Frozen Shoulder: Why Your Shoulder Won't Move (And How to Fix It)

I'm Dr. Patrick Denard, a shoulder specialist at the Oregon Shoulder Institute, where I do 100% shoulder surgery and treat shoulder conditions. So let's talk about frozen shoulder. I want to talk about the symptoms, causes, and treatment of frozen shoulder. Frozen shoulder is otherwise known as adhesive capsulitis. It causes pain and stiffness of the joint. It affects the glenohumeral joint, which is the ball and socket joint. This is the joint that helps your shoulder move The shoulder is the most mobile joint in the body, and when you get stiffness from adhesive capsulitis or frozen shoulder, it is very painful. It's one of the more painful conditions I see in the clinic along with calcific tendonitis, and it really causes a lot of symptoms for people in terms of pain and inability to do their activities. Now, this affects about 2% of the population overall. Some people, the of those will get it in at some point in their lifetime. And the hallmark is a normal joint with the inability to move the ball and socket joint. What do I mean by that? I mean they have X-rays without arthritis. So some people will actually come in with shoulder arthritis and they'll tell me, yeah, they had frozen shoulder years ago. And that's probably not the case. They probably always had arthritis and they were dealing with some inflammation from arthritis, but the symptoms of arthritis can kind of come and go. So one of the first things you need to do is, is get an X-ray. And you can see that people have a normal ball and socket joint. And then you do a careful physical exam. On that physical exam, the biggest thing that I look for is lack of motion. And in particular, you look for lack of external rotation. So that's rotation out to the side. A really good way to pick that up is horizontal abduction. So coming up in the throwing position and being able to come back. If you cannot come back the same amount as the other side, or your elbow sits in front of your body, that's a really good indicator that you have frozen shoulder if you have normal X-rays. Now, unfortunately, this condition can be often missed. The severe cases when somebody cannot get to shoulder level are very obvious, but like anything, it's a spectrum, and you can have mild frozen shoulder, you can have moderate or severe frozen shoulder. So it's really important to get the right diagnosis. The most common thing people report is they will say they have difficulty reaching out to the side or behind the back, especially in the early stages. A really frequent story that people will come in and report is reaching back and they even felt like a popping sensation. Probably that's just because that's the point at which they first noted the symptoms, because frozen shoulder or adhesive capsulitis affects the capsule, which is the closest layer to the shoulder, and the capsule is responsible for maintaining joint stability. When it gets impacted by frozen shoulder, adhesive capsulitis, it basically gets very, very tight and restricts that range of motion, and it'll start very subtly and then get worse. So somebody goes to their endpoint range of motion that they can normally do, and suddenly suddenly they have this severe pain or feedback that they can no longer do that. Sometimes they'll also report some mechanical type of symptoms with this. And although most shoulder pain is typically going to occur deep in the shoulder or the front and the side, frozen shoulder is one of these conditions that in fact sometimes people have symptoms below the elbow. It's one of the rare shoulder conditions where it can radiate down below the elbow. So what are the causes? Well, most of the time it's considered idiopathic. What does idiopathic mean? We don't know. Okay, so the causes are not fully understood. There's no clear connection between arm dominance or occupation. For instance, most cases occur without injury. People just sort of develop symptoms. You can get it after injury, but that's much less common than just idiopathic frozen shoulder. The biggest association or factor that's associated with adhesive capsulitis is diabetes. People who have diabetes will get it sometime between 10 and 20% of cases. And if somebody has diabetes, their 5 times more likely to get frozen shoulder in their lifetime. There's some other conditions that have been associated with frozen shoulder as well, such as low thyroid or hypothyroidism. So that's something that's worth checking. But the big two that I check for if I see somebody with frozen shoulder is diabetes and hypothyroidism. In some cases, it's actually one of the first times that we pick up diabetes for somebody. Again, injury can be a cause, but it's much less common. So if somebody has a fall on an outstretched arm, they can have an injury to the capsule. It's probably, again, a different mechanism because in diabetics it probably relates to vasculature. You get microvascular disease that leads to this inflammation and adhesions. Whereas if somebody has an injury, it's a different process, but it manifests the same. What about treatment? The good news with frozen shoulder is that the majority of people can get better without surgery. Somewhere around 80% of people are gonna get better without surgery. The bad news is that it can take a long time. If you look at the natural history, it's somewhere between a year and two for resolution. If somebody just goes about the normal course and lets it sort of go through its process. That involves a freezing, frozen, and thawing process. As we talk about, typically pain is the first hallmark followed by loss of range of motion. Then the pain subsides and somebody continues to get the range of motion back slowly. That's a long, long time. So what can we do to speed up the process? There's some simple things like anti-inflammatories, ibuprofen, Aleve, that can be taken. But the mainstay treatment in my mind is a glenohumeral injection. That's a steroid injection into the ball and socket joint. I prefer to do that under ultrasound guidance so I can see directly where I'm putting the injection. And that steroid helps calm down the inflammation inside the shoulder. Now, there's a lot of conditions for the shoulder that I actually wouldn't have a steroid injection for, but frozen shoulder is one of those that 100%, if I had a frozen shoulder, gimme a steroid injection because the data shows that people can get better quicker with that. How frequent those steroid injections occur, typically you can do up to 3. This is one of the conditions where we'll allow a few more and And we can do those about 1 month apart. So I always start with 1 and I will see how it goes. I'll see somebody a month later. Let's see if they're resolving, if their pain's pretty much resolved. And in some cases you can see them basically get 80% better after injection. Great. We just hold off. If it's sort of in the middle in terms of the recovery, then we're gonna talk about perhaps doing another injection, particularly if they're very painful. If they have no relief, then we wanna look at other options. Another really important thing with frozen shoulder is stretching exercises. So check out my shoulder stretches video on the website or