Adhesive capsulitis, otherwise known as frozen shoulder, causes severe shoulder stiffness and pain. It begins gradually without an obvious cause. Most patients first notice it as a pain when they reach. Soon the shoulder hurts continuously and lacks movement.

Adhesive capsulitis results from inflammation of the joint capsule. The joint capsule is a stretchy, loose sack which creates a water-tight seal around the joint to contain the lubricant fluids. When it becomes inflamed, the capsule tightens and thickens, "shrink-wrapping" the joint to limit movement. The inflammation makes the capsule very painful when stretched.

Adhesive capsulitis affects people in mid-life, women more often than men. There is some family predisposition. People who get it in one shoulder have a 15% chance of getting it in the other shoulder. Scientists do not know the cause, but a virus, auto-immune disorder, or misguided injury repair are possibilities. A particularly tough form of adhesive capsulitis can occur in diabetic patients.

Adhesive capsulitis is generally self-limited and will resolve over two years without treatment. However it is so painful most patients want treatment to get better quicker. Fortunately, adhesive capsulitis rarely re-occurs in the same shoulder.

Adhesive capsulitis is different from rotator cuff tendonitis, although they can be hard to tell apart at first. Rotator cuff tendonitis is caused by pinching of a tendon. Adhesive capsulitis hurts to move in any direction, whereas rotator cuff tendonitis hurts just to move in certain ways. One good physical test to distinguish the two: adhesive capsulitis limits external rotation, whereas rotator cuff problems do not. Rotator cuff tendonitis also does not hurt as much during the day. Treatments for adhesive capsulitis and rotator cuff tendonitis are different, and sometimes we distinguish them by seeing which treatment works.

Adhesive capsulitis is also different from other causes of shoulder stiffness. Arthritis of the shoulder can make it stiff, but the diagnosis is usually evident from x-rays. Also patients may have stiffness from prior surgeries. This is not the classic adhesive capsulitis, and treatment may be different.

The course of adhesive capsulitis is described to have three phases. The inflammatory phase occurs at the onset, has intense pain, and has progressive stiffness. The frozen phase is much less painful but stiffness persists. The thawing phase is a distinct improvement in range of motion over several months.

Most treatment for adhesive capsulitis aims to convert the inflammatory phase to the frozen phase. This relieves the pain. Most patients are then willing to wait for the disorder to resolve on its own.

In the past we thought physical therapy was the best way to get back range of motion. Now we believe it may be counter-productive and unnecessarily painful during the inflammatory phase of adhesive capsulitis. Frequently patients have already tried therapy before they come to our office.

Instead of therapy, most shoulder surgeons recommend a cortisone injection into the joint. A shot into the joint is different from one into the shoulder bursa given for rotator cuff tendonitis. That is why many patients with adhesive capsulitis say their prior cortisone shot "didn't work." The shot into the joint is no more painful, just a less common technique.

A cortisone shot into the joint dramatically relieves the painful inflammatory phase of adhesive capsulitis. It works best when done early in the disease, because the extent of fibrosis or stiffening of the capsule is less. Sometimes it takes a second shot a few weeks later to get the desired effect. Additional shots are not recommended because the side-effects of cortisone start to outweigh the benefits.

Oftentimes the cortisone shot reduces pain by 50% or more. I also give patients anti-inflammatory medication, pain medication, and a home stretching program. Usually the problem goes away in a few months with no sequelae.

Sometimes the cortisone shot doesn't help much. First, I check to make sure the diagnosis is correct with more x-rays, an ultrasound, or an MRI test. We might try treatment for rotator cuff tendonitis with a cortisone shot into the shoulder bursa. If it still appears to be adhesive capsulitis, I recommend a new trial of physical therapy. If the therapy doesn't work we will consider manipulation or arthroscopic surgery.

Shoulder manipulation sounds medieval but it actually works very well. It involves putting the patient briefly to sleep, moving their arm, and giving them a cortisone shot in the shoulder joint. This breaks up the scar tissue in the joint capsule. It is like having 100 physical therapy visits rolled into one. Surprisingly, the shoulder is not very painful afterward. The very tender scar tissue is no longer stretched, so it doesn't hurt as much. We start therapy within a day or two to maintain the gain in movement. Most patients say manipulation is a giant step toward getting better.

Arthroscopic surgery can be used in conjunction with manipulation. It is helpful if patient has elements of both adhesive capsulitis and rotator cuff tendonitis. Usually I check your x-rays for any evidence of spurs which can cause rotator cuff tendonitis. If you have them, I recommend the arthroscopic surgery to remove the spurs at the same time as the manipulation. If the spurs are absent or small, I do not recommend the arthroscopy. In these cases I believe less surgery is better.

The past ten years have really increased our understanding of adhesive capsulitis. Please share this information with your friends and primary care doctor so we can improve treatment of the next person.