What is adhesive capsulitis (frozen shoulder)?

As the name frozen shoulder suggests, sometimes a patient who has had intermittent shoulder complaints (retrospectively, minor rotator cuff injuries) may notice stiffness as their primary complaint. In these patients, pain upon extremes of motion is the main complaint. This pain occurs with motion in virtually any direction. Although adheasive capsulitis (frozen shoulder) can occur without any history of rotator cuff problems, it is certainly quite common for rotator cuff complaints to precede adhesive capsulitis by months to years. At any rate, in these people, there is little evidence of impingement or inflammation. Instead, the normally flexible shoulder joint becomes limited in almost all planes of motion, and the patient’s function is greatly impeded. For example, patients may present to their physician with the complaint that “I cannot fasten my bra” or “I cannot comb my hair”. This condition can be extremely disabling despite lack of inflammation and despite normal strength within the range of motion which the patient has maintained. Unlike the other rotator cuff disorders mentioned above, in adhesive capsulitis the mainstay of treatment is to regain full flexibility by gradually pushing the limits of range of motion to the point of pain.

How are rotator cuff conditions treated?

The most crucial aspect of treatment is the avoidance of impingement. This means avoiding upward and outward activities or at least reducing their frequency. However, in order to avoid developing a frozen shoulder, one full range of motion per day should be performed by the patient. This includes forward elevation, external rotation, and internal rotation. (examples of these exercises are shown.) In patients who are more acute or who cannot remember to avoid impingement, immobilization in a sling for several days can be quite useful. Generally, anti-inflammatory medications are quite beneficial in this condition. Often, physical therapy can provide modalities such as ultrasound or electricity, which can help to reduce the inflammation as well. At times, if inflammation is persistent, introduction of medication can help to reduce inflammation. This can be done by use of electricity (iontophoresis) or ultrasound (phonophoresis) where the medication is driven near the tendons without necessity for the condition. Frequent injections are to be avoided since cortisone can cause further weakness of a tendon which is often already injured. In addition, physical therapy can be useful in reducing the fibrosis (scar formation) that results in inflexibility of the rotator cuff tendons. This can help to reduce symptoms and prevent the future likelihood of injury.

What can be done to prevent progression or future injuries to the rotator cuff?

It is important to fully rehabilitate the rotator cuff tendons. This includes strengthening of the tendons of the rotator cuff. This is especially important because the muscles which perform opposing actions, the chest and back muscles (pectoralis and latissimus dorsi) are naturally much stronger than the rotator cuff muscles. As a result, once a rotator cuff injury has occurred, this mismatch of strength in the shoulder region is even more greatly accentuated. It is vital that exercise address this mismatch and regain the normal strength ratio in the shoulder girdle in order that proper mechanics of the shoulder joint be restored. In addition, avoidance of predisposing factors is of great importance. For example, when playing tennis, throwing the ball at “two o’clock” instead of directly overhead (“twelve o’clock”) reduces the likelihood of impingement. Similarly, swimming and throwing techniques can be varied and weight lifting regimens modified to avoid recurrence of impingement.

Lastly, there are people who despite the best management, require a surgical procedure because of repeated episodes of impingement. It is comforting that, due to the advance of arthroscopic surgery, this procedure often can also be performed without a major incision and a prolonged healing period.