JAAOS: When That Shoulder Aches Too Much to Move

Treatment options for stiff and painful shoulders caused by adhesive capsulitis

ROSEMONT, Ill., Sept. 7, 2011 /PRNewswire-USNewswire/ -- Adhesive capsulitis, sometimes described as "frozen shoulder," is a condition where the connective tissue around the shoulder joint becomes chronically inflamed, causing thickening and tightening in the affected joint. Diagnosing adhesive capsulitis can be difficult because its symptoms—restricted movement and considerable pain—are similar to a variety of shoulder-related musculoskeletal conditions, including arthritis. Proper diagnosis of adhesive capsulitis may require extensive investigation into the patient's medical history to eliminate other causes.

According to a recent literature review published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), "patients with a painful stiff shoulder are frequently diagnosed with frozen shoulder" which is a vague diagnosis because there are many factors that contribute to motion loss in the shoulder, says Robert J. Neviaser, MD, Professor and Chairman of the Department of Orthopaedic Surgery at George Washington University Medical Center in Washington, D.C., who co-authored the review with his son, Andrew S. Neviaser, MD, Assistant Professor in the department.

Adhesive capsulitis is not necessarily the result of an injury. The condition can start out as some soreness in the shoulder before the patient begins to notice some progressive restriction of movement.

Common adhesive capsulitis symptoms include:

• Night pain, and patients typically cannot sleep on the affected side.
• Restricted movement to the extent that patients tend to have difficulty dressing, combing their hair, or reaching into a back pocket.
• Many patients have minimal or no pain once the shoulder gets fairly restrictive in motion, but will notice pain when suddenly reaching beyond the limits of the stiffness.

Populations most at-risk:

• Women between ages 40 and 60 are most prone to develop adhesive capsulitis.
• People with diabetes have an increased risk of developing the condition.
• Persons with less physically active occupations than in persons who perform manual labor—usually the non-dominant shoulder is the one involved.

Managing pain/restoring shoulder movement:
The best way to help restore the patient's range of movement and significantly reduce shoulder discomfort begins with gentle, progressive stretching exercises over weeks, sometimes months, in order to relieve adhesive capsulitis symptoms.

"The first step in treatment is a physical therapy program to stretch the capsule slowly and progressively. This is usually successful. We limit surgical interventions to patients who do not show adequate progress over a period of months of physical therapy, and are still significantly restricted in their movement and function in daily life. If surgery is required, arthroscopic capsular release—removal of the thickened and scarred capsule—has shown improved pain relief and restoration of shoulder function two to five years after the surgery, but while successful, surgery is rarely needed," said Dr. Neviaser.

Notes on diagnosis:
According to Dr. Neviaser, "As a result of an inflammatory process, the joint lining develops scarring which becomes a restraint to movement—like a tether. And within the limits of what that restraint or tether allows, the person is usually uncomfortable, but they can function. If they suddenly reach beyond that, without thinking—such as going to reach for something—then they develop a sharp, severe pain, because what they're doing, effectively, is microscopic tearing of the scar tissue."

"Probably the only condition that is similar during the physical examination is shoulder-joint arthritis," said Dr. Neviaser. "But with shoulder-joint arthritis, when you try to move the shoulder, you often get a ratchety, grinding sensation—which you do not get with adhesive capsulitis, and of course, the x-rays will show the arthritic changes." While MRIs and other imaging tests can be valuable in excluding other causes of the symptoms, they are not generally required for diagnosis.

Disclosure: Neither of the following authors nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. A. Neviaser and Dr. R. Neviaser.

About JAAOS

More information on frozen shoulder, and surgical and non-surgical treatments can be found at http://orthoinfo.aaos.org/topic.cfm?topic=A00071.

To find an orthopaedic surgeon who specializes in shoulders and elbows, visit the American Orthopaedic Should and Elbow Surgeons' website at http://www.ases-assn.org.

SOURCE Journal of the American Academy of Orthopaedic Surgeons