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related talks:  rotator cuff tearbiceps tendon tear; biceps tendonitis; SLAP tear; shoulder arthritis; rotator cuff arthritis

What is Adhesive Capsulitis ("Frozen Shoulder")?

Adhesive capsulitis, better known as a "frozen shoulder" is an inflammatory condition that causes severe pain and limited motion of the shoulder.  

Frozen shoulder is a cycle where pain in the shoulder causes decreased motion (stiffness), and this stiffness causes more pain with any motion, and so the shoulder loses more motion, and now the shoulder is even stiffer...and around and around.

Its usually seen in women 40-70 years old, who experience either a minor traumatic injury or have an underlying inflammatory condition like rheumatoid arthritis. 

There are four recognized causes of a frozen shoulder.  

1) Post-traumatic stiffness and

2) post-surgical stiffness are a result of scar tissue formation and muscle contractures (muscle gets tight after not using it).  

3) Frozen shoulder is also seen as a result of endocrine disorders (especially diabetes).  

4) The last cause (it isn't really a cause) but a fancy name "Idiopathic" meaning no one knows why.  

adhesive capsulitis

A stiff and painful shoulder was coined the name "frozen shoulder" by Dr. Codman (the founder of shoulder surgery in the late 1800s) and was later described as "adhesive capsulitis" by Dr. Navisor after observing a severely thickened ("scarred") shoulder capsule in patients presenting with persistent symptoms of shoulder pain and stiffness. The underlying disease is a thickening of the joint capsule and the joint synovium (synovium is the soft tissue inside the joint which makes joint fluid - the motor oil of the joint).  

How is Adhesive Capsulitis ("Frozen Shoulder") diagnosed?

Adhesive capsulitis is diagnosed based on your doctors findings after examining your painful shoulder.  

X-rays, and MRIs will usually fail to show significant abnormalities.  

A frozen shoulder often appears very similar to Rotator Cuff Tears (for more on this, see the talk).  In both cases people complain of shoulder pain and poor shoulder motion.  But there are important differences.  A rotator cuff tear will allow for passive motion (someone else moving the arm) because the shoulder is weak and painful from the rotator cuff tear, but its not stiff.  In contrast, a frozen shoulder is stiff and will have poor motion and pain no matter who moves the arm.

Sometimes an MRI is ordered to rule out a rotator cuff tear, but the MRI will not show anything that  definitively points to frozen shoulder.  Diagnoses depends on a doctors skill at evaluating the shoulder.

How is Adhesive Capsulitis ("Frozen Shoulder") treated?

Treatment depends on the cause of the frozen shoulder, however, treatment should always begin with noninvasive treatment.  

Physical therapy is the best starting point and a lot of patients do very well, although post-traumatic and post-surgical types of frozen shoulder respond the least to therapy.  

In cases of post-traumatic or post-surgical frozen shoulder, where there is a high suspicion of scar tissue underlying the condition, the goal is to break up the scar tissue.  When physical therapy fails, the next option is manipulation under anesthesia.  Under this technique, the shoulder is moved while the patient is asleep, and the scar tissue is broken up (something that would be very painful to an awake patient).  This procedure may accidentally tear healthy tissue such as the rotator cuff, the labrum, and may even cause a fractures or dislocation of the arm bone (humerus). 

Arthroscopic (using a small camera and mini-tools) removal of scar tissue is the final option and has been shown to significantly improve pain compared to other nonoperative modalities, as well as improve range of motion.  Following surgery, patients are usually started on steroids and physical therapy to immediately start motion in the shoulder.   The shoulder can also be hooked up to a "continuous motion machine" for 4 hours a day for 2 weeks.  The focus is getting better shoulder motion, and preventing the stiffness from returning.

The unknown form of frozen shoulder ("idiopathic frozen shoulder") almost always improves with time, and will resolve on its own.  Unfortunately it can take months to go away, but persistence is key because most symptoms will resolve.  

What is the long term outcome?  

The patients usually do well as long as they approach the condition in a stepwise manner, trying a few weeks or months of physical therapy before trying anything more aggressive.

In todays fast moving world, many people are unwilling to wait months to see improvement with conservative measures.  They often opt for arthroscopic release of the stiffness.

There can be residual symptoms of mild pain and swelling after any of the above mentioned treatments.