Thawing Out Frozen Shoulder

What can you do when your arm gets “stuck”?

Pain and stiffness stopped Lynn Sygiel whenever she tried to brush her hair, open a door, or reach into her back pocket. Any time she moved her left arm, it hurt. Getting dressed became an ordeal. “Even pulling up tights was painful,” says Sygiel, 58.

She didn’t know what the trouble was and couldn’t remember straining her arm or shoulder. “It was kind of out of the blue,” she says. The pain was so bad that she could hardly sleep at night. Then, her left shoulder got so stiff, she could barely lift her arm from her side.

Her doctor gave her anti-inflammatory medicine, which eased the pain but not the stiffness. “I had no strength whatsoever” to lift or carry anything, says Sygiel, director of Y-Press, an Indianapolis-based youth journalism program.

A month later, Sygiel met an orthopedic specialist, who quickly diagnosed her condition—frozen shoulder. Officially known as adhesive capsulitis, the term refers to the way the capsule, or lining, of the joint thickens and gets sticky. Irritated and inflamed, the shoulder capsule contracts so much that the top of the arm can’t move; it freezes in the joint.

Although Sygiel never heard of frozen shoulder, she soon discovered that other female friends and acquaintances experienced the painful condition, too.

“It is extremely common, especially in perimenopausal women,” says Dr. Jennifer L. Solomon, a specialist in physical medicine and rehabilitation at the Hospital for Special Surgery in New York.

The disorder strikes about two percent of the population, according to the American Academy of Orthopaedic Surgeons (AAOS). But that estimate is “probably low, based on the fact that a lot of people are misdiagnosed or not diagnosed at all,” says Dr. Peter Sallay, a shoulder expert with Methodist Sports Medicine/The Orthopedic Specialists in Indianapolis. Sallay and his partner see between 300 and 400 patients with frozen shoulder a year.

And most of those patients are between the ages of 40 and 65, at least two thirds of them women.

The risk of frozen shoulder is higher in people who have diabetes, thyroid problems, Parkinson’s disease or cardiac disease, according to the AAOS. In rare cases, frozen shoulder occurs when an arm is immobilized after an injury or surgery. Many cases of frozen shoulder occur like Sygiel’s—seemingly out of the blue. She woke up one morning wondering why her shoulder hurt.

While there are several theories about the cause of idiopathic (arising spontaneously or from an obscure or unknown cause) frozen shoulder, no definitive explanation has yet emerged, Solomon says. Because the condition occurs most commonly among middle-aged women, some experts feel hormonal changes are at work.

“Hormonal imbalances may cause a systemic reaction, which causes inflammation of the capsule,” she says. “It’s like Saran wrap. The Saran wrap tightens up.” The persistent inflammation results in fibrosis, or scarring, in the shoulder, causing the capsule to stiffen and shrink.

“We don’t know what causes it and we don’t know why it goes away,” Sallay says of the bizarre condition. Oddly, it never recurs in the same shoulder.

While researchers have studied the capsular material looking for biochemical markers in frozen shoulders, nobody has really found a common triggering cause.

“The fact of the matter is that patients for no good reason typically wake up and have pain,” Sallay explains. “And then the pain gets worse, and then they start to lose range of motion.”

After a period of stiffness, the pain ebbs, and patients start to recover range of motion. More than 90 percent of people with idiopathic adhesive capsulitis will eventually resolve their condition. “The length of time it takes to resolve varies,” says the orthopedic surgeon. “It can range anywhere from one to three years. Most people resolve within 18 months, in my experience. Frozen shoulder is one of those things that really test a patient’s psychological stamina.”

The Road to Diagnosis

Frozen shoulder is typically diagnosed by analyzing a patient’s medical history and through a physical examination to assess range of motion. With some shoulder problems, the doctor is able to move the affected arm, but with frozen shoulder, neither the patient nor the doctor can move the arm beyond a certain point.

Unfortunately, the condition is frequently misdiagnosed.

“The most common scenario is that a patient sees a family doc who says, ‘You have bursitis, an inflammation of the cushion between bone and tendon, or tendonitis,’ ” says Sallay.

Many people suffer through the painful disorder—and eventually recover—but never get an accurate diagnosis.

To rule out other possible reasons for shoulder pain and immobility, such as a rotator cuff tear, the doctor usually will order an x-ray, MRI, or other type of imaging test.

To Treat or Not to Treat

There are several schools of thought on how and when frozen shoulder should be treated. “There is a debate about it,” Solomon says. “It’s a controversial subject.”

Solomon and her colleagues say early diagnosis and immediate treatment with a cortisone injection and physical therapy is vital. She likes to start treating people in what is known as Stage 1 of the condition—the freezing stage—when the pain is increasing and the shoulder is losing mobility.

