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Frozen shoulder describes a condition in which the movement of the shoulder becomes limited. This condition can develop for many reasons, but it is very painful and can have a serious impact on your daily life. Luckily, with physical therapy, exercise and other interventions, frozen shoulder is very treatable. Orthopaedic sports medicine specialist Dr. Vikas Patel explains about what causes this condition —and the best ways to approach treatment.

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What to Know About Frozen Shoulder with Dr. Vikas Patel

Podcast Transcript

Intro:
There's so much health advice out there, lots of different voices and opinions, but who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough intimate health questions so you get the answers you need. This is the Health Essentials podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Annie Zaleski:
Hello, and thank you for joining us for this episode of the Health Essentials podcast. I'm your host, Annie Zaleski and today we're talking about frozen shoulder with orthopedic sports medicine specialist, Dr. Vikas Patel. Frozen shoulder, which is also known as adhesive capsulitis, describes a condition in which the movement of the shoulder becomes limited. The condition can develop for many reasons, but it is very painful. It can have a serious impact on your daily life. Luckily with physical therapy, exercise and other interventions, frozen shoulder is very treatable. Dr. Patel is here to talk about what causes frozen shoulder and the best ways to approach treatment. Dr. Patel, thanks so much for being here.

Dr. Vikas Patel:
Thanks for having me.

Annie Zaleski:
So first off, talk to us a little bit. What is frozen shoulder?

Dr. Vikas Patel:
So frozen shoulder, also known as adhesive capsulitis, is a term where the capsule or, I like to call it a balloon that sits around the shoulder joint has shrunken down, and usually due to adhesions it has shrunken down and in turn causing pain and limited motion of the shoulder.

Annie Zaleski:
So, as far as I know there are three stages of frozen shoulder. Is that correct?

Dr. Vikas Patel:
Yeah. We do have terminology for the three stages and it's pretty simple. Freezing, frozen and thawing. So, the three stages just go through the range and the pain levels, those sort of things like that. So in that early stage, the first stage of freezing, that's where we're seeing some of the onset of the pain, some of the motion is decreasing, those sort of things like that. Then it gets to a point where it's frozen and that's where it's stuck at that point where pain is at that level, the motion is staying at that level. And then the thawing phase, the third phase is where it's opening up and that's where we're seeing that the is improving, the pain is improving with that.

Annie Zaleski:
Excellent. So how common is frozen shoulder then?

Dr. Vikas Patel:
It's relatively common. I think from a incident standpoint of a general population, it ranges from about three to five percent of general population. It is a little bit more common in diabetics. Most recent numbers are around 20% of diabetics do develop frozen shoulder.

Annie Zaleski:
So why does someone end up developing frozen shoulder? Why would a diabetic develop frozen shoulder maybe more than someone else in the population?

Dr. Vikas Patel:
That's a good question and I don't think we fully understand why diabetics have a higher correlation of developing frozen shoulder, but along with why else could it happen mainly it's due to decreased motion. So it's a lot of times we'll see it post surgical where it needs to be in slings and immobilization. Sometimes it will occur after an injury and subconsciously as anybody would if we injure a body part, we use less of it. And in turn that can kind of cause the adhesions and the capsule to shrink down and develop a frozen shoulder.

Annie Zaleski:
So in addition to diabetes, are there other conditions in particular that might make people more at risk for developing this?

Dr. Vikas Patel:
There's some thought in some autoimmune disorders that there could be some correlation with that. There's also a enzyme called HLA-B27 that has a higher correlation with frozen shoulder as well.

Annie Zaleski:
So what shoulder injuries or injuries to the upper part of the body might make people more prone to developing frozen shoulder?

Dr. Vikas Patel:
So a lot of times when you could have a fall and you injure your rotator cuff and that sort of thing like that, again, we have a kind of defense mechanism built into us that we're going to not use the shoulder as much. And in turn that can make the capsule angrier, develop the frozen shoulder and make that worse. Along with that, you can injure the capsule. So remember the capsule is the balloon around the shoulder joint. You can injure that capsule when we have a fall or sometimes, more commonly with a fall, but sometimes reaching too far, grabbing something and lifting something heavily, that sort of thing like that can anger the capsule as well.

Annie Zaleski:
Is there a typical age range where someone might develop this or could it develop at all ages?

Dr. Vikas Patel:
More commonly we see is age range of 40 to 60 years old. A lot of times after 60 it could be issues of arthritis as a problem. Under can be the joint is still developing, capsule, everything is still developing. So more commonly we see is 40 to 60. And going along with that kind of population group, females are a little bit more common to develop this than males are.

Annie Zaleski:
Do doctors know why that is?

