Martin R. Coleman, MD
Treating shoulder pain is what I do every day at OSC. I see folks who have developed arthritis due to aging, those who have sustained severe injuries in accidents and those whose pain just suddenly appears, seemingly without cause. One of the more “mysterious” ailments which I treat is Frozen Shoulder Syndrome, a.k.a., Adhesive Capsulitis. In this article, I will talk about the causes, which patients affected and what treatments are available to treat Frozen Shoulder Syndrome.
Let’s say you are a middle-aged woman who has had to have some sort of surgery which requires you to be relatively immobile for several weeks during your recovery period. After a few weeks of greatly reduced activity, you may notice that your shoulder is tender and hurts when you move it. While puzzling, you shrug this off as a side-effect of the surgery and assume you will soon feel better. Although you soon get back to your normal level of activity, you continue to hurt and the pain increases when you move your shoulder. After a few more weeks, your shoulder is extremely achy and is becoming more stiff, even resistant to movement. You probably are taking some OTC pain reliever and trying to put ice or heat on your shoulder to alleviate the discomfort. As more time goes by, the pain starts to lessen, but you find that your shoulder is very difficult to move and that your range of motion is limited, even when someone tries to help you move your shoulder. You start to worry and decide to see a physician. This is one of the ways that frozen shoulder syndrome may develop and would be a scenario that I could see in my practice.
We really don’t know why Frozen Shoulder Syndrome (FSS) develops. For some reason, the normally strong and healthy tissue that surrounds our shoulder joint, called the shoulder capsule, becomes stiff, thick and inflamed. Less synovial fluid may be produced to lubricate the shoulder joint. The tissue may form adhesions, which are like little knots in the tissue. Pain and stiffness ensue and finally immobility. We do know that women develop it more often than men, it tends to strike in middle-age, and that folks who have diabetes, cardiac issues, or over or under- active thyroids are more prone to its development. We also know that there is a correlation to FSS with forced immobility, such as when a person needs to keep relatively still to recover after a surgery or an injury.
The symptoms of FSS are straightforward. As mentioned in our scenario above, the progression of symptoms after onset is fairly typical for each patient. There are 3 stages to the condition: Freezing, Frozen and Thawing, each with its own hallmark symptoms. Freezing is the beginning stage of the disease, where pain and discomfort increase and this can take anywhere from 6-9 months. The Frozen stage is shorter in duration (4-6) months and is usually less painful, but the shoulder limited in its range of motion. The Thawing stage happens during the recovery period, is slow (6 months to 2 years), and is when strength and the range of motion is regained.
How do I treat someone with FSS? Obviously, that will depend on what stage of the disease they are in, the physical examination that I perform and their range of motion test results. I will ask the patient to move the arm/shoulder under their own power (active range of motion) and then I will move their arm/shoulder for them (passive range of motion). In each of these tests, I expect to see limited range of motion. I may order x-rays, but mostly to rule out other causes of pain, such as arthritis. X-rays are great for visualizing bone, but not for soft and connective tissue problems. An MRI is usually not ordered unless I suspect that the patient also has a rotator cuff issue and need to confirm that diagnosis.
The good news is FSS can be treated and it will get better. The bad news is that it can take several years and can require the patient to be diligent about range of motion exercises. Most cases do not require surgery and are treated conservatively with OTC drugs like Aleve or Ibuprofen, Steroid injections into the shoulder joint and a specific Physical Therapy program designed to increase range of motion. Most patients will recover from FSS by using these treatments.
A small percentage of patients will need to have surgery to remedy their FSS. This involved either manipulation under anesthesia, arthroscopic surgery of the shoulder or both. Manipulation under anesthesia, involves putting the patient to sleep, while I go in and manually force the tight shoulder capsule to move. This stretches or tears the scar tissue that has developed and allows the patient to move their arm and shoulder freely. While that sounds unpleasant, it is actually very effective and the patient feels no pain while under anesthesia. Often, I will also perform arthroscopic surgery to surgically cut through some of the tightest bands of the shoulder capsule. I do this through several very small incisions in the shoulder, into which a place a camera and my surgical instruments.
Recovery time tends to be lengthy and as I mentioned before, it is imperative that the patient work to maintain and improve the range of motion attained through surgery. While some patients will have some residual pain and loss of motion, most are pain free and regain all their range of motion. Patients with diabetes can have a recurrence of FSS, so it is especially important for them to be vigilant about their exercises.
Martin R. Coleman, M.D. is a board- certified Orthopaedic Specialist with Orthopaedic and Spine Center in Newport News, Virginia. His area of specialty is the treatment of shoulder injuries and arthritis, with a focus on Traditional and Reverse Shoulder Replacements. To make an appointment, please call 757-596-1900.