www.mayoclinic.

com/health/frozen-shoulder/DS00416

Frozen Shoulder
(Adhesive Capsulitis)
Medical Author: William C. Shiel Jr., MD, FACP, FACR
Medical Editor: Dennis Lee, MD

What causes a frozen shoulder?

How is a frozen shoulder diagnosed?

What conditions can mimic a frozen shoulder?

How is a frozen shoulder treated?

What is a frozen shoulder?

Frozen Shoulder At A Glance

Find a local Orthopedic Surgeon in your town

What is a frozen shoulder?

A frozen shoulder is a shoulder joint with significant loss of its range of motion in all directions. The range of
motion is limited not only when the patient attempts motion, but also when the doctor attempts to move the joint
fully while the patient relaxes. A frozen shoulder is also referred to as adhesive capsulitis.

What causes a frozen shoulder?

Frozen shoulder is the result of inflammation, scarring, thickening, and shrinkage of the capsule that surrounds
the normal shoulder joint. Any injury to the shoulder can lead to frozen shoulder, including tendinitis, bursitis, and
rotator cuff injury. Frozen shoulders occur more frequently in patients with diabetes, chronic inflammatory arthritis
of the shoulder, or after chest or breast surgery. Long-term immobility of the shoulder joint can put people at risk
to develop a frozen shoulder.

How is a frozen shoulder diagnosed?

A frozen shoulder is suggested during examination when the shoulder range of motion is significantly limited, with
either the patient or the examiner attempting the movement. Underlying diseases involving the shoulder can be
diagnosed with the history, examination, blood testing, and x-ray examination of the shoulder.
If necessary, the diagnosis can be confirmed when an x-ray contrast dye is injected into the shoulder joint to
demonstrate the characteristic shrunken shoulder capsule of a frozen shoulder. This x-ray test is called
arthrography. The tissues of the shoulder can also be evaluated with an MRI scan.

What conditions can mimic a frozen shoulder?

Inflammation of the shoulder joint (arthritis) or the muscles around the shoulder can cause swelling, pain, or
stiffness of the joint that can mimic the range of motion limitation of a frozen shoulder.
Injury to individual tendons around the shoulder (tendons of the rotator cuff) can limit shoulder-joint range of
motion, but usually not in all directions. Often during the examination of a shoulder with tendon injury (tendinitis
or tendon tear), the doctor is able to move the joint with the patient relaxed beyond the range that the patient can
on their own.

How is a frozen shoulder treated?

The treatment of a frozen shoulder usually requires an aggressive combination of antiinflammatory medication,
cortisone injection(s) into the shoulder, and physical therapy. Without aggressive treatment, a frozen shoulder
can be permanent.
Diligent physical therapy is often key and can include ultrasound, electric stimulation, range-of-motion exercise
maneuvers, ice packs, and eventually strengthening exercises. Physical therapy can take weeks to months for
recovery, depending on the severity of the scarring of the tissues around the shoulder.
It is very important for people with a frozen shoulder to avoid reinjuring the shoulder tissues during the
rehabilitation period. These individuals should avoid sudden, jerking motions of or heavy lifting with the affected
shoulder.
Sometimes frozen shoulders are resistant to treatment. Patients with resistant frozen shoulders can be
considered for release of the scar tissue by arthroscopic surgery or manipulation of the scarred shoulder under
anesthesia. This manipulation is performed to physically break up the scar tissue of the joint capsule. It carries
the risk of breaking the arm bone (humerus fracture). It is very important for patients that undergo manipulation to
partake in an active exercise program for the shoulder after the procedure. It is only with continued exercise of
the shoulder that mobility and function is optimized.

Frozen Shoulder At A Glance

Frozen shoulder is the result of scarring, thickening, and shrinkage of the joint capsule.

Any injury to the shoulder can lead to frozen shoulder.

A frozen shoulder is usually diagnosed during an examination.

A frozen shoulder usually requires aggressive treatment.

REFERENCES:

Koopman, William, et al., eds. Clinical Primer of Rheumatology. Philadelphia: Lippincott Williams & Wilkins, 2003.
Kelley's Textbook of Rheumatology, W B Saunders Co, edited by Shaun Ruddy, et al., 2000.

Last Editorial Review: 12/11/2007

http://www.medicinenet.com/frozen_shoulder/article.htm

Adhesive Capsulitis

Adhesive Caps ulitis , or a frozen s houlder, is a poorly understo od condition in

whic h the deepes t layers of s oft tis s ue, called the j oint caps ule, becom e
diseased. S houlder range of motion becomes very limited and painful. The
cause of a frozen s houlder is still not known but minor traum as,
hyperthyroidis m, diabetes, psychiatric patients , pos t-s urgical patients , and
prolonged immobilization of the s houlder may in s omeway caus e this
condition. The dis eas e is characterized as having freezing, frozen, and
thawing stages , and is s elf-limiting (in time it goes away on its ow n). Howeve r,
it can take two years or more to reco ver from this conditio n.
Physical therapy co nsis ting of patient education, stretching, j oint
mobilization, and a hom e exercis e program can h elp s peed recover y. For a
small percentage of frozen s houlder patients , it may take two years or more to
reco ver.
http://www.physicaltherapyflagstaff.com/library_shoulder_26