Dr. Vikas Patel:
Again, that's something that we don't fully understand why. I think that's just one of those many mysteries of why certain diseases are in certain genders or race or anything like that. Just, there's not a full understanding on that.

Annie Zaleski:
So what are some common symptoms of frozen shoulder? How do you know you have this?

Dr. Vikas Patel:
So, the two most common symptoms are going to be pain and decreased range of motion. Pain is usually one that is significant. It's more than just kind of oh, it's a sore achy, it's a significant if I move my shoulder any little bit. And then decreased range of motion, a lot of times that progressively gets worse to a certain degree to a certain point. And then you're stuck at that point and just not able to improve that range of motion.

Annie Zaleski:
Does frozen shoulder tend to come on right away or is it something that develops over time?

Dr. Vikas Patel:
More commonly it is a gradual onset. If we think about that capsule or that balloon kind of shrinking down that can take time to occur. So capsule shrinking down, those adhesions occurring and the pain worsening, the range of motion worsening. And so in that freezing stage that can vary two to six months of where that pain increases over that timeframe, that decrease motion worsens over that timeframe. And so a lot of times it is a gradual onset rather than, "I woke up and the next day I have frozen shoulder."

Annie Zaleski:
So speaking to that, I think a lot of times people worry about that sleeping in an awkward position or moving their arm the wrong way could make frozen shoulder worse. Is that something people should worry about?

Dr. Vikas Patel:
That is not something to worry about. In fact, what we want is, is we want motion with the arm and with the shoulder to try to help open up that capsule or that balloon. So sleeping on it wrong or stretched out or any which way that won't have an effect on frozen shoulder itself. It's just a matter of comfort level. So what I usually say to patients is that whatever feels comfortable sleeping wise, however it is, sleeping on your opposite shoulder, sleeping on your back, whatever it is that's comfortable, that's the best position for you.

Annie Zaleski:
Are there any activities that you could do that might make frozen shoulder worse or exacerbate some of the pain and symptoms?

Dr. Vikas Patel:
So this is the same thing where it comes down to the symptoms. So again, what we want with the frozen shoulder is range of motion. We want the patients to be able to move their arm and try to break open those adhesions and break open that scar tissue. And so again, kind of pain as our guide. So if there's certain activities that bother it, well then, obviously we need to be monitoring that and consulting with a health professional and that sort of thing like that. But if there's certain things that are not bothering it and it's kind of helping and keeping things loose then that's what we want.

Annie Zaleski:
What do you typically hear from people when they talk about how frozen shoulder affects their daily lives?

Dr. Vikas Patel:
Absolutely. So if you can imagine, your shoulder normally moves in a large capacity and it's free and all that. If we shrink it down and now you only have 25% of what you normally can do with that shoulder or that arm, or 30%, 50% think about day to day activities that you could normally do reaching up at above the fridge or at that high counter to grab a coffee cup, reaching back and behind the car, those sort of things like that. Now those motions are limited because of the shrunken capsule and so now you can't do that, and on top of that it hurts to do that. So to think about those sort of things of everyday activity. When we see patients with these it's everyday things that bothers the patients with. And like I said, the pain is pretty significant with these.

Annie Zaleski:
That's probably a really good sign then, too, if you suspect you might have it. If you're finding that there's more difficulties in pain doing activities you normally would do easily, I would imagine.

Dr. Vikas Patel:
Absolutely. Yeah. So we get that all the time where, it was doing good and over the last couple months just progressively getting worse of just, I can't can't reach up high enough. I can't reach back behind me far enough. Plenty of women that say I can't reach to do my bra strap, I can't reach to do my hair. Those sort of things like that where you're just like noticing worsening over weeks and months of those symptoms.

Annie Zaleski:
Let's move on to start talking about diagnosis and treatment. How is someone diagnosed with frozen shoulder? And what do doctors do to kind of determine that this is the diagnosis?

Dr. Vikas Patel:
Yeah. So when we see patients in the office, we do like getting an x-ray. We would prefer getting an x-ray for this. The main reason is that frozen shoulder will not show up on x-ray, but the main reason is to rule out other causes, in particular arthritis. Arthritis can kind of be a similar symptom profile of pain, decreased range of motion in the shoulder. So that's the first thing that we like to do is get an x-ray, rule out any other causes that could be causing pain, decreased range of motion. Then obviously taking a history of how long things have been going. Has there been an injury, anything like that? And then the main thing that we look at is range of motion. So we check the range of motion of going straight up with the arm, straight out and up with the arm and then kind of in and reaching out.

