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Patient information: Frozen shoulder (Beyond the Basics)

FROZEN SHOULDER OVERVIEW

Frozen shoulder is a condition that causes shoulder pain and limits the shoulder’s range of motion. The limitation in movement affects both active and passive range of motion. That means that your movement is restricted at the shoulder joint both when you try to move your own arm and when someone else (such as your doctor) tries to move your arm for you.

Frozen shoulder is also called “adhesive capsulitis”, “painful stiff shoulder”, and “periarthritis”. We will use the term “frozen shoulder” throughout this article.

EPIDEMIOLOGY

Frozen shoulder is fairly common, affecting 2 to 5 percent of the general population. The condition is most common in people in their 50s and 60s, and rarely affects anyone younger than 40. Women are more often affected than men.

Frozen shoulder usually affects only one shoulder (left or right) and gets better on its own, but it can last two to three years or even longer. People who get frozen shoulder on one side can go on to develop it on the other.

FROZEN SHOULDER CAUSES

Frozen shoulder most often happens as a result of a shoulder injury, such as a rotator cuff tear, a bone fracture affecting the shoulder, or shoulder surgery. It can also happen after people have other types of surgery, such as heart or brain surgery.

Frozen shoulder can also happen without a preceding injury and tends to preferentially affect people with certain diseases and conditions. People with diabetes, for example, have an increased risk of developing frozen shoulder. In fact, 10 to 20 percent of people with diabetes develop the condition.

Frozen shoulder also seems to be more common among:

People who have been immobilized for prolonged periods

People who have had a stroke

People who have Parkinson disease

People who have taken antiretroviral medications (particularly medications called protease inhibitors) to treat HIV infection

People who have diseases affecting the thyroid gland, a gland in the neck that produces hormones that control how the body uses and stores energy

Experts do not know for sure what causes frozen shoulder, but they suspect it develops when the joint becomes inflamed and scar tissue forms. As this happens, the tissues inside the joint shrink and harden, making the shoulder harder to move.

FROZEN SHOULDER SYMPTOMS

People who have frozen shoulder often go through three phases of symptoms:

The first phase lasts two to nine months and involves diffuse, severe, and disabling shoulder pain that is worse at night. During this phase, the shoulder becomes increasingly stiff.

The second, intermediate phase, lasts 4 to 12 months. During this phase, the shoulder becomes very stiff and has limited mobility, but the pain gradually lessens.

The third, recovery phase, lasts 5 to 24 months. During this phase, people gradually regain range of motion.

If you have frozen shoulder, the pain and stiffness it causes may seriously interfere with your ability to do everyday tasks, such as dress and bathe, or even work. Even once the pain of frozen shoulder starts to improve, the shoulder stiffness may still be quite limiting. For example, the condition might impede you from reaching overhead, to the side, across your chest, or from rotating your arm all the way around from front to back. This could make it impossible for you to scratch your back or put on a coat.

FROZEN SHOULDER EVALUATION AND DIAGNOSIS

If you have symptoms of frozen shoulder, your healthcare provider will examine you to learn what movements elicit symptoms and how limited your mobility is. As part of the evaluation, he or she will likely ask to watch as you move your own arm and shoulder (called active range of motion), and also explore what you feel if he or she moves your arm and shoulder for you (called passive range of motion).

People with frozen shoulder have limitations in both active and passive range of motion (picture 1). They also tend to have the most trouble rotating their arm or shoulder outward—away from their body, and putting the affected arm behind their back. When they reach the limit of their range of motion, the problem is not just that moving beyond a certain point is painful; it actually feels as though the arm is stuck.

In most cases, healthcare providers can tell when a person has frozen shoulder based on the results of the physical exam. Still, in some cases it’s hard to tell the difference between frozen shoulder and other shoulder problems, such as a painful or torn rotator cuff. If your healthcare provider is uncertain about your diagnosis, he or she might refer you to an orthopedist (a doctor who specializes in muscle and joint problems).

Injection test — An injection test can help determine whether a person has frozen shoulder or another shoulder condition. The test involves injecting the person’s shoulder with an anesthetic. In people with frozen shoulder, an injection test will not improve mobility, whereas in people with other shoulder problems it usually does.

Imaging — People with suspected frozen shoulder very rarely need imaging tests such as x-rays, magnetic resonance images (MRIs), or ultrasounds. Still, healthcare providers do sometimes order them to make sure other problems are not causing the symptoms.

