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January 2009: Management of the Stiff Shoulder

01 Jan 2009

Dr. Benjamin A. Goldberg is a board-certified fellowship-trained orthopedic surgeon at Weiss Memorial Hospital. His specialties include treatment of shoulder and elbow disorders. This includes surgery for rotator cuff tears, instability/recurrent dislocations, arthritis, stiffness and trauma.

Management of the Stiff Shoulder

Dr. Benjamin A. Goldberg
Orthopedic Surgeon
University of Illinois—Chicago
(312) 996-1300

In 1934, orthopedic surgeon and medical reformer Ernest Codman, M.D., coined the term “frozen shoulder” to describe shoulder stiffness and pain, saying it was “difficult to define, difficult to treat and difficult to explain from the point of view of pathology.” Others have called this condition “adhesive capsulitis” to describe a “chronic inflammatory process involving the capsule of the shoulder.” Neither of these terms completely addresses the causes of stiffness about the shoulder. Stiffness can be caused by fibrosis (fibrous tissue) or from abnormalities of the shoulder bones, the joints surface, or the muscles and tendons.

Diagnosing the stiff shoulder
The first step to determine the root of shoulder pain is for your doctor to perform a complete health history to reveal any previous surgery, trauma or repetitive injury you may have experienced.

A thorough physical examination emphasizing mobility should detect whether motion restrictions are global (restricted motion in all directions) or focal (selected directions). The majority of stiff shoulders, whether unknown or post-traumatic in origin, occur between 40 and 60 years of age. Although osteoarthritis can cause joint stiffness, radiographs (film records) can easily rule out this condition if they show a normal joint space.

By definition, idiopathic frozen shoulder—or shoulder pain for no known reason—means global stiffness without loss of strength, stability or joint stiffness. Idiopathic frozen shoulder is caused by an abnormal shortening of the muscular tissue within the shoulder that occurs because of a build up of fibrous tissue within the joint enclosure, rather than as a result of a significant trauma or side effect from surgery.

Related conditions
It is estimated that between 3 and 5 percent of the general population is affected by frozen shoulder. The following conditions increase your chances for experiencing a frozen shoulder:

  • Diabetes (up to a 30 percent increase in occurrence and up to a 42 percent increase if experiencing symptoms in both shoulders)
  • Osteoarthritis
  • Hyperthyroidism and hypothyroidism
  • Coronary artery disease, bypass surgery or catheterization
  • Emphysema
  • Chronic bronchitis
  • Pancoast tumors and other neoplasms of the chest
  • Parkinson’s disease
  • Stroke
  • Thoracic outlet syndrome

Treatment for the stiff shoulder
The primary method of treatment for a stiff shoulder is prevention. Immobilization increases the risk of the shoulder becoming stiff after surgery or injury. However, many primary care physicians recommend refraining from moving the shoulder after a strain or minor injury. Nonsteroidal anti-inflammatory drugs or analgesics such as acetaminophen are effective in alleviating pain from shoulder stiffness.

In our experience, the majority of patients can be successfully treated with a strictly home-based exercise program emphasizing stretching. A single instructional visit to the physical therapist is usually adequate, with monthly visits to the physician and therapist to determine whether symptoms and motion are improving. If exercise worsens symptoms, the intensity but not the frequency of stretching is modified, and an intra-articular injection of a local long-acting anesthetic and glucocorticoid may be helpful. Isometric strengthening exercises are begun once motion and comfort have been restored. Resistance strengthening is not started until the patient has recovered functional range and comfort.

If therapy is not successful, surgery may be indicated. Examination under anesthesia usually confirms the restriction of shoulder motion and determines directions of motion restriction. The range of motion of both shoulders is compared. I routinely use arthroscopy, a minimally invasive endoscopic procedure, to release recalcitrant capsular contractures without compromising the integrity of the shoulder.

In summary
A thorough history and physical examination usually reveals the diagnosis (idiopathic frozen shoulder or post-traumatic stiff shoulder) and the anatomical lesions causing stiffness, and identifies other treatable conditions associated with shoulder stiffness (such as diabetes).

Shoulder stiffness can last for several years unless it is properly diagnosed and treated. Analgesics, anti-inflammatory medications and therapeutic stretching exercises are used initially for three to six months. A gentle home program of passive stretching is effective in most patients. When the home program is not effective, a manipulation or surgical release may be necessary.

Operative management coupled with an aggressive rehabilitation program can provide significant relief of pain and restoration of shoulder motion. Approximately 90 percent of patients can expect a good result with these treatment plans.

For more information
If you would like more information about the diagnosis and care of the stiff shoulder, or would like to schedule an appointment, call Dr. Goldberg’s office at (312) 996-1300.