So we measure the right shoulder versus the left shoulder, or what have you, and see if there's a difference in range of motion. If there's a difference in range of motion and it's the fact that I am forcing you, and I cannot force you to get up any higher or any further as far as range of motion, then we start thinking of frozen shoulder as a cause of pain. We also test the rotator cuff along with other parts of the shoulder to make sure that there's no other, again, underlying injury that could be causing the pain, decrease of motion, those sort of things like that. So if all the other tests check out, rotator cuff testing, your labrum testing, everything else in the shoulder check out, and it's the pain and the range of motion that's our issue then frozen shoulder is generally our diagnosis.

We generally do not need MRIs for these. A lot of times MRIs again, will be used for to rule out other causes of pain and issues with the shoulder. Sometimes we won't see any findings of frozen shoulder on MRI. Sometimes we do see some thickening of the capsule, some of those things like that.

Annie Zaleski:
You know, I think that brings up a good question. Can someone have frozen shoulder in both shoulders at the same time?

Dr. Vikas Patel:
You normally see it in one shoulder at a time. It's not unreasonable to have it in both shoulders. Thinking back, just kind of off the top of my head, I think I may have had one case of where we had it on both sides over the years. So it's not impossible, don't get me wrong there. That's where we're going to see that it's going to be more of an underlying issue of like a diabetic that might be more common we'll see that in. So, like I said, it's not impossible, but not very common.

Annie Zaleski:
If someone's been diagnosed with frozen shoulder what are some common treatments?

Dr. Vikas Patel:
So there's a multitude of things that can be done. Again, our main goal is to get that capsule, that balloon that sits around the shoulder back to its normal size. So honestly, if you left it alone, if the patient left it alone and just did everyday stuff and went on with life, it would actually go back to its normal self. Now on average, unfortunately, that can be two to three years. So, obviously not many people want to be decreased range of motion and in pain for that timeframe. There's a lot of things that we could do to help expedite those things. So one of the mainstays that we do is physical therapy, and that's where a physical therapist can help, what we call passive range of motion, where they help you move that arm and try to open up that capsule so it frees up. So, that's one of the mainstays of treatment that we do.

Another treatment that we do to help more with discomfort and pain is a cortisone injection. Cortisone, strong anti-inflammatory, usually inflammation is a process, usually a cause of pain in this. So cortisone can help decrease the inflammation involved and help with the pain, and in turn also help tolerate the physical therapy exercises, those sort of things like that. So, the two mainstays of treatment are cortisone injection and physical therapy. Your end stage or last resort is surgical treatments. There are a couple surgeries that can be done.

One of them is what's called a manipulation under anesthesia. So basically what's done is you're taken to the OR, you're put under anesthesia and, it sounds a little barbaric, but basically what's done is that we manipulate your arm and shoulder to try to help open up that capsule. Then the second one, which sometimes can be done in conjunction with the manipulation under anesthesia, is sometimes done on its own, is a capsule release, where this one is a lot less barbaric where it's done through a scope. So small little incisions and what they do is just cut the capsule open and try to expand it that way. But obviously with surgery, there's always risk involved with that with any surgery.

Annie Zaleski:
The exercises that people are doing, what are some common ones, and would this be something that people would also do at home after physical therapy?

Dr. Vikas Patel:
Absolutely. So I think that's a key component for all physical therapy, but definitely with this, is that not just the exercises while in physical therapy and seeing the physical therapist, but also the home program. So a lot of the things we do and teach is more of like towel stretches. So taking a towel and reaching back and reaching forward, reaching out to the side, those sort of things like that. You know, you could use a band doing those things as well. What we call pendulum exercises of dangling the arm down and doing circle motions, going up and down, left and right. And also a third one would be like climbing the wall and trying to reach up higher and higher every few times that you do that.

So it is very important, no matter what kind of treatment is done for this, especially for a physical therapy standpoint, it's very important that the home exercises are key with this, because just doing it the one time or once a week, once every couple weeks with the physical therapist is just not enough. So, we have to be very cognizant about being good about it at home as well.

Annie Zaleski:
So how quickly would you see results after starting treatment?

Dr. Vikas Patel:
So, that's something that varies. If we do catch it earlier on it is a little bit easier to open up, but if we catch it where it's more in that freezing phase, then it's a little bit easier to pass through that frozen phase and get into the thawing phase which is where we want it to be. So, it does vary. Again, on average of leaving it alone, two, three years. With those sort of things, we can help try to expedite that to maybe more months or maybe like a year, sort of thing.

Annie Zaleski:
That was actually going to be one of my questions too, is how long does this treatment last? Is it till the pain is gone? Can you ever be cured from this?

