The capsule of the shoulder is the deepest layer of tissue that connects the ball and socket of the shoulder. In the stiff shoulder, this capsule has lost its normal flexibility, severely restricting shoulder mobility. The medical term for this is adhesive capsulitis. If a tight painful shoulder is not associated with joint surface destruction such as arthritis, then it is usually the result of capsular stiffening and adhesions. This tight shoulder condition is frequently termed a "frozen shoulder". It is known to cause chronic aching pain which is typically worse at night and often aggravated by movement. Motion is usually lacking in all directions.
The first line of treatment is to restore the normal mobility of the shoulder using an exercise and stretching program. This involves your commitment and persistence with frequent stretching exercises, at least five times every day for a few minutes. Some patients, such as those with diabetes, may have a particularly refractory type of frozen shoulder requiring more than the usual home exercise regimen. Patients with this condition benefit greatly from working with a physical therapist regularly in addition to their home program. Six weeks of adherence to this program will usually produce noticeable results. Most of the time this treatment produces satisfactory improvement. If it does not, steroid injection can sometimes decrease the pain and "jump start" the progress with motion. SURGERY IS USUALLY NOT NEEDED, but if it is, surgery is generally very successful. It is important for patients to understand that they should look for improvements in MOTION before decrease in pain. Consider improvements in motion to be encouraging, when the motion is closer to normal pain will decrease generally.
When exercises and possibly injection has failed to produce improvement, we consider more aggressive measures such as manipulation under anesthesia (sometimes with injection of cortisone-like agents), and surgical release of tissues that are tight. Usually, the release can be done by minimally invasive arthroscopic techniques. Manipulating a frozen shoulder involves gentle stretching of the shoulder in all directions. Open release of a frozen shoulder involves lengthening the tight tendons restricting motion, along with division and removal of the thick-contracted capsular tissue. Often arthroscopy (looking inside the shoulder through several small incisions) can be an effective way to determine the possible cause of stiffness and to avoid major "open" surgery on your shoulder. Arthroscopy can also be very effective at times to release the tight capsule and remove excess scar formation. Rarely but especially in the setting of previous surgery, an open surgical procedure may be necessary. The amount of time you may be in the hospital depends on your level of discomfort and your ability to maintain the increased motion obtained at surgery. If this procedure is done as an outpatient, it is critical that arrangements be made before surgery to have physical therapy the next day. Often it is best to make arrangements to stay in the hospital for aggressive therapy for the first few days to be sure and maintain improvements in motion.
Once a full range of motion has been restored with manipulation or surgical release, we immediately begin motion. Early motion is critical to maintain free mobility of the joint. The raw surfaces of released tissues will rapidly stick together again if held in one position (as in a sling). This passive motion, (machine or therapist assisted), must be coupled with your active participation in a program designed to help you maintain and augment your gains. Your own personal motivation and dedication is important to your recovery.
The risks of closed manipulation include fracture, tearing of the tendons and recurrence of stiffness. The risks of surgical release include recurrence of stiffness and risks similar to any operative procedure: nerve or muscle injury or loss, bleeding, and superficial or deep infection. Both manipulation and surgical release carry a small risk of general systemic (such as heart or lung failure) or anesthetic (such as allergic reactions) complications. If you have specific questions or concerns regarding possible complications, please ask your doctor.
In summary, this treatment program requires a dedicated effort on your part to resist the natural tendency to rest your shoulder. Those who gain the best motion and comfort motivate themselves with persistent stretching exercises. We will provide you with illustrations that review specific exercises on your own. Sometimes we allow you to do all the exercises on your own, but often people need the guidance and assistance of their own therapist. We will work with you to restore your shoulder motion and comfort. We will need to check your shoulder motion on a frequent basis to assure optimal progress.