Frozen Shoulder = Adhesive Capsulitis: The Stiff Shoulder

Stiff shoulders are very common in my practice.  Patients often do not even notice that the shoulder is stiff as it is usually a gradual problem that may be present for a while before patients even notice the loss of motion or the pain that accompanies this condition.  

Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.  Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.

Anatomy

 

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

The shoulder capsule surrounds the shoulder joint and rotator cuff tendons.

Description

 

In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.  The hallmark sign of this condition is being unable to move your shoulder - either on your own or with the help of someone else. It develops in three stages:

Freezing

In the"freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

Thawing

Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

 

Cause

 

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Symptoms

 

Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Doctor Examination

Physical Examination

After discussing your symptoms and medical history, I will examine your shoulder. I will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion."  We will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.

Imaging Tests

Other tests that may help us rule out other causes of stiffness and pain include:

X-rays. Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of problems with soft tissues, such as a torn rotator cuff.

Treatment

 

Frozen shoulder generally gets better over time, although it may take up to 3 years.

The focus of treatment is to control pain and restore motion and strength through physical therapy.

Nonsurgical Treatment

More than 90% of patients improve with relatively simple treatments to control pain and restore motion.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.  I generally recommend one injection into the bursa followed by therapy.  Two weeks later, I usually inject the shoulder joint itself with a steroid.  This is a second injection but it goes into a separate part of the shoulder joint so it does not create any issues with excess cortisone.


Physical therapy. Specific exercises will help restore motion. These may be under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before the stretching exercises.. 

I advise patients to stretch frequently throughout the day.  
5 minutes of stretching 5 times a day.  
You should feel some stretching but it should not be painful.  
You cannot do all of the exercises in 5 minutes 5 times a day, but patients can do some stretching in that time.


Below are examples of some of the exercises that might be recommended.

• External rotation — passive stretch. Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

External Rotation - Passive Stretch
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. 
 
• Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.

Forward Flexion - Supine Position
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. 
 
• Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

Crossover Arm Stretch
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Surgical Treatment

If your symptoms are not relieved by therapy and anti-inflammatory medicines, you and your doctor may discuss surgery. It is important to talk with your us about your potential for recovery continuing with simple treatments, and the risks involved with surgery.

The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

Manipulation under anesthesia. During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.
I generally do not advise this as there is risk of fracture and rotator cuff tear.

Shoulder arthroscopy. In this procedure, your we will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.

In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have very good outcomes with these procedures.

This is my preferred treatment if any procedure for frozen shoulder is advised.

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining damaged by frozen shoulder. 

 

Recovery. After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to three months. Some patients will take 6-12 months to achieve maximum recovery.  

 Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.

Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion. In some cases, however, even after several years, the motion does not return completely and a small amount of stiffness remains.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.

From my web site.

Reference

Thanks,

JTM, MD

Biceps Tendon Tear at the Elbow

The biceps muscle is in the front of your upper arm. It helps you bend your elbow and rotate your forearm. It also helps keep your shoulder stable.

Tendons attach muscles to bones. Your biceps tendons attach the biceps muscle to bones in the shoulder and in the elbow. If you tear the biceps tendon at the elbow, you will lose strength in your arm and be unable to forcefully turn your arm from palm down to palm up.

Once torn, the biceps tendon at the elbow will not grow back to the bone and heal. Other arm muscles make it possible to bend the elbow fairly well without the biceps. However, they cannot fulfill all the functions, especially the motion of rotating the forearm from palm down to palm up. This is called supination. Significant, permanent weakness during supination will occur if this tendon is not surgically repaired.

Anatomy

The biceps has two tendons that attach the muscle to the bone in the shoulder and one tendon that attaches at the elbow. The tendon at the elbow is also called the distal biceps tendon. It attaches to the radial tuberosity. This is a small bump on one of the bones in your forearm (radius) near your elbow joint.

Description

Biceps tendon tears can be either partial or complete.

Partial tears. These tears do not completely sever the tendon.

Complete tears. A complete tear will split the tendon into two pieces.

The biceps muscle helps you bend and rotate your arm. It attaches at the elbow to the radius bone on a small bump called the radial tuberosity.

A complete tear of the distal biceps tendon. The tendon is detached from the bone.

In most cases, tears of the distal biceps tendon are complete. This means that the entire muscle is detached from the bone and pulled toward the shoulder. Distal biceps tendon rupture is equally likely in the dominant and non-dominant arm.

