Patient Information Guide

Frozen Shoulder Syndrome

237 Route 108, Suite 205
(Adhesive Capsulitis) Somersworth, NH 03878
Ph: (603) 742-2007
Fx: (603) 749-4605
Summary: www.sosmed.org
Frozen shoulder syndrome results when the
capsule surrounding the ball and socket joint becomes thickened and contracted by
inflammation and/or scar formation. This condition may occur secondary to
previous injury or surgery, may be related to underlying medical conditions such as
diabetes or heart disease, or may occur for unknown reasons. Progressive shoulder
stiffness results in pain and loss of function. The natural history of frozen shoulder
is generally one of gradual recovery that may occur anywhere between 3 months
to 3 years. The majority of cases resolve within 12-18 months.

The following sections will review the risk factors for this condition, typical signs
and symptoms, diagnosis and treatment options. It is important for patients to
realize that many of the prescribed treatments are not curative rather are designed
to alleviate symptoms while the disease runs its course.

Definition:
The glenohumeral joint (ball and socket joint) is surrounded by a fibrous capsule
that is reinforced with several ligaments. This capsule/ligament complex serves
several functions: 1) keep the joint water tight; 2) provide support to help hold the
ball in the socket at the end ranges of shoulder motion; 3) provide sufficient
volume to allow the shoulder to move through an incredibly wide range to position
the hand in space.

When frozen shoulder syndrome occurs, this capsule becomes inflamed, thickened
and contracted. This process dramatically affects shoulder mobility. The contracted
capsule prematurely reaches maximal stretch before the shoulder reaches its
normal end range of motion. As the capsule contracture increases, shoulder motion
decreases.

Certain types of frozen shoulder can also occur from scar tissue that develops
between the muscle layers of the shoulder joint and shoulder girdle.

Causes:
Idiopathic: This terms indicates that the cause is unknown. Idiopathic cases
account for the majority of patients presenting with onset of shoulder stiffness.

Systemic Illness: Diabetes, hyperthyroidism (overactive thyroid), cardiovascular

disease, lung disease, depression and Parkinson’s disease have all been associated
with frozen shoulder syndrome. Diabetes has the most notable association and
frozen shoulder may occur in roughly 15% of diabetic patients, particularly those
who have been on insulin treatment for greater than 10 years.

Post-operative: Shoulder surgery for conditions such as rotator cuff tear, proximal
humerus fracture, shoulder instability and arthritis may result in stiffness due to
aggressive scar formation during the healing process. Prolonged immobilization to
protect a surgical repair may lead to stiffness. Frozen shoulder syndrome has also
been reported following neck surgery, open heart surgery, and radiation therapy
for breast and lung cancer.

Post-traumatic: Shoulder or arm injury may result in a frozen shoulder from

prolonged immobilization, scar formation during tissue healing or from a
mechanical block to movement as may occur if bony fractures heal in the
wrong position.

Risk Factors: In addition to the risk factors of prolonged immobility, diabetes and
other systemic illnesses mentioned above, age and gender are also risk factors for
frozen shoulder. This condition occurs more frequently in women and most
commonly between the ages of 40-65. The average age from a large series of
patients followed with this condition was 55 years.

Stages of the Disease

Note: these phases apply only to idiopathic frozen shoulder and that which
develops from systemic illness. They do not apply to post-operative and post-
traumatic frozen shoulder.

Inflammatory Phase: this initial phase occurs over 3 weeks to 3 months and is
marked by relatively severe shoulder pain. During this phase, the capsule becomes
inflamed and the process of thickening and contracture begin. Initially, pain
predominates without significant stiffness, but gradual loss of motion ensues. Pain
at rest and night pain accompany pain with active use.

Freezing Phase: during this phase, shoulder motion continues to decrease until it
approaches a minimum range. Pain increases during this phase approaching a
plateau. The time course of freezing is variable but generally lasts between 3
months and 9 months after the onset of frozen shoulder.

Frozen Phase: this phase is characterized by fixed loss of motion that does not
increase or decrease. The shoulder remains uncomfortable during active use as
well as at night. Pain diminishes relative to the first two phases and is more
manageable. The frozen phase also varies in duration but may lasts between 6
months to a year.

Thawing Phase: Thawing is marked by gradual return in range of motion and

progressively decreasing pain. The shoulder is no longer irritable. This phase
generally begin somewhere between 1-2 years after the onset of frozen shoulder.