“If people are diagnosed very early and treated appropriately, the course of recovery is much quicker, sometimes by several months,” Solomon says. And she does not agree with the notion that a frozen shoulder will thaw in a year or two, no matter what you do or don’t do.

Generally, Solomon recommends a corticosteroid injection into the shoulder. Steroids can reduce inflammation and pain, and increase range of motion. “You can see that very quickly,” she says.

She also prescribes gentle physical therapy, giving the therapist a detailed protocol. “If too aggressive with physical therapy, you can cause a flare-up,” she says.

A similar treatment plan worked well for Sygiel. The same day she was diagnosed with frozen shoulder, she received a steroid injection, and the pain eased over a couple of days. Then she went to a physical therapist. Twice a week for six weeks, the therapist carefully guided her arm and shoulder in a series of gentle exercises designed to increase range of motion. She also applied heat, to literally thaw the joint. The physical therapist also provided Sygiel with daily exercises to do at home.

Six months after her shoulder pain began, Sygiel recovered 90 percent of her normal range of motion. “I can’t reach all the way behind me,” she admits, but she is grateful to have most of her strength and mobility back.

Not all doctors believe a patient needs to rush into treatment. There’s no way to shorten the course of the disease, Sallay says. “Once it starts, it’s like a locomotive going downhill.”

Patients tend to be referred to him after weeks or months of debilitating pain and stiffness. Many have already tried physical therapy and found their pain is getting worse, not better. “They’re typically very apprehensive,” and desperate for sleep and pain relief, he says.

“The first thing I tell them is, don’t go to the therapist. Stop. And within a week, they’re better in terms of pain,” he says. “I tell people, this is like a campfire that’s burning; the embers are still there. But if you go and stoke those embers, it’s going to take a whole lot longer to settle this down.”

During the early stages of adhesive capsulitis, he recommends ice, pain medication, and anti-inflammatories. Steroids, either oral or injected, are effective in many people.

Sallay says the time for physical therapy is when the inflammatory phase is over. “You can accelerate the thawing phase with physical therapy,” he says.

When All Else Fails—Last Resort

Only a small percentage of frozen-shoulder cases do not improve with medical treatment, therapy, and time. For these people, doctors may do a procedure called shoulder manipulation or mobilization—forcing the arm to move—under anesthesia. Others require arthroscopic surgery.

That’s what happened to Natalie Heck, 45.

Heck’s right shoulder started hurting in January 2007. “I had trouble sleeping, had a lot of pain, and was losing a lot of strength,” says Heck, a married mother of two teens. “Grocery bags were difficult; a 12-pack of soda was painful.”

Her family doctor suggested a cortisone injection, thinking she might have bursitis. “The shot didn’t alleviate any pain,” she says. Physical therapy, in fact, exacerbated the condition.

“I started feeling pain in my wrist, numbness and tingling all the way down my arm,” she recalls. Because she worked all day on a computer keyboard, she struggled to do her job.

An orthopedic surgeon ordered an MRI, diagnosed a rotator cuff tear and impingement, and recommended immediate surgery. A second specialist diagnosed frozen shoulder. Looking for a tie-breaker, Heck consulted Dr. Sallay, who agreed with the frozen shoulder diagnosis. Because Heck wanted to avoid surgery, she followed Sallay’s suggestion of a ”wait and see” period to see if her pain and stiffness gradually disappeared.

It didn’t. “I lasted until the end of October and asked to have the surgery scheduled,” Heck says.

Heck underwent a short outpatient procedure called “arthroscopic capsular release.” Using an arthroscope, the surgeon loosened the contracted ligaments and removed scar tissue. Taking medication for the considerable pain and swelling, Heck began physical therapy “the very next day.”

After three weeks, “I could tell there was some improvement” in range of motion, she says. Eight months after the surgery, Heck’s shoulder was almost normal. “I don’t experience the pain or the weakness.”

For the thousands of people suffering from the debilitating shoulder condition, Heck hopes researchers soon determine the cause of frozen shoulder and develop better diagnosis and treatment methods. She would also like to know why the condition seems to run in her family—her mother suffered through frozen shoulder 20 years ago.

“I’d like them to find out,” Heck says, “because now my 13-year-old daughter is wondering if she’s going to get it.”

A Series Of Stages

Frozen shoulder typically has three stages, according to the American Academy of Orthopaedic Surgeons:

Stage 1: The freezing stage may last six weeks to nine months. Pain develops. As it worsens, the shoulder loses motion.

Stage 2: The frozen stage may last four to nine months. Pain fades but the stiffness remains.

Stage 3: The thawing stage may last five to 26 months. Shoulder motion gradually returns toward normal.

When a shoulder “freezes” up, stretching and range-of-motion exercise can help restore function and reduce stiffness: more than 90 percent of patients improve with simple treatments, according to the American Academy of Orthopaedic Surgeons.

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September 22, 2008