Frozen Shoulder Syndrome

“Frozen shoulder” is the common term for adhesive capsulitis, is a term that describes a painful and stiff shoulder that has lost much of its normal range of motion. Characteristically, frozen should involves losing your shoulder’s range of motion both actively (when you move your own shoulder) and passively (when someone else moves your shoulder passively). Before a diagnosis of frozen shoulder is made by your doctor will perform a careful history and physical examination, and may order imaging studies like MRI or X-Ray to rule out other painful conditions that may limit range of motion.

Frozen Shoulder Syndrome often comes on insidiously, meaning there is no specific injury or incident associated with the onset of frozen shoulder symptoms. Frozen Shoulder Syndrome also tends to come on gradually, with diffuse pain of the shoulder slowly progressing over weeks to months. In general, the frozen shoulder tends to progress through three phases: (1) freezing phase, (2) frozen phase, and (3) the thawing phase.

- The first phase, freezing, is characterized by a gradual onset of pain for 2 – 9 months, worse with movement and worse at night, as the pain increases so does the range of motion decrease.

- The second phase, frozen phase, is characterized by 4 – 20 months of stiffness, with range of motion about 50% of the other arm.

- The final phase, the thawing phase, is characterized by a 5–26 month period of resolution of symptoms. This phase does involve a gradual improvement of shoulder range of motion and function, but even in this period many people do require treatment to reach full range of motion.

The cause of frozen shoulder is not completely understood. However, an autoimmune theory has been postulated, suggesting that inflammation from inappropriate activity of one’s own immune system is causing the frozen shoulder. We do know that it tends to occur more often in middle age, it is slightly more common in women than men, and it tends to occur more frequently in diabetics.

How to manage Frozen Shoulder Syndrome (FSS).

Symptom relief can be achieved by an injection of a cortisone steroid and taking oral anti-inflammatory medication (NSAIDs) like ibuprofen or naproxen. These options can offer short term pain relief and offer the most benefit during the first “freezing” phase of frozen shoulder. The cortisone steroid injection may produce temporary relief, sometimes even as much as 6 weeks, but often pain returns. With repeated cortisone injections can lead to damage to tissues around the injection, including softening of tendons, softening of cartilage, and osteoporosis of bone. In addition cortisone injections can elevate one’s blood sugar and dampen one’s immune function. NSAIDs like ibuprofen or naproxen can also help with symptoms management. However, long term use of NSAID’s also have the potential to damage the kidneys and cause ulcers in the stomach or intestine.

Our approach to Frozen Shoulder Syndrome involves starting off with prolotherapy injections with numbing medication (lidocaine or Marcaine) injected as a large amount into the shoulder joint. This numbs the shoulder joint and allows for initiation of the proliferation of connective tissue cells called fibroblasts. While the joint is numbed we can also begin gently manipulating the anesthetized joint. This allows us to break up scar tissue and adhesions in the joint capsule, and begin the process toward restoring full range of motion. Often we have to do at least 3 of these treatment sessions once a week. This is then followed by initiating a series of 3 Platelet Rich Plasma (PRP) injections once a month for 3 months. The PRP releases one’s own innate growth factors to promote healing, tissue regeneration, and release of one’s own stem cells. We also recommend doing these series of injections in combination with initiating physical therapy.

Another option that is sometimes very successful in reducing shoulder pain and improving shoulder ROM is a procedure called Manipulation Under Anesthesia (MUA). MUA involves placing a patient under general anesthesia performed by a general anesthesiologist, or sometimes it may be performed by something called a brachial plexus block that blocks the nerves to the arm and shoulder. Generally this option is most effective in stage II of FSS, about 6-9 months after onset of symptoms. It is consider a good option to those who have failed injection therapies.