Symptoms and Signs

Symptoms: Progressively worsening pain without preceding injury is the typical
history of a frozen shoulder. Patients often think they have bursitis or a rotator cuff
tear because the shoulder hurts with active use. Strength is generally unaffected
but limited by pain. Increasing difficulty with daily activities including dressing and
hygiene are common complaints. Night pain and pain that awakens patients from
sleep is one of the most troublesome symptoms. Some patients have pain that
radiates into the neck, back or upper arm due to shoulder fatigue.

Signs: the physical exam of a frozen shoulder demonstrates loss of both active and
passive motion. This motion loss may be globally restricted in all ranges or may be
focally restricted in specific ranges. Loss of internal rotation (ability to put the hand
behind the back) is usually the most affected. Strength testing generally indicates
intact rotator cuff function. Rotation of the ball in the socket is smooth and without
grating as occurs in arthritis.

How is a Frozen Shoulder Diagnosed?

In straight forward cases, the patient’s history and physical exam may be all that is
necessary to make a diagnosis of frozen shoulder. If the exam raises suspicion that
the frozen shoulder may have developed secondary to another problem such as a
rotator cuff tear or fracture, X-rays may be helpful to screen for other underlying
causes. In the absence of previous injury or surgery, the X-rays of a frozen
shoulder that is classified as idiopathic or due to systemic illness are usually
normal.

Other imaging studies as MRI and arthrograms may also be helpful in ruling out
underlying causes such as rotator cuff disease. These studies may also show
capsular contracture and thickening.

What is the Natural History of Frozen Shoulder Syndrome?

Generally speaking, frozen shoulder syndrome is a self-limited process that
resolves with time. The time it will take for the disease to run its course cannot be
predicted in any one case. On average frozen shoulder syndrome lasts between 9
and 18 months. There are a few exceptions to this rule. Firstly, frozen shoulders in
diabetics behave somewhat differently: they last longer, they are more resistant to
treatment and they are more likely to recur. Secondly, post-operative or post-
traumatic frozen shoulders may not resolve spontaneously. Because the stiffness in
these cases results from actual scar tissue forming between tissue layers rather
than an inflammatory contracture of the shoulder capsule, these types of frozen
shoulder may require more aggressive treatment.

What is the Chance of Recurrence?

Idiopathic frozen shoulder has little chance of recurrence once fully resolved. The
highest chance of recurrence is for patients with diabetes. There is a 50% chance
that frozen shoulder could occur on the opposite side and a 30-50% chance that it
could return on the affected side.

How is Frozen Shoulder Treated?

The mainstays of treatment for these types of frozen shoulder are activity
modification, physical therapy and home exercises, non-steroidal anti-inflammatory
medications and patience.
 Activity Modification: patients with frozen shoulder are encouraged to remain
active and use the affected extremity. Activities which stress the shoulder
and cause significantly worsening pain, however, may increase the
inflammation in the shoulder capsule. This is particularly true in the
inflammatory and freezing phases of the disease. Trying to work through the
 pain is not recommended, and patients may have to modify their work and
recreational activities until the pain reaches a plateau
 Physical Therapy: the goals of physical therapy are as follows: 1) gently
stretch the shoulder to prevent worsening stiffness and improve mobility; 2)
decrease pain and inflammation through techniques such as ultrasound and
cold therapy; 3) gently strengthen the rotator cuff and shoulder girdle
muscles to prevent atrophy from disuse of the shoulder; 4) instruct patients
on the proper techniques for a home exercise program. We generally
recommend that patients attend a structured physical therapy program for
about 6 weeks to accomplish these goals. Physical therapy may be most
effective in the frozen phase of the disease. Overly aggressive stretching
during the inflammatory and freezing phases may actually worsen
inflammation and prolong the disease and patients should avoid trying to
work through the pain.

 Home Exercise Program: gentle stretching exercises should be performed 2-

3 times daily to prevent adhesions from reforming between therapy
sessions. As much as possible, these sessions should be performed after the
shoulder has been relaxed by a hot shower, bath, or aerobic exercise. An
important principle of the stretching exercises is to allow the muscles to
relax so that the stretch can be applied to the soft tissues without muscle
interference. Tissues of a tight shoulder do not like to be stretched suddenly,
roughly, or with a lot of force. Thus the strategy is to apply a gentle stretch
so that at most minimal soreness results. Any soreness should go away
within 15 minutes after you stop the exercises. Improvement in the range of
motion and comfort may not begin until six weeks of persistence with the
program. One should not stop these exercises until the frozen shoulder has
regained normal motion and comfort.