on YouTube. That'll really help you show or help you see the shoulder stretches that are important. Essentially what you want to do are doorframe stretches, which are really good for bringing the arm back that same area where you have limitation. Frozen shoulder typically affects the front and inferior part of the shoulder the most, That's why that position is most limited. So you really want to get into a door, work on those doorframe stretches. That's very beneficial. You can also do what are called sleeper stretches where you lay on your side and you're pushing your arm down. That helps stretch the posterior capsule. And then finally, taking the arm overhead. Now, because it can be painful, that can be hard to do. So one of the things you can do is simply lay down and use the opposite arm to take your arm up overhead and help stretch, especially if you're in a laid-down position. That's a really good stretch, but you can see those demonstrated on my video else. Now this is different and it's important that the diagnosis is correct because this is different than rotator cuff because in rotator cuff it's all about strengthening very much like calcific tendonitis. If somebody has a frozen shoulder and they go to a therapist and they're just strengthening, strengthening, strengthening, that is a painful process that is just going to be very defeating because you're just going to be really limited in what you're doing. So the, So focus is bring the inflammation down first, work on stretching at the same time. As the range of motion comes back and the pain comes down, then you can work on strengthening to help get that last little bit in terms of order of treatment. Now what about if the, the, now what about if the frozen shoulder does not resolve with injection, anti-inflammatories, and stretching? Well, the option then becomes what's called an arthroscopic lysis of adhesions. What do I mean by that? You look inside with a camera, Somebody goes to sleep, put a camera inside the joint, and under direct visualization, release the adhesions inside the shoulder. That's a process where you use a little shaving device and an electrocautery device. The shaving device is used to remove the inflammation. The cautery device is actually used to cut the adhesions and then afterwards manipulate the shoulder through its normal range of motion. Now, some people will do a manipulation under anesthesia alone. I would really caution you against this because What can happen is things are very tight, and if you manipulate the arm, in most cases, yes, the capsule will release. But there are cases where people have tried to do that and other things release, like you get a broken arm or a fracture. That's definitely something to avoid. The other thing is that you really aren't clearly taking out those adhesed areas and the inflamed areas. So it's always my preference to do this arthroscopically, looking with a camera. Do the release, and then move the arm. And if we do that properly, most of the time somebody will go from having very limited range of motion to just by simply doing the release, we'll move the arm and somebody has near full range of motion. The manipulation is only for perhaps the last little bit. In other words, it's very controlled. You treat the pathology and that's the way to go. If somebody has that procedure, that's an outpatient procedure, takes about 30 minutes. What I have people do is they go home the same day, I have them start therapy 3 times a week for 3 weeks afterwards, because we want to get right back into doing physical therapy to prevent their adhesions from recurring. The recovery timeline of something like that is on the order of a few months. I'll typically tell people 3 to 4 months for full recovery. Now, why is that if we've gotten all your range of motion right out of the gate? Well, the muscles themselves are also going to get thick and contracted as a result of frozen shoulder. And that's because you've essentially had this occur over time. So everything gets really tight. So you release the capsule. Yes, but you still need to work through the, uh, condition overall because if you don't use parts of your body, you get tight. Just like if you don't stretch your hamstrings, they're gonna get tight over time. So 3 to 4 months is the total full recovery, even though right at the time of the procedure when somebody's asleep, all have their range of motion., at that time. Some things that I like to do to improve that recovery process, I like to do a steroid dose pack after surgery. That's a 5-day course of steroids that really helps keep the inflammation down. There's data showing that that's very effective for pain relief in general after shoulder surgery, but I really like it in the setting of frozen shoulder or in calcific tendinitis where there's an inflammatory type of process because we want to try to keep that inflammation down to help you work with rehab. Another thing that may be beneficial is considering curcumin or turmeric. There's data in other fields that shows that this reduces adhesion. So I think it's reasonable for people to consider. And then lastly, in some cases you can even consider medications like lisinopril or metformin. These are, uh, medications for hypertension and for diabetes. I don't use these routinely, but in some very severe cases, or if somebody has recurrent stiffness, this can be a consideration. Because they mechanistically reduce adhesions in the shoulder, especially lisinopril. So it's a consideration, but it's not a mainstay sort of treatment. When do you consider doing a surgery for adhesive capsulitis or frozen shoulder? There's a couple of studies that have looked at this, and the data essentially says somewhere between 7 and 9 months of symptoms. So if somebody comes in and sees me for their first time and they've had an injection, they've done stretching, they're really painful, it's been going on for 7 months, probably they're going to be better off doing the release of adhesions to get back quicker. Is in some cases, if you let the frozen shoulder go on for a long time, even though historically we've said full resolution after a couple of years, the reality is some people will get left with a deficit in range of motion. Between that and the quality of life impact, the data shows that 7 to 9 months of symptoms, you tend to do better with surgery compared to continued conservative treatment. But if somebody comes in, it's their first diagnosis, they've not had any injection, we're definitely going to try an injection first, try stretching, follow for a few months on monthly intervals, watch their progress. And again, fortunately, most of those people resolve. So summary on frozen shoulder is it's a very painful condition, the hallmark being loss of range of motion. I will tell you though, it's one of those conditions that is very gratifying to treat in clinic because if you get the right diagnosis and the right treatment, especially with injection first, I'll have people come back and they just feel like they're cured, which is a really cool thing to do without surgery. So hopefully that helps you understand frozen shoulders, sort of the symptoms, causes, and treatment from beginning to end. And good luck with your shoulder.