Frozen shoulder (adhesive capsulitis)

Frozen shoulder, also known as adhesive capsulitis, is a disorder characterized by
pain, stiffness, and loss of range of motion in the shoulder. It affects about two
percent of the general population, and it is most common in women who are over 40
years of age.
Etiology
The causes of frozen shoulder are not fully understood. The process involves
thickening and contracture of the shoulder joint capsule. The process does not occur
in any other joint in the body. For reasons unkown, the nondominant shoulder is

affected more often than the dominant one. Frozen shoulder is not normally
associated with calcium deposits, rotator cuff injuries, arthritis or malignancies. The
x-rays of the shoulder are completely normal.
Medical problems associated with increased risk of frozen shoulder include diabetes,
thyroid disease, Parkinson's disease, and cardiac disease. Frozen shoulder affects
about 10 to 20 percent of people with diabetes, therefore a work-up for diabetes or
other disorders may be recommended if a frozen shoulder occurs.
Another risk facter for development of frozen shoulder is prolonged immobilization.
After an injury to the shoulder, early motion is usually recommended (assuming that
the shoulder is stable) in hopes of avoiding the development of a frozen shoulder.
Diagnosis
This condition is diagnosed by a doctor based on the history of the patient's
symptoms and physical examination. X-rays or MRI (magnetic resonance imaging)
studies are sometimes used to rule out other causes of shoulder stiffness and pain,
such as rotator cuff tear.
Symptoms
The hallmark of frozen shoulder is pain with restricted motion of the shoulder. The
pain is usually dull or aching. It usually becomes worse with motion, and it limits the
patient's use of the affected shoulder and arm. Motion is also limited when someone
else attempts to move the shoulder for the patient, as when a doctor performs a
physical exam. Some physicians have described the normal course of a frozen
shoulder as having three stages. Each stage has been reported to last roughly 4
months, but the time frame for each patient can be highly variable.

Stage 1: During the "freezing" stage the patient gradually develops a painful
shoulder. As the pain worsens, the shoulder loses motion.

Stage 2: The pain slowly subsides during the "frozen" stage, but the limited
range of motion remains.

Stage 3: During the "thawing" stage the shoulder motion slowly returns
toward normal.

Conservative Treatment

Frozen shoulder will generally improve without surgery. Th

recovery process, however, can be painfully slow (occasio
up to two to three years).
A person with a stiff and painful shoulder should see a
physician to ensure that no other injuries or illnesses are
present.

Treatment is focused on pain control and restoration of mo

Pain control can be achieved with anti-inflammatory
medications (ibuprofen, naproxen, aspirin, etc.) as well as
injectioned corticosteroids. Physical therapy may help a pa
to regain shoulder motion. Stretching or range-of-motion
exercises for the shoulder may be done at home or with th
assistance of a physical therapist. Example exercises are
in Figures 1, 2, and 3. A physical therapist can provide
additional exercises, as well as other treatments such as
massage and heat. If the patient does not respond to thes
treatments, nerve blocks may be tried to minimize pain an
allow for more aggressive physical therapy.

Most patients improve with these simple treatments. Howe

in some cases the motion does not return completely even
after several years. Fortunately, this loss is usually small a
does not cause functional limitations.

Surgical Treatment
The vast majority of individuals will get better if given sufficient time, so surgery is not
often required. Surgical intervention is considered only after an appropriate course of
physical therapy and anti-inflammatory medications has failed.
Surgical intervention is aimed at stretching or releasing the contracted joint capsule
of the shoulder. This usually consists of manipulation under anesthesia and/or
shoulder arthroscopy:

Manipulation under anesthesia (Figure 4) involves putting the patient to sleep,

then gently and slowly forcing the shoulder to move. This process causes the
capsule to stretch, and soft tissue adhesions are broken.

With shoulder arthroscopy, the surgeon makes several small incisions around
the shoulder. A small camera (scope) and instruments are inserted through
the incisions. The joint capsule is viewed with the scope, and the tight portions
of the joint capsule are released

Often, manipulation and arthroscopy are used in combination to obtain a full range of
motion for the shoulder joint. Most patients have very good results with these
procedures. It is critically important to begin physical therapy immediately after
surgery to maintain the motion that was achieved intraoperatively.

Figure 4. a. This woman was unable to raise her right arm due to adhesive capsulitis. After many months of working with a physical
therapist and taking anti-inflammatory medications, she still has a poor range of motion. b. A general anesthetic is administered and
patient is asleep. The arm is then gently taken through a range of motion, which breaks up the adhesions and loosens the shoulder
With manipulation she is able to achieve full forward flexion. c. The shoulder is manipulated in another plane (cross-body adduction)

ww.shouldersurgeon.com/frozen_shoulder/index.htm