 NOTE: Many patients will have engaged in previous program of physical

therapy but may have failed to improve. Often, the programs have focused
on muscle strengthening exercises for a presumed diagnosis of rotator cuff
tendonitis or impingement syndrome. Little emphasis will have been placed
on a thorough and comprehensive flexibility program, and muscle
strengthening may actually increase shoulder pain in the early phases of the
process. Our repeated observation is that may patients who have failed
previous physical therapy will benefit from further treatment once the
appropriate diagnosis has been established and the exercises focused on
stretching rather than strengthening. This in combination with a properly
performed home exercise program will often provide substantial benefit with
time and persistence. Most importantly, patients must recognize that
recovery of motion is a slow process. One should not give up if immediate
and early gains are not seen

 Non-steroid Anti-inflammatory Medications (NSAIDS): these medications

include Ibuprofen, Motrin, Advil, Naprosyn, Alleve, Bextra, Celebrex, and
many others. They act both to reduce inflammation and to relieve pain. They
may be more effective in the early phases of frozen shoulder syndrome
when the shoulder capsule is inflamed. Once the inflammatory process has
 plateaued and patients reach the frozen phase, these medications are not
likely to have significant benefit. Long term use of NSAIDS may be
associated with risks such as irritation of the stomach lining, ulcers and
kidney problems. Patients should become informed about the possible short
and long-term side effects of each medication prior to use.

 Other Medications: Narcotic pain medications, muscle relaxants and sleeping

pills are generally not recommended for frozen shoulder syndrome as
prolonged use may diminish their effectiveness and may cause medication
dependence or even addiction.

Other non-operative treatments for frozen shoulder syndrome include cortisone

injections into the shoulder joint, nerve blocks, and acupuncture.

 Cortisone Injections: Cortisone is a powerful anti-inflammatory medication

that can be injected directly into the shoulder joint so that it acts locally on
the inflamed shoulder capsule. As with oral medications, it may be most
effective in the inflammatory and freezing phases of the process which are
dominated by inflammation. Occasionally, 2-3 shots spaced over several
months may be necessary to have an effect. The results of this treatment
are variable and some patients do not respond. Nevertheless, cortisone
injections remain a reasonable alternative in patients with moderate to
severe discomfort whose quality of life is significantly affected by the
disease. The injections are generally well tolerated and have minimal side-
effects. In patients with diabetes, cortisone shots may temporarily elevate
the blood sugar and careful glucose level monitoring is recommended for the
first few days after treatment.

 Nerve Blocks: the suprascapular nerve supplies sensation to the shoulder

capsule. There is growing evidence that blocking this nerve with a series of
injections may help alleviate some of the discomfort of frozen shoulder.
These injections are performed by the anesthesiologists who use a device
called a nerve stimulator to target the injection into the proper location.
Nerve blocks are not a cure for frozen shoulder. Rather, their purpose is to
reduce the effect of shoulder discomfort on the patient’s quality of life and
facilitate a home exercise program.

 Acupuncture: This is an ancient medicinal art that uses needles inserted into
the body at points along the meridians just under the skin. These needles
stimulate, disperse and balance the flow of energy, relieve pain, and treat a
variety of chronic, acute and degenerative conditions. There is anecdotal
evidence that acupuncture may be helpful in managing the pain associated
with frozen shoulder. As with most other treatments, however, acupuncture
is not a cure and does not necessarily shorten the course of the disease.

Who Should Consider Surgery

Surgery may be considered if a concerted effort at non-operative treatment has
failed to result in improvement in comfort and function after 6-9 months. Surgery
is entirely elective. The decision should be based on how frozen shoulder syndrome
affects a person’s quality of life and one’s tolerance for waiting out the process.

Surgery should be performed during the frozen phase of the disease process.
Surgery performed during the inflammatory or freezing phases is likely to fail with
recurrence of shoulder pain and stiffness. If patient’s have reached the thawing
phase, surgery is not indicated as resolution can be expected with further non-
operative treatment.

