tight portions of the joint capsule using pencil-sized instruments inserted through small incisions around your shoulder. This allows precise cutting without risking injury to the surrounding structures. Following the cutting of the tight portions of the joint capsule, a gentle manipulation maneuver will be performed to completely release the tightening and increase range of motion. Intensive physical therapy following the procedure is required to maintain the increased range of motion gained during surgery. Most patients have very good outcomes with this procedure.

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining caused by frozen shoulder (right).

Physical therapy after surgery is necessary to maintain the motion that was achieved with surgery. Recovery time can vary from 6 weeks to 3 months. Commitment to daily range of motion exercises after surgery is the most important factor in achieving an optimal outcome.

Long-Term Outcomes After Frozen Shoulder Surgery
Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion. In some cases, however, even after several years, the motion does not return completely and a small amount of stiffness remains.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present. The risk for someone with a frozen shoulder eventually developing frozen shoulder in the other shoulder is approximately 35%.

If you would like to schedule a consultation with Dr. Jurek for frozen shoulder treatment, please call (206) 386-2600. You may also request an appointment online.