FROZEN SHOULDER TREATMENT

In most cases, frozen shoulder gets better on its own, even without treatment. However, there are cases in which people never regain the full range of motion they had before.

There are a few treatment options for frozen shoulder, which can be combined, but there’s no obvious course of action that is right for everyone. Treatment options include physical therapy, medications to manage pain and inflammation, and—in extreme cases—surgery.

If you are being treated for frozen shoulder, remember that recovery can be a slow process, and that you need to give treatment time to work. If you are in pain, you can take nonprescription pain medications, such as acetaminophen (sample brand name: Tylenol) or medications called nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen (sample brand names: Advil, Motrin). If your pain is severe and does not get better with these options, your healthcare provider may offer you a prescription-strength painkiller.

Exercises to help recovery — Once the initial pain of frozen shoulder lessens, your healthcare provider might want you to do certain exercises to improve your shoulder mobility. Depending on your situation, your healthcare provider might recommend that you see a physical therapist or suggest that you do these exercises on your own. Start out slow, and do not push yourself too much at first. Let pain be your guide. If an exercise hurts too much, modify it or stop doing it. Later, as your pain subsides and your mobility improves, you can try to push yourself—and your arm and shoulder—further.

During the first two to three months of recovery, rest your shoulder and do gentle range of motion exercises (picture 2).

As you start to get better, you can add in more exercises that build strength, but don’t do exercises that cause undue pain. Some strength-building exercises are shown in the Movies:

Abduction-adduction with exercise band (movie 1)

Flexion extension with exercise band (movie 2)

Seated external rotation with elbow resting on table (movie 3)

Steroid pills and injections — Medications called “glucocorticoids,” known commonly as “steroids,” can provide some short-lived relief from frozen shoulder symptoms. When using steroids to treat frozen shoulder, healthcare providers typically inject them directly into the shoulder joint. They tend not to prescribe steroids in pill form for frozen shoulder because the pills can cause widespread side effects, and because injections tend to be more effective. Still, even the injections provide only short-term relief and work best if given early in the development of symptoms. What’s more is that it’s not always easy to get the needle into the right spot in the joint, so the medication does not always end up where it is needed.

Another treatment, called “hydrodilatation,” involves injecting the shoulder with glucocorticoid and saline to expand the joint, and this often provides effective short-time relief. However, it remains unclear whether relief stems from the glucocorticoid or dilation of the joint.

Unproven treatments — There are some treatments of frozen shoulder that remain unproven, such as laser therapy.

Surgery — People who do not get better with other treatment options can undergo surgery to “release” the shoulder joint. But experts recommend waiting at least a year before considering surgery. In some cases, surgery can help, but surgery also carries risks and can cause damage of its own.

SUMMARY

Frozen shoulder is a painful condition that limits the shoulder’s range of motion. The condition can happen on its own or as a result of an injury, such as a rotator cuff tear, and it usually gets better on its own.

Experienced doctors can usually diagnose frozen shoulder based on the symptoms it causes and how it limits movement. They do not usually need to do imaging or other tests to diagnose the condition.

There is no clear recommendation on how to treat frozen shoulder, but we believe it is best to rest the shoulder at first, and do gentle shoulder mobility exercises. Later, when the symptoms start to improve, people can do increasingly ambitious range-of-motion exercises.

In people with moderate to severe symptoms, steroid injections directly into the shoulder joint usually provide short-term relief.

Only people who have had symptoms for a year or more and are not getting better should consider surgery.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Frozen shoulder (The Basics)
Patient information: Rotator cuff injury (The Basics)
Patient information: Separated shoulder (The Basics)
Patient information: Shoulder impingement (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient information: Rotator cuff tendinitis and tear (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Evaluation of the patient with shoulder complaints
Frozen shoulder (adhesive capsulitis)
Radiologic evaluation of the painful shoulder
Shoulder impingement syndrome

The following organizations also provide reliable health information.

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

American Academy of Orthopaedic Surgeons

     (http://orthoinfo.aaos.org/)

National Institute of Arthritis and Musculoskeletal and Skin Disease

     (www.niams.nih.gov)

American Physical Therapy Association

     (www.apta.org)

Arthritis Foundation

     (www.arthritis.org)

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Literature review current through: Jul 2014. | This topic last updated: Sep 11, 2013.
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