The shoulder is one of the most common joints that I treat with a variety of diagnoses. One of the most challenging shoulder problems to take care of for patients is adhesive capsulitis. It is a challenge for the entire team including: patient, medical providers, surgeons, physical therapists and rehab experts who take care of these patients. Adhesive capsulitis is the medical term better known as “frozen shoulder.”

The shoulder is a “ball and socket” joint, but the socket is not very deep. It therefore relies on stability from the surrounding structures. The most important of these is the capsule. The capsule is the casing around the joint that is somewhat analogous to the “casing when you rip a drum stick off a turkey.” This capsule is normally relatively thin, but fairly strong. It has several thickenings in it which are considered ligaments (the glenohumeral ligaments). The shoulder joint is one of the most mobile joints in the body. The capsule normally has an elasticity to it that allows for the extensive range of motion that the shoulder joint is able to exhibit.

A patient can develop adhesive capsulitis for a number of reasons. One of the most common is what is called insidious onset. Insidious basically means that there is no known underlying cause. Many times, even though it seems insidious, it can be traced back to a minor injury, aggravation, tendinitis, bursitis, immobilization or something that caused the patient to develop pain in the shoulder joint. Diabetes, thyroid disease and female gender have also been linked as risk factors. There are times when a patient had a more “major” injury such as a rotator cuff tear/labral tear/dislocation, etc. Whatever the trigger may be, it starts a vicious cycle that can be described in the following way:

The patient has pain in the shoulder and therefore doesn't move it quite through the same extremes of range of motion they normally would because of the pain. This self limitation of motion causes the shoulder to begin stiffening. The capsule thickens and tightens up little by little. As the shoulder gets stiffer it becomes more and more painful. The more painful it gets, the less the patient uses it. The less the patient uses it, the stiffer it gets. The stiffer it gets, the more painful it gets. The cycle continues onward with more pain and less range of motion or mobility.

Thus leading to the vicious cycle of a “frozen shoulder.”

Joints are meant for movement, especially the shoulder, and if they are not or cannot be moved they tend to get stiff from the capsules losing their elasticity and thickening up. The capsule goes from a consistency of almost a rubbery silk to a thickened piece of leather. This can be a very painful condition as any patient who has ever had it will tell you.

It can also be extremely frustrating because the only way to get motion back in a joint is to manually stretch it out. Even gradual stretching can cause a significant amount of pain. The other very frustrating part of this process is that it can take a very long time to improve and resolve with conservative treatment such as physical therapy.

Likely the greatest frustration for patient, provider and rehabilitation specialist is the time commitment required to treat this condition. This does not take days or weeks to resolve; it usually takes months. There have even been published studies in diabetics that show it can take up to two years to fully regain full range of motion of a shoulder. Diabetes is one of the more common risk factors for adhesive capsulitis, though it is not fully understood as to why.

Often patients will not believe the provider when told what the diagnosis is and what the course of treatment entails. They can't believe that it will take as long to recover as they are told. There are times when people even leave and go elsewhere for other treatment because they can't believe that something like this, which causes so much pain and takes so long to get better from, cannot be “cured easily.”

Unfortunately, there is no quick fix for adhesive capsulitis. Heat and warm showers while working on range of motion can help. Pain medications, muscle relaxants and occasionally cortisone shots can also help some, but there is no substitute for the physical therapy to get the range of motion back. Most orthopedic surgeons try to exhaust all conservative measures and utilize physical therapists who are very patient in taking care of this type of problem. There are surgical ways to treat adhesive capsulitis if all conservative efforts have been exhausted, but they do have risks. A manipulation under anesthesia can be performed. A manipulation under anesthesia is when the patient is taken to the Operating Room, placed under general anesthesia and then the surgeon literally, forcefully manipulates, stretches, pushes, pulls on the shoulder to obtain range of motion back. To some, it can be a fairly “grizzly” procedure in that often times multiple pops, snaps, tears and rips can be heard and felt (along with multiple oohs and ahhs by the anesthesiologist and operating room staff). While the majority of time this forcibly allows the patient's shoulder to get back to “normal” range of motion, there are potential complications such as, but not limited to: fracture; dislocation; tearing of muscles/tendons/ligaments, etc.

Another concern is that when the patient wakes up they are usually still in a lot of pain and their brain also “remembers” where the shoulder was prior to the manipulation making it still very hard to get the range of motion back. Many surgeons will also perform an arthroscopy to try to shave away some of the scar tissue and adhesions and maybe even do some releases of the thickened capsule to loosen it up. Even in that case, the bottom line is still that the biggest correlation with post op range of motion is pre op range of motion.

So, even if the shoulder is manipulated under anesthesia and “cleaned up” arthroscopically, if the patient did not have their motion back prior to the surgery, many times they can still have difficulty and/or not get it back after the surgery. Patients can even sometimes end up doing worse because of these factors.

Therefore, even if a patient has an underlying pathology such as a rotator cuff tear, labral tear, etc. it is best to get all of the range of motion back prior to surgery.

This may seem like a “doom and gloom” article. The truth is that adhesive capsulitis is a painful limiting condition that takes a long time to recover from. There are no short cuts and the truth can hurt.

There is good news however. Despite the lengthy time involved to treat it and the significant pain, the vast majority of people do get better. When they do get better, these are some of the happiest and most appreciative patients.

So, in review, adhesive capsulitis is a difficult problem to deal with. The good news is that it is not a “death sentence” and the vast majority of time it can be treated conservatively. Patience, experience, clinical skill and shoulder rehabilitation with physical therapy are all required. The earlier treatment is sought, the quicker it can be “nipped in the bud” by physical therapy and the quicker the patient will recover from the pain and normalize their range of motion.

Dr. Marc P. Pietropaoli is a board certified/fellowship trained orthopedic surgeon/sports medicine specialist and is president of Victory Sports Medicine & Orthopedics in Skaneateles