Shoulder pain is relatively common, affecting one in five adults at some time. Before making a diagnosis your doctor has to rule out a number of other shoulder problems including rotator cuff tear (common among athletes, especially baseball pitchers) and arthritis of the shoulder joint which tends to be more common with aging. Frozen shoulder is particularly common among postmenopausal women in their 50s. Rather than being a chronic, static condition, frozen shoulder has three distinct stages, often referred to as freezing, frozen and thawing. Although these may last for up to two years, the shoulder eventually heals, with perhaps some decreased range of motion.
The first stage, the freezing stage, usually begins as pain and stiffness that people notice as they have trouble with every day activities such as reaching back to zip up a dress or reaching up to an overhead cupboard. Sleep often becomes a problem as the people find it difficult to get comfortable. The early pain and stiffness tends to get worse as scar tissue is formed. This first stage can last from three to eight months, and the pain usually sends people to the doctor.
In the second or frozen stage the pain often improves, but the shoulder becomes increasingly stiff as adhesions limit joint movement. The adhesion is actually caused by contracture of the ligaments surrounding the joint. The shoulder normally has a loose joint capsule, or lining, that allows the long bone of the upper arm a wide range of motion. When shoulder ligaments and the joint capsule contract, motion can be affected in one or more directions. Scar tissue can build up and the joint becomes frozen. This second adhesive stage lasts up to six months.
The third or thawing stage is not as painful. By this time it may be hard to move the shoulder even a little, but then the stiffness gradually starts to disappear and movement slowly returns. Some people may still experience pain at this stage, but it is usually not as severe.
Treatment usually focuses first on pain relief and physical therapy to break up the scar tissue. Acetaminophen and NSAIDs such as ibuprofen and aspirin can relieve pain and inflammation and make it more comfortable to do gentle stretching exercises.
Stretching and exercising the shoulder can be very painful, and it is often helpful to work with a physical therapist. Heat pads and gentle warm up stretches can help ease into an exercise session. Ice packs can help with cool downs. As well as structured exercise people are advised to put everyday things such as coffee mugs and toothbrushes in places that require a stretch to retrieve them.
About 90 percent of people will show an improvement after several weeks of NSAIDs and physical therapy. For those who haven not responded to this conservative therapy an injection of corticosteroids into the shoulder joint often gets good results.
Injecting into the joint requires skill and should only be carried out by a physician with experience in this procedure. Oral corticosteroids can be used in some cases, but they may not be appropriate for patients with diabetes. Diabetics have a higher incidence of frozen shoulder and also tend to have more stiffness and pain.
Other treatment options include procedures to release the adhesions constricting the joint capsule. One method involves manipulating the shoulder under anesthesia (MUA). One study showed that 75 percent of patients had near normal range of motion after MUA. MUA involves risks, however, and should be performed by an orthopedic surgeon experienced in the technique.
Surgery, either arthroscopic (with a small incision and a scope to guide instruments) or open surgery can also be used to release adhesions.
Frozen shoulder is a painful, slow-moving condition that requires determination and effort on the part of the person. As long as progress is being made most medical experts encourage patients to stay the more conservative course.
By: Kerri Musselman, Pharm.D.
