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What is Frozen Shoulder, and How can it be Treated

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On this video I’m talking about what is frozen shoulder, how do you diagnose it, when should you be suspicious that you could have it, and what are the treatments that can help you out with your condition.

On today’s episode I’m talking about frozen shoulder also known as adhesive capsulitis, a very painful condition that causes severe limitation and range of motion in your shoulder causing not only pain and significant limitation in activities and abilities. So what is frozen shoulder. Frozen shoulder is a condition that is defined as severe limitation in your shoulder range of motion having ruled out other conditions that could cause that same limited range of motion.

You see this most classically in individuals who are in their 50s or 60s, there’s a slight increase in prevalence amongst women compared to men, and there definitely some significant risk factors that can make you more prone to this including if you have metabolic syndrome which can include active diabetes, uncontrolled hypothyroidism. If you’ve had a recent shoulder injury as well, and if you’re more prone to inflammation in general from various autoimmune conditions.

The cause of frozen shoulder is not that well understood, but the thinking is that there’s an initial inflammatory component, then a neurogenic or neurologic aspect to it, and then eventually a fibrosis part of it that causes significant contractures of the shoulder joint capsule. The capsule is essentially a layer of tissue that surrounds the shoulder joint that adds support as well as stability to the shoulder joint when that gets inflamed and then eventually fibrotic and scar down it leads to significant limitation range-of-motion. Why that occurs is not entirely understood but that transition from inflammation then to fibrosis and contractures and scar tissue is one that is pretty well understood.

There are generally three stages to frozen shoulder. There’s an initial freezing stage which means that there’s a progressive limitation in shoulder range of motion, that’s probably the inflammatory component. There’s then a significant frozen stage where there’s significant contracture and scarring down of the shoulder capsule where the range of motion is then severely limited, that’s probably now the more fibrotic stage. And then there’s a slow progressive thawing where that loosens up. That progression can take anywhere from 6 to 24 months and can leave residual limitation and range of motion. Because of that prolonged course as well as that residual limitation in range of motion that can occur, it’s important to treat this and diagnose it early so that you can improve your overall prognosis long term.

Diagnosis of frozen shoulder requires a few things. Number one a good history to really gauge your progressive loss of range of motion as well as to screen if you could have some other conditions systemically that could be causing this. So for example if you’re at risk for diabetes, if you’re at risk for hypothyroidism, or some other inflammatory conditions, you want to make sure you are properly screened for that if there’s any consideration of a systemic cause for frozen shoulder. Once that’s been done a good examination to help document your level of impairment as well as limitation of range of motion and some imaging.

The imaging that I recommend is a simple x-ray and diagnostic musculoskeletal ultrasound. MRI and CT scans are generally not needed for this diagnosis. You need an x-ray to help make sure you don’t have any other significant bony pathology or arthritic issues that could be causing that limitation or range of motion. And you need a good diagnostic musculoskeletal ultrasound to help screen to make sure you don’t have any significant rotator cuff pathology that could be causing your limitation of range of motion because realistically if you have a rotator cuff injury you will be treated a bit differently than how you would a frozen shoulder. And again the diagnosis of frozen shoulder requires ruling out other conditions including a rotator cuff tear.

I am a bif fan of diagnostic musculoskeletal ultrasound because you can look at soft tissue injuries including tendon and ligamentous injuries in a very quick and detailed fashion you can also examine how limited your range of motion is and how much impingement that restriction is causing your shoulder as well with ultrasound. That is a relatively efficient and quick and easy way to help make this diagnosis.

Early diagnosis and early treatment are key in order to get a good result with this condition. So if you have progressive pain and progressive reduction in range of motion I would recommend getting checked out by your trusted physician by doing a proper relatively focused evaluation you can figure out if you have an early stage of frozen shoulder and if so you can start the treatment for that relatively quickly, which can then help prevent the progression and actually turn it around faster.

First-line treatment for frozen shoulder is typically physical therapy. Physical therapy in a safe and controlled fashion can help you go through a range of motion to try to bring that back relatively faster and quicker. That’s important because they can push you when they need to push you and they can kind of hold back a bit when it’s maybe safer to do so, and I’d recommend going that route first line for sure.

