Frozen shoulder is a descriptive term for a problem in which a shoulder begins to lose motion just as if it were “frozen”. This is a very well described but poorly understood problem. It is more common in women than men and most commonly occurs in the 50’s. Far and away the most common history is for the shoulder to develop stiffness spontaneously. However, a frozen shoulder can occur after a minor trauma, a fracture, after extremity surgery or sometimes even with neck pain. Whatever the cause, the shoulder begins to lose motion and becomes stiff. As the arm stiffens it is painful to push the shoulder to the extremes of motion. The natural tendency is to restrict the motion from these painful portions of the range of motion. The shoulder then becomes stiffer. Finally, it’s painful to move to new areas and it becomes a vicious cycle to where the shoulder is so painful the individual cannot even raise the shoulder above eye level.

It is unclear what exactly causes a frozen shoulder but probably begins with an inflammation of the capsule (the housing around the shoulder joint). We do know that the reason the shoulder motion is restricted is that the capsule shrinks, just as “heatshrink” plastic wrap on packaging. As this capsule contracts, the shoulder volume decreases and the shoulder gets progressively tighter. No one understands why but this can be caused by several different mechanisms.

Treatment consists of exercise, exercise and more exercise! This is one area of medicine where you should definitely work to the point of discomfort. Usually simple exercises at
home are all that is necessary. Occasionally formal physical therapy is required.

Even more rarely, a manipulation under anesthesia or even an arthroscopy is necessary. This is a procedure where you are put to sleep and the surgeon stretches the shoulder to achieve full range of motion. Usually only one manipulation is necessary. Afterward aggressive physical therapy is necessary to maintain the new gains in motion.

At least one research study has shown that if left alone a frozen shoulder almost always improves. Unfortunately this takes 5-7 years and few people are willing to wait that long. Therefore, the more aggressive approach is the one that is usually recommended. Either way, the long term results are usually good and doesn’t usually lead to arthritis or restricted range of motion.

2010 © G. Klaud Miller M.

Rotator cuff disease is a common problem. The rotator cuff consists of the fusion of the tendons of four muscles (the subscapularis, supraspinatus, teres minor and teres major) that surround the shoulder joint. Their job is to 1) turn the shoulder in, as if going into your back pocket, 2) to turn the shoulder out, as in twisting the arm with the hand away from the body and the elbow at your side, 3) to stabilize the shoulder and initiate the motion of lifting your arm overhead. They provide a secondary stabilizing mechanism in shoulder dislocations.

Rotator cuff disease is very common and a rotator cuff tear can be present in as many as 50% of the people who have no shoulder symptoms by the age of 65. Rotator cuff injury or degeneration is more common on the dominant side in people who perform jobs which require a lot of shoulder motion, such as painting, wall papering and carpentry. Similarly, sports which involve a lot of overhead throwing such as baseball or tennis may also contribute in some people.

There are two common ways for rotator cuff disease to manifest itself. The most common is for the 50-60 year old active person to begin to have shoulder pain. Commonly there is pain at night and after heavy activity. The painter may notice difficulty reaching high spots and will usually develop more difficulty later in the day. A common, but not universal finding, is for a biceps tendon to rupture. Some authorities may argue that this does not occur unless there is already rotator cuff disease. The same authorities advocate routine exploration of the shoulder joint for a rotator cuff tear whenever a biceps tendon ruptures.

The actual rupture of the rotator cuff tendons themselves may be in an acute traumatic episode such as a fall or a sudden twist. The more common scenario is for an insidious onset of pain over several months or even years. It is usually the pain at night which prevents sleep that brings the individual in to see us.

The pathology is actually degeneration and wear of the tendon itself. The blood supply to the tendon comes from either end and there is a “watershed” area in the middle which has a very poor blood supply. Unfortunately, this corresponds almost exactly with the area of maximum impingement on the tendon from the bone (acromion) above it and the ball part of the humerus below the tendon. The net effect of use and abuse over many years is wear and the tendon may ultimately fail. The pain is classically caused by bringing the arm up sideways to an overhead position.

IMPINGEMENT SYNDROME

Impingement syndrome is a variation of “standard” rotator cuff tendinitis. It occurs in a much younger group anywhere from age 20-40. It is almost universally in young individuals who are active in overhead throwing type sports. The symptoms are primarily pain with lifting your arm forward (as if you were going to paint a wall). There will frequently be pain at night and restricted motion secondary to pain.

Because the rotator cuff usually does not tear, range of motion may not be inhibited at all.

The patient may notice pain only with or after significant throwing. A common finding is a “hooked” acromion. The acromion is the bone above the rotator cuff tendons and it should be smooth or minimally curved. If there is a very large hook or spur anteriorly, the rotator cuff tendon will be pinched every time the arm is lifted forward. This causes the rotator cuff tendons to become irritated and inflamed.

There are classically three stages to the impingement syndrome; 1) The stage of inflammation usually responds to exercise and anti-inflammatory medicines. This stage is totally reversible. 2) The stage of hemorrhage and fibrosis. In this stage there may be some permanent residual damage. The shoulder function is usually mildly to moderately compromised. 3) Actual tear of the rotator cuff.