Dr. Vikas Patel:
So yes you can be cured from this. My recommendation is always that continuing with all the modes of treatment as long as we need to until pain is gone and the range of motion is back to near completely normal. Usually the pain will go away quicker than the range of motion will come back. So I think just keeping up, again harp on therapy exercises, but keeping up with those is a super important part of improving the range of motion.

Annie Zaleski:
So one treatment for frozen shoulder is called a brisement procedure. What is this? And when might someone with frozen shoulder get this done?

Dr. Vikas Patel:
So this is something that's a little bit newer and exciting, especially here at the Cleveland Clinic that we're doing a version of that with some additive things into it. So what is a brisement procedure? How to explain it is a hydro dilatation. So what we do, it's an injection procedure done in the office, done under ultrasound guidance. What I do is we do give a numbing injection around the nerve to kind of numb up the arm, make it a little bit more comfortable. Then we take a large amount of fluid, about 20 cc's or 20 milliliters of fluid that is a concoction of numbing medicine, sterile water, and then steroid as long as they're a controlled diabetic. So we take that concoction and inject it into the capsule to try to expand the capsule. And in turn, try to also at the same time as it's expanding, it's breaking up those scar tissue, breaking up the adhesion.

There's been some studies that show that that is somewhat effective in improving range of motion. The cortisone part does help with the pain, but what we're doing more recently here at the Cleveland Clinic is we're doing that procedure and then immediately right after doing that we're having you see the physical therapist. Then the physical therapist will do some passive range of motion stretching. So we want to take advantage of while the shoulder's feeling is full up and kind of expanded, and the numbing injection helps calm down some of that pain, that we can expand that capsule even more by stretching it out through the physical therapy. With these two combined, which hasn't really been done, and this is what's been exciting, we've seen significant improvement and significant results with this where a month after an injection procedure like this, we see decreased pain where we have minimal to no pain and significantly improved range of motion where, it's not complete, and we reiterate, it's not complete, but patients are very satisfied with the amount of range of motion that's improved, and most importantly also pain relief.

Annie Zaleski:
Who's a good candidate for having this procedure?

Dr. Vikas Patel:
So, that's something that we continue to look at. In my opinion, I have started to just start off with that procedure now and go straight into it. And then from there going into still going to have the physical therapy, still going to have the follow ups with that. Now you could always consider just doing a regular cortisone injection, maybe if it's like an earlier phase, that sort of thing like that. But, a lot of times when patients are coming to us, they've already in that frozen phase and it's been going on for a while. And so I kind of counsel the patients saying this is our options. Most patients would agree and say, yep, let's do that after I explain that this helps expedite even faster.

Annie Zaleski:
Now, the more involved surgical procedures you mentioned, at what point does a doctor determine, okay, this is what we're going to have to do because other interventions are maybe not working?

Dr. Vikas Patel:
The question of when do we proceed to surgery is very patient dependent. So we want to exhaust all of the options, physical therapy, cortisone injections, brisement procedures if that's a possibility, and the last resort is the surgical option, because there are risks with the surgery involved. And so there is no set timeframe or anything like that. There's no really number of injections. It really does come down to the surgeon and the patient and kind of alright, we're not really getting anywhere with any of these treatments. I think it's time to move on and get to the next step.

Annie Zaleski:
So if someone is undergoing treatment for frozen shoulder are there any activities or things that you should avoid just to make sure you're not making anything worse?

Dr. Vikas Patel:
I think, again, we want motion. Motion is important for this. So we actually want you to try to be as active as you can. So keeping it moving, and again, pain is your guide, but trying to keeping it as loose, keeping it as moving, that sort of thing like that. A lot of common things that we see after we injure ourselves again with frozen shoulder is that we stop using it. And so that's where frozen shoulder can develop. So, we want to get things moving. We want you to try to be as active as possible.

Annie Zaleski:
So is there anything else we haven't talked about or any angles that you maybe want to mention we haven't discussed yet?

Dr. Vikas Patel:
No, I think we covered a lot of different things about frozen shoulder here today. I think it's just important to have patients know that this is very painful and very debilitating for the patient in the fact of how much it affects their daily lives. And so definitely if you're starting to think of that, definitely come in, start seeing one of our healthcare professionals and have it evaluated and take it from there.

Annie Zaleski:
Awesome. Thank you so much, Dr. Patel, this has been really interesting. I appreciate your time today.

Dr. Vikas Patel:
Absolutely. Thanks for having me.

Annie Zaleski:
Frozen shoulder is a painful, but treatable condition. Working closely with your doctor other healthcare professionals, including a physical therapist can help alleviate pain and restore range of motion. If you'd like to find out more information about frozen shoulder treatment, please visit Clevelandclinic.org/sportsmedicine.

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