Waiting it out is the best option for this common shoulder problem

When you find it’s becoming harder to move your arm in any direction, and your shoulder hurts, you may have a fairly common affliction: adhesive capsulitis, also known as frozen shoulder.

“Sometimes I see two or three newly diagnosed patients a day,” said Falmouth Orthopedic Surgeon Donald E. O’Malley, MD. Those don’t include patients he sees for follow-ups on the condition, he added.

Frozen shoulder occurs when the capsule of connective tissue surrounding the ball and socket joint of your shoulder becomes thicker and stiffer, making motion difficult, according to the American Academy of Orthopaedic Surgeons. An estimated 2-5 percent of the population has the condition, says the National Library of Medicine. Women reportedly are affected more often than men, but Dr. O’Malley said that may be because women more often seek medical treatment than men. While it mainly strikes people age 40-60, “I’ve seen it in 30-year-olds,” he said.

Diagnosis

There’s no diagnostic test for frozen shoulder. Health history and a physical exam determine the diagnosis. People with frozen shoulder will have stiffness moving their affected arm in all directions, as opposed to someone with an injury that causes pain in a specific plane of motion, Dr. O’Malley said. Most cases get labeled idiopathic, with no known cause. A smaller number occur following shoulder surgery, such as a rotator cuff repair, or trauma from an injury or accident.

While the cause of frozen shoulder is unknown, evidence suggests it may be an autoimmune reaction, with the body’s immune system attacking the stretchy protein elastin in the capsule, Dr. O’Malley said. It’s a mystery why the problem happens just in one shoulder, he added.

“Families with a history of autoimmune disease … it is seen in about 60 percent of patients,” he said. Autoimmune diseases include lupus, rheumatoid arthritis and Sjogren’s syndrome. Also associated with the condition is having certain diseases, including diabetes, thyroid disease and hypertriglyceridemia, or taking Dilantin (phenytoin) for a seizure disorder, Dr. O’Malley said.

Treatment

Frozen shoulder progresses through three phases, according to the American Academy of Orthopaedic Surgeons:

• Freezing – shoulder becomes stiffer and pain increases for a period ranging from six weeks to nine months.
• Frozen – pain abates, but not stiffness, for the next four to six months.
• Thawing – shoulder gradually recovers range of motion over a span of six months to two years.

Dr. O’Malley said he typically sees new frozen shoulder patients during the freezing phase. He starts them on oral steroids to reduce pain and inflammation. He may also order a prescription-strength NSAID, such as meloxicam.

“Inflammation causes scar tissue,” which contributes to stiffness of the joint capsule, he said. He may inject the joint with a steroid if the patient hasn’t improved at a follow-up visit about four weeks later.

In addition to medication, Dr. O’Malley instructs patients how to increase shoulder motion through gentle pendulum exercises. Some orthopedic surgeons order physical therapy for frozen shoulder patients, he said, but he avoids it as more vigorous exercise may cause micro-tears in the capsule. Patients will not improve if they keep re-injuring the joint.

Treated or not, the condition usually fades away in about two years, though some cases last longer.
“Ninety-nine percent of cases resolve,” Dr. O’Malley said. “The remaining 1 percent we have to look for a reason for not resolving.”

Surgical Solutions Falling Out of Favor

Among surgical options are:

• Arthroscopic capsular release – cutting the stiff portions of the capsule and shoulder ligaments.
• Manipulation under anesthesia – manually rotating the arm while the patient is unconscious.
• Hydrosilation – injecting the joint with a large amount of saline solution.

“I used to do joint release years ago,” Dr. O’Malley said. “Nine out of 10 ended in worse pain. I stopped doing them.”

Both manipulation under anesthesia and hydrosilation use force to free up the arm, which injures tissue, he said. Manipulation can fracture the humerus (upper arm bone), according to the National Library of Medicine. Hydrosilation can cause neuropathy of the axcillary nerve that runs through your shoulder, Dr. O’Malley said.

“You’re tearing the capsule,” he said of those two procedures. “When you tear anything in the body, you cause scar tissue.”

Surgery may be necessary to help patients whose condition resulted from injury or trauma, but Dr. O’Malley said he never does surgery for idiopathic adhesive capsulitis.

“Just wait it out, it’s going to get better,” he said.