Other traditional first-line options include anti-inflammatory medications and steroids. I would caution both of these. Anti-inflammatory medications can help short term but they have a lot of potential issues longer term. As an example they can increase your risk of stomach ulcers, heart disease, liver damage, and kidney damage. Preferentially I recommend using over-the-counter supplements including glucosamine chondroitin, omega-3, and turmeric. These can help with not only pain but they can also help with inflammation. They are much safer than taking anti-inflammatory medications or chronic narcotic medications and I think if they can help in terms of pain that is a preferable route to use.

In terms of steroids you want to be careful with these as well. Oral steroids by mouth really don’t have any evidence of efficacy for long-term effectiveness of frozen shoulder. Steroid injections on the other hand can help with pain and even help with the symptoms of frozen shoulder. The issue is that steroid injections are not healthy or helpful for the actual tissue of the shoulder whether you’re talking about the shoulder joint or the tendons, and so if there are other options, and there are which I will discuss shortly, I think you’re better off avoiding steroid injections whenever possible. Two other treatments I would caution to avoid. The first is surgery. There is no evidence that surgery is beneficial for frozen shoulder so I would avoid that if possible. The second is manipulation under anesthesia. This is a process where you are sedated or put under general anesthesia and then the surgeon relatively aggressively manipulates your shoulder to give it more range of motion. The risk here is that because you are knocked out and not able to give any feedback that if the range of motion you’re put under is too aggressive and pushes it too far that you may actually damage other soft tissue areas including the labrum, the rotator cuff tendons, and ligaments as well. I think there are better options besides these two which have limited evidence of efficacy and may have some additional risks that are not really worth it.

If you have failed conservative management with physical therapy and over-the-counter supplements, my preferred next step is actually a different type of injection. A safer and better option is what’s called platelet lysate hydrodistension. What’s involved in that is the following- we take a sample of your own blood from a blood draw, concentrate that into a high concentration of your own platelets, then crack open the platelets and just take the growth factors from that. We combine that with a little bit of numbing medication and then inject that into the shoulder joint. We put in enough volume to stretch the shoulder capsule to break apart some of the adhesions and scar tissue, then over the next couple days on your own, while you’re in the office, and then even with physical therapy have them really more aggressively push the range of motion in the shoulder to help loosen it up even further. This is a better option than utilizing a steroid injection which is unhelpful or unhelpful and unsafe for the tissue. Platelet lysate is in fact healthy and safe for your tissue and can be done on a number of occasions repeated to actually help with the frozen shoulder. In addition it’s done in a manner that is done with your own control as opposed to manipulation under anesthesia where you don’t really have control of how aggressive that pushing through range of motion is done, This allows you to control that which is really important from a safety standpoint that you control how this is done. And then lastly this is one that can help accelerate the process of recovery from having a frozen shoulder which makes a difference in terms of your recovery in terms of your ability to gain range of motion and pain relief and functional improvement.

Three other key pearls and notes that you should be aware of. Number, one if you need to be evaluated for a shoulder issue in particular frozen shoulder make sure that you’re getting your neck evaluated as well. A pinched nerve in the cervical spine or an arthritic facet joint in the cervical spine can also translate to not only pain in the shoulder but sometimes also weakness and can affect your range of motion as well. When you see your physician make sure that they’re checking out the neck as well. There are a couple things that they can do by history and examination to determine if you need additional evaluation with imaging as well. Number 2 make sure that if there’s any suggestion that you are prone to systemic inflammation that that gets evaluated and treated appropriately as well. It’s important because excessive systemic inflammation can make you more prone to frozen shoulder and can make it more complicated as well. Number three make sure that if there are signs of risk for metabolic syndrome or other metabolic conditions like poorly controlled diabetes or hypothyroidism that that gets evaluated properly as well, and if needed gets treated as well.

So hopefully this content has given you a better understanding of what frozen shoulder is, when you should be concerned about it, how to be properly evaluated, and what are some best principles when it comes to treatment, and best options for treatment as well.

Question of the day: if you’ve had frozen shoulder and you’ve recovered, how did you get better, what treatment modalities did you pursue, what worked for you.

 

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