How to diagnose frozen shoulder

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in the shoulder joint.

Adhesive capsulitis reduces the shoulder's range of motion. Frozen shoulder usually affects one shoulder, although some people may develop it in both shoulders.

The condition usually improves on its own. Most people eventually regain nearly full shoulder range of motion and strength once signs and symptoms improve.

Frozen shoulder typically develops in three stages:

•Painful stage. During the painful stage, which can last anywhere from two to nine months, pain occurs with any movement of the shoulder.
•Frozen stage. Pain may begin to diminish during this stage, which may last from four to 12 months. However, the shoulder becomes stiffer and the range of motion decreases notably.
•Thawing stage. During the thawing stage, which can last up to 12 months, the condition may begin to improve.

The pain associated with frozen shoulder may be aching or burning. For some people, the pain worsens at night.

The precise cause of frozen shoulder is not known. It can occur after an injury to the shoulder or prolonged immobilization of the shoulder, such as after surgery or an arm fracture. People who have diabetes have a greater risk of frozen shoulder. For this reason, frozen shoulder may have an autoimmune component. People with other health conditions, including heart disease, lung disease and hyperthyroidism, also may have an increased risk of developing frozen shoulder.

When frozen shoulder occurs, the shoulder capsule becomes inflamed and stiff. The inflammation may cause the tissue to become fibrotic. As a result, pain and loss of movement occurs. In some cases, mobility may decrease so much that performing everyday activities — such as combing hair, brushing teeth or reaching — is difficult or even impossible.

Although the exact cause is unknown, certain factors may increase the risk of getting frozen shoulder. These factors include:

•Gender. Women are more likely to have frozen shoulder than men are.
•Age. People between the ages of 40 and 65 are more likely to experience frozen shoulder.
•Diabetes. For unknown reasons, frozen shoulder is more common in people with diabetes.
•Immobility. People who have experienced prolonged immobility of their shoulder — perhaps due to trauma, overuse injuries or surgery — often experience frozen shoulder.
•Systemic diseases. People with an overactive thyroid (hyperthyroidism), cardiovascular disease or Parkinson's disease may experience frozen shoulder.

Under normal circumstances, a person should be able to move their shoulder in all directions without pain.

The primary means of diagnosing frozen shoulder is a physical examination. During the exam, the doctor may test active movement (movement without assistance) by asking the patient to raise and lower their arm to the front, sides and back of the body. The doctor may also test passive movement (movement with assistance) by manually moving the arm to determine range of motion. The physician may press on parts of the shoulder to see what might cause pain. Loss of both active and passive movement and a pattern of tightness and pain are strong indicators of frozen shoulder.

The doctor may order an MRI scan to exclude other structural shoulder problems.

Most treatments for frozen shoulder involve moving and stretching the shoulder muscles.

A physical therapist will help the patient maintain as much mobility in the shoulder as possible. The exercises may be painful at first. The patient should continue to use the involved shoulder in as many daily activities as possible within the limits of pain and range of motion constraints.

Gradual stretching the shoulder muscles may help restore enough flexibility to enable the patient to resume their everyday activities.

One such exercise, known as wall crawling, may help stretch the shoulder muscles. During this exercise, the patient stands erect, faces a wall and extends the affected arm directly in front of the body so that the fingertips touch the wall. The patient then “creeps” up the wall with the fingertips, and walks toward the wall as they reach higher and higher. The patient should avoid arching the back. The exercise is repeated with the fingertips creeping down the wall as the patient walks backward. Then the exercise is repeated with the arm extended sideways to a wall.

Patients with severely limited mobility can use a modified version of the wall-crawling exercise Lie on a bed and dangle the arm over the side. Creep along the floor (parallel with the bed) with the fingertips. Repeat the exercise with the arm extended sideways.

Other treatments:

•Non-steroidal anti-inflammatory drugs (NSAIDs). These medications may help relieve pain and inflammation associated with frozen shoulder. Acetaminophen (Tylenol, others) also may be effective for pain relief.
•Heat or cold. Applying heat or cold to the shoulder can help relieve pain.
•Corticosteroids. Injecting these anti-inflammatory hormones into the shoulder joint can help decrease pain during the initial painful phase. However, they do little to improve the shoulder's range of motion.
•Surgery. In a small number of cases, surgery is an option to remove scar tissue and adhesions from inside the shoulder joint. Doctors usually perform this surgery arthroscopically.

In some cases, manipulating the shoulder under general anesthesia may help to improve motion. Newer treatment options include injecting fluid into the shoulder joint to expand the shoulder capsule and break up adhesions.

Once pain has lessened, exercise the arm daily. Flexibility and strengthening exercises — such as swimming and lifting weights — may help. As a patient progresses into the thawing phase, the physical therapist can advance the stretching and strengthening program to maximize the shoulder's range of motion and function.

Acupuncture has been used effectively in some people with frozen shoulder to provide pain relief.

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