TREATMENT

Treatment of rotator cuff disease depends upon the age of the person, mechanism of injury, time from injury to treatment as well as the functional demands of the patient. The initial treatment of impingement syndromes or rotator cuff tendinitis is anti-inflammatories and exercises. In the vast majority of people the shoulder will respond very well. Even with a true rotator cuff tear, the older individual may achieve perfectly satisfactory function with exercises, anti-inflammatory medicine and activity modification. If the pain does not improve over 2-3 months of anti-inflammatory medication and rest, then surgery is indicated. The reason to perform surgery is for pain relief. If the person has very poor motion but no significant pain, repair is not generally recommended for that particular shoulder. Range of motion frequently is not improved after surgery. If you don’t have full motion before surgery, surgery will probably not improve your motion. Pain is the only thing that is consistently improved.

The first step is an arthroscopic acromioplasty. In this procedure the hook of the acromion is burred down flat to remove the bony pressure on the rotator cuff. Scar tissue can also be resected. If the rotator cuff is intact this procedure may be all that is necessary.

In some selected cases an arthroscopic debridement alone might be done with the idea of achieving pain improvement without tendon repair. Massive rotator cuff tears may not do well even with open repair. However, an arthroscopic debridement may improve pain significantly.

Most rotator cuff repairs can be done arthroscopically but some tears, especially massive tears, need open surgery. Results are usually very good with a good return of function. A high degree of success is possible with return to sports. It takes six months to a year to return to throwing type activities especially at a premier level.

© G. Klaud Miller M.D. 2010

Instability of the shoulder is a more common problem than in any other single joint. This occurs because the shoulder joint, while a ball-in-socket joint, has a very shallow socket. Someone described the shoulder joint as a basketball on a cymbal or a golf ball on a tee. This allows a tremendous range of motion of nearly a hemisphere. The penalty for this motion is instability. Compare the range of motion of the shoulder to the hip, which is also a ball-in-socket joint. However, the hip has a much deeper socket and sacrifices motion for stability.

Instability of the shoulder occurs in multiple situations. The most common cause is a fall on an outstretched hand or an injury such as a tackle in football. 98% or more of shoulder dislocations will be anteriorly (the ball comes out of the socket and moves anteriorly). In this situation the arm will usually be held slightly abducted and externally rotated. Reduction can usually be accomplished with pain medicine and sedation.

A posterior dislocation is much less common and occurs in approximately 2-4% of cases. This usually occurs with a fall with the arm at the side and an posteriorly directed force. This is most common in auto accidents. This dislocation is commonly missed and difficult to diagnose. The classic position is to have the arm at the side and internally rotated. The treatment is closed reduction.

A third kind of instability in multi-directional. In this instability the ball can go anteriorly, posteriorly or inferiorly or any combination of the three. This type of instability rarely responds to non-surgical treatment. The patient choices are to live with the instability or progress to surgery.

There are different types of instability. The pure traumatic type is the typical one. There is also a voluntary dislocation. This occurs when the individual can “pop” the shoulder out at will. This is often done as a means of entertainment. The final classification is an involuntary dislocation. This is usually an individual who voluntarily dislocated the shoulder so many times that he has totally lost control of the stability and it will dislocate despite his best efforts to maintain that stability.

Prognosis

Some of the older authors from the 60’s and 70’s advocated three weeks of immobilization before starting a mobilization period. They felt that this significantly decreased the chances of repeat dislocation.

However, more recent studies have suggested that the risk of repeat dislocation is primarily age dependent and immobilization is of secondary importance. The chance of dislocation depends upon the age at the time of the first dislocation. If the individual was less than 20 years old, the chance of repeat dislocation is approximately 50% and may be higher. Between ages 20-30 the chances of repeat dislocation is 30-40%. The chance of repeat dislocation if the first dislocation occurs over age 30 is 10% or less. Similarly, different studies have argued about the values of post dislocation physical therapy. My personal philosophy after a first time dislocation is to immobilize for three weeks and then begin an aggressive physical therapy program. I feel that this is the best chance of achieving a stable shoulder long term. While there are certainly arguments that this is not necessary I think that a three week period of immobilization is a “cheap insurance policy” if we can possibly prevent repeat dislocations.

If the shoulder dislocates a second time surgery may be recommended. After a third dislocation there is no option and surgery will be necessary to prevent redislocations. There is some evidence to suggest that repetitive dislocations can lead to premature arthritis.

TREATMENT

There are well over 100 procedures that have been described for the treatment of shoulder instability. However, they fall into three basic categories. 1) Muscle transfer techniques. These are rarely used anymore except as an adjunct to other procedures. 2) The Bankart procedure consists of reattaching the ligaments that extend between the ball and the socket. 3) The Bristow procedure involves taking the small piece of bone with the attached biceps tendon muscle to the front of the socket. This effectively blocks redislocation. The results of the Bankart and Bristow procedure have been approximately the same in the literature. The chance of dislocation after one of these procedures is in the 1-2% range. There is a small risk of injury to the nerves and the standard risk of infection common to any surgical procedure. Shoulder surgery has no unusual incidence of infection.

Recently, there has been the development of arthroscopic techniques. These essentially do a Bankart type procedure. This can be achieved through the small arthroscopy incisions. The arthroscopic procedures have the primary advantage of avoiding the restriction of motion that commonly occurs in standard open surgery. However, they also have slightly higher rate of redislocation. Therefore, I usually recommend arthroscopic procedures for those individuals that absolutely require a throwing motion. This might include high school pitchers and quarterbacks. I would recommend a standard open procedure for a high school football lineman. A young girl with relatively low demands may also be better off with the cosmetically more aesthetic arthroscopic technique if she is willing to accept the higher rate of repeat dislocation.