Other arm muscles can substitute for the injured tendon, usually resulting in full motion and reasonable function. Left without surgical repair, however, the injured arm will have a 30% to 40% decrease in strength, mainly in twisting the forearm (supination).

Rupture of the biceps tendon at the elbow is unusual. It occurs in only one to two people per 100,000 each year, and rarely in women.

Cause

The main cause of a distal biceps tendon tear is a sudden injury. These tears are rarely associated with other medical conditions.

Injury

Injuries to the biceps tendon at the elbow usually occur when the elbow is forced straight against resistance. It is less common to injure this tendon when the elbow is forcibly bent against a heavy load.

Lifting a heavy box is a good example. Perhaps you grab it without realizing how much it weighs. You strain your biceps muscles and tendons trying to keep your arms bent, but the weight is too much and forces your arms straight. As you struggle, the stress on your biceps increases and the tendon tears away from the bone.

Risk Factors

Men, age 30 years or older, are most likely to tear the distal biceps tendon.

Additional risk factors for distal biceps tendon tear include:
Smoking. Nicotine use can affect nutrition in the tendon.
Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness.

Symptoms

A distal biceps tendon tear can cause the muscle to ball up near the shoulder. Bruising at the elbow is also common.

There is often a "pop" at the elbow when the tendon ruptures. Pain is severe at first, but may subside after a week or two. Other symptoms include:

• Swelling in the front of the elbow
• Visible bruising in the elbow and forearm
• Weakness in bending of the elbow
• Weakness in twisting the forearm (supination)
• A bulge in the upper part of the arm created by the recoiled, shortened biceps muscle
• A gap in the front of the elbow created by the absence of the tendon

Doctor Examination

Medical History and Physical Examination

After discussing your symptoms, your doctor will review the events of the injury to determine how it occurred. During the physical examination, your doctor will feel the front of your elbow, looking for a gap in the tendon. He or she will test the supination strength of your forearm by asking you to rotate your forearm against resistance. Your doctor will compare the supination strength to the strength of your opposite, uninjured forearm.

In addition to the examination, your doctor may recommend imaging tests to help confirm a diagnosis.

Imaging Tests

X-rays. Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause elbow pain.

Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears.

Treatment

Nonsurgical Treatment

Nonsurgical treatment may be considered for patients who are elderly and inactive, or who have medical problems that make them high-risk for modest surgery.

Patients must weigh the decision to proceed with nonsurgical treatment carefully, because restoring arm function with later surgery may not be possible.
The tendon should be repaired during the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten.
While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.

Surgical Treatment

Procedure. Doctors use several procedures to reattach the distal biceps tendon to the forearm bone. Some doctors prefer to use two incisions, while others only one incision. There are pros and cons to each approach.

Sometimes the tendon is attached with stitches through holes drilled in the bone. Other times, small metal implants are used to attach the tendon to the bone.
Be sure to carefully discuss the options available with your doctor.

X-rays showing metal implants called suture anchors that have been used to secure the biceps tendon to the bone.

Complications. Surgical complications are generally rare and temporary. They occur in about 6% to 9% of patients.

• Numbness and/or weakness in the forearm can occur and usually goes away.
• New bone may develop around the site where the tendon is attached to the forearm bone. While this usually causes little limitation of movement, sometimes it can reduce the ability to twist the forearm. This requires additional surgery.
• Rerupture after full healing of the repair is uncommon.

Rehabilitation. Right after surgery, your arm may be immobilized in a cast or splint.
Your doctor will soon begin having you move your arm, often with the protection of a brace. He or she may prescribe physical therapy to help you regain range of motion and strength.
Resistance exercises, such as lightly contracting the biceps or using elastic bands, may be gradually added to your rehabilitation plan.
Be sure to follow your doctor's treatment plan. Since the biceps tendon takes 2 to 3 months to fully heal, it is important to protect the repair by restricting your activities.
Light work activities can begin soon after surgery. But heavy lifting and vigorous activity should be avoided for several months.
Although it is a slow process, your commitment to your rehabilitation plan is the most important factor in returning to all the activities you enjoy.
Surgical Outcome. Almost all patients have full range of motion at the final follow-up doctor visit.
After time, return to heavy activities and jobs involving manual labor is a reasonable expectation.


From the AAOS.org


Thanks,


JTM, MD