That’s the difference between golf and many other sports. You go
to some sporting events, they just leave you or give you the cold shoulder
and move on. ~Bernhard Langer
In the medical field, there are an innumerable eponymous conditions or
signs usually named after the physician who first described them. Some
orthopedic terms are humdingers: Apley’s grind test, Babinski sign,
Barlow’s maneuver, Osgood-Schlatter disease, Lachman test, and Sever’s
disease, just to name a few. There are also symptoms that pantomime a
certain noun or verb such as the hornblower’s sign, chauffer’s
sign, and the empty can sign. While performing a good physical exam, a
physician may observe these signs, thereby helping with a diagnosis. One
of the issues that I see in patients on a regular basis doesn’t
have any funny names, but it does have a recognizable mantra that I think
every attending physician has taught every resident who has told every
patient diagnosed with adhesive capsulitis who ever walked into a doctor’s
office. This is a condition known as frozen shoulder. Believe me, you
would way rather someone gave you the cold shoulder than have one that
is frozen. Why is it called frozen shoulder? Because when someone gets
adhesive capsulitis, the shoulder will go through three phases (hence
Freeze, Frozen, Thaw.
Frozen shoulder is a condition of insidious onset that causes progressive
pain and stiffness in the shoulder. Once the shoulder becomes “frozen,”
it is extremely hard to move. It usually affects people between the age
of 40 and 60, and in my patient population it seems more common in women
than men. The causes of frozen shoulder are poorly understood. In the
majority of cases, there is no identifiable cause. Occasionally, a trauma
or even prolonged immobilization due to surgery can be the inciting factor.
There is a higher propensity of frozen shoulder in diabetic patients.
Other medical conditions associated with frozen shoulder include hypothyroidism,
Parkinson’s disease and cardiac disease. Consequently, these patients
are usually slower to improve and have a greater chance of needing surgical
intervention to correct the problem.
I always like to review a little anatomy to confirm a patient has a basic
understanding of the body when I start describing the disease process
and treatment options. The shoulder is basically a ball-and-socket joint
like the hip. It consists of three bones: the upper arm (humerus), shoulder
blade (scapula), and collarbone (clavicle). Unlike the hip, which can
be categorized as a constrained joint with a deep boney socket, the shoulder
has a shallow socket where the upper arm fits into the cup of the shoulder
blade. In order for this to be a stable joint, the shoulder has a strong.
thick joint capsule that surrounds the joint. At the interface of the
bones, the joint is bathed in synovial fluid, lubricating the joint and
shoulder capsule. This usually protects the joint and keeps it stable
under strain or stress.
The hallmark of frozen shoulder is its progressive limitation of shoulder
motion. The pain is usually described as dull or aching and localized
in the shoulder region. Patients can have pain up into their neck or down
to the elbow as they try to use other muscles around the shoulder to compensate
for lack of motion. With a frozen shoulder, the strong joint capsule becomes
even thicker and tighter. Adhesions develop that impede motion and decrease
the amount of joint fluid available. It develops in three stages:
Freezing: This is the stage consistent with the most pain as the shoulder loses
range of motion. Freezing can last from six weeks to nine months.
Frozen: During the frozen stage, most of the pain has subsided but the significant
stiffness remains and impedes even basic daily activities. This stage
can last for four to six months.
Thawing: This is obviously when the shoulder motion slowly improves. Most patients
will regain full strength and range of motion. This typically takes from
six months to two years.
Exam with Medical Provider
After thoroughly discussing your medical history and duration of symptoms,
the doctor will examine your shoulder. The pertinent exam findings with
frozen shoulder are the inability to move the arm during “active
range of motion” and that same lack of motion with the doctor trying
to move the arm, called “passive range of motion.” People
with frozen shoulder lack both active and passive range of motion. X-rays
are taken during the visit to look for any bony abnormalities, such as
arthritis that may mimic frozen shoulder. MRI studies create better images
of the soft tissue that will show the thickened capsule or any other soft
tissue pathology such as a rotator cuff tear that may have initiated the
Stretch! Stretch! Stretch! . . . now stretch some more!
The focus of treatment with frozen shoulder is to control the pain and
restore motion and strength. I always tell people suffering from frozen
shoulder that they must be extremely patient. There is no quick-fix cure.
More than 90 percent of my patients improve with a simple regimen of prescribed
anti-inflammatory medicines to control pain and physical therapy. There
are times when the improvement will plateau, and in these situations,
I will use a localized cortisone injection to specifically target the
Physical therapy is important to incrementally restore motion. These exercises
should be performed under the supervision of a physical therapist or a
home exercise program. Before stretching, applying heat is recommended
to loosen up the shoulder. Here are a few exercises that can be tried at home:
External rotation stretch. Stand in a doorway and bend the elbow of the affected arm 90 degrees to
reach the doorframe. Keep your hand in place, and as you walk through
the door, slowly rotate your body to stretch the shoulder. Hold for 30 seconds.
Forward flexion supine stretch. Lie on your back with your legs out straight. Use your unaffected arm to
lift the affected arm over your head until you feel a gentle stretch.
Hold for 30 seconds.
Cross arm stretch. Gently pull one arm across your chest with your unaffected arm as far as
possible until you feel a gentle stretch. Hold for 30 seconds. Relax and repeat.
Surgical treatment, though not generally necessary, may be an option once
a patient has failed prolonged conservative treatment. This is accomplished
by manipulation of the shoulder under anesthesia or release of adhesion
arthroscopically. In many cases, these procedures are used in combination
for maximal results. After surgery, physical therapy is reinitiated to
maintain the motion gained from surgery.
Long term outcomes after surgery are generally good with most patients
reporting decreased pain and increased functional range of motion.
Frozen shoulder is a debilitating disease with elusive causes. Though recovery
can be slow and tedious, most patients become pain free with a functional
range of motion of their shoulder by following a prolonged conservative
treatment regimen of anti-inflammatory medicine and physical therapy.
Patience is definitely a virtue when it comes to frozen shoulder. Remember,
it takes time to
froze, and finally
thaw. If you ever find yourself suffering from this issue, you may have to
run the theme song from the movie Frozen on a repeating playlist and “Let
it go . . .”