Patients with post-operative, post-traumatic and diabetic frozen shoulder may be

more likely to require to surgery as the chance of spontaneous resolution is less for
these types of frozen shoulder. In post-operative cases, surgery should generally
not be performed until 4-6 months after the original operation to minimize the risk
of further injury to healing tissues.

The success of surgery can be maximized if patients are motivated and committed
to the recovery process. Thus, one should not consider this course unless a
substantial allotment of time and effort can be devoted to the goal of a comfortable
and functional shoulder. The gains made at surgery are otherwise easily lost

What Does Surgery Entail?

In cases of idiopathic frozen shoulder and in some post-operative and post-
traumatic cases, a manipulation under anesthesia may be all that is necessary to
free up the stiff shoulder. This procedure involves putting the patient to sleep both
to block pain and provide muscle relaxation. The shoulder is then forcefully
stretched in all directions. This process usually tears the contracted shoulder
capsule and any adhesions that have formed between the joint surface and muscle
layers. Following the manipulation, cortisone is injected into the shoulder joint to
hinder further post-operative scar formation and aid in post-manipulation pain
relief.

In some instances, if the scar tissue is too thick, a manipulation under anesthesia
may not succeed in restoring shoulder motion. In these cases, an arthroscopic
surgery is required to cut and resect portions of the capsule that are too contracted
to respond to manipulation. This surgery is called an arthroscopic capsular release.
Once the capsule has been released, the shoulder is manipulated again until full
motion is achieved. Arthroscopic surgery has the advantage of looking inside the
joint so that any other problems can be assessed and treated if necessary.

Patients with a diabetic frozen shoulder always require an arthroscopic capsular

release in addition to a manipulation under anesthesia. This is not because the
capsule is overly contracted, but because the recurrence rate after manipulation
alone is unacceptably high. By removing portions of the shoulder capsule, the
likelihood of recurrence is reduced.

In many cases, an implantable pain pump is inserted into the shoulder joint. The
pump delivers numbing medication at a slow and steady rate to provide pain relief
for 48 hours following the operation. This extended window of analgesia facilitates
early range of motion and helps reduce muscle spasms. Once the pump is empty,
the patient removes the tubing from the shoulder and discards the pump system.

What Does Recovery Involve?

Recovery from a manipulation under anesthesia with or without an arthroscopic
capsular release involves immediate range of motion exercises to prevent recurrent
stiffness. Slings are highly discouraged as they only promote stiffness. There are
no specific restrictions as far as lifting, pushing, pulling or using the arm for other
activities. Generally, the shoulder may be sore for a few weeks following surgery
and overly aggressive use of the extremity is discouraged so that the shoulder
does not become inflamed.

We routinely employ continuous passive motion machines for two weeks after
surgery for frozen shoulder. These machines are set up in the patient’s home and
take the arm through a range of motion at a controlled rate. Because the machine
does the work of the muscles, passive motion facilitates muscle relaxation and
improves early motion. This is critical to preventing adhesions from forming
between tissue planes. Patients are instructed on how to use these machines prior
to surgery so that when they return home from the hospital they may immediately
start the process. Generally, the CPM machine should be used 3-4 times per day
for 45-60 minutes each session.

Non-steroidal anti-inflammatory medications and ice are useful modalities to

reduce pain and swelling and also discourage scar tissue formation. Patients who
can tolerate NSAIDS are encouraged to use them for a period of 3 weeks following
surgery. Ice should be used following CPM and exercise sessions for 20-30 minutes
at a time.

Patients are encouraged to attend outpatient physical therapy following surgery in

addition to a daily home exercise program to maintain shoulder flexibility. The
home exercises are critically important as formal therapy sessions may only be
scheduled 2-3 days per week. The propensity to form new scar tissue exists for at
least 6 weeks after both manipulation and arthroscopic capsular release. Thus, a
maintenance flexibility program is essential we after surgery

Potential Risks and Complications of Surgery

The risks of surgery include, but are not limited to, infection, damage to nerves
and blood vessels, fracture of the humerus, instability of the shoulder joint,
recurrent stiffness and complications related to anesthesia. While these risks and
complications are infrequent, they can occur in anyone. Patients should consider
these when electing to undergo surgery. Any one of these problems can limit the
outcome of the procedure.