Frozen Shoulder Treatment and Surgery

What Is Frozen Shoulder (Adhesive Capsulitis)?

Frozen shoulder is a condition characterized by inflammation of the shoulder joint capsule (the envelope-like structure that holds and surrounds the joint), followed by thickening and hardening (fibrosis). This thickening and hardening causes the joint capsule to lose its normal flexibility and contract. As a result, the range of motion of the shoulder joint is markedly restricted in every direction (raising the arm, moving it outward, and rotating it inward and outward), and severe pain is felt during these movements.

Frozen shoulder is different from osteoarthritis, which is characterized by cartilage wear in the joint; here, the problem is primarily in the joint capsule. Although frozen shoulder tends to resolve on its own over time in most cases (usually within 1 to 3 years), this process can be quite painful and functionally limiting. The goal of treatment is to shorten this process, control the pain, and regain shoulder range of motion as quickly as possible.

What Causes Frozen Shoulder? Risk Factors

The exact cause of frozen shoulder is often not fully known (idiopathic). However, certain conditions and factors can increase the risk of developing frozen shoulder:

• Age and Sex: It is most commonly seen between the ages of 40 and 60 and is slightly more common in women than in men.
• Diabetes: In diabetic patients, the risk of developing frozen shoulder is significantly higher than in the general population (up to 5 times higher), and it usually follows a more severe course.
• Thyroid Disorders: An underactive (hypothyroidism) or overactive (hyperthyroidism) thyroid gland can also increase the risk.
• Prolonged Immobilization: Prolonged immobility of the shoulder after an injury (fracture, rotator cuff tear, etc.) or surgery (e.g., using an arm sling) can trigger the development of frozen shoulder.
• Other Conditions: Cardiovascular disease, Parkinson’s disease, and certain autoimmune diseases have also been associated with frozen shoulder.
• Trauma: It can sometimes begin after even a minor shoulder injury.

Symptoms and Stages of Frozen Shoulder

Frozen shoulder generally progresses through three stages, each with its own characteristic symptoms:

1. Stage 1: Freezing Stage (Painful Period):
   
   • Duration: Usually lasts 2 to 9 months.
   • Symptoms: Pain is the dominant feature in this stage. A widespread, deep, dull ache typically begins in the shoulder. The pain increases over time, is often worse at night, and may wake the patient from sleep. Shoulder movement gradually becomes restricted due to pain, but stiffness is not yet very pronounced.
2. Stage 2: Frozen Stage (Stiffness Period):
   
   • Duration: Usually lasts 4 to 12 months.
   • Symptoms: Pain usually begins to ease somewhat in this stage, but shoulder stiffness and restricted movement become most pronounced. Movement of the shoulder in every direction (raising the arm, moving it outward, and especially rotating it inward and outward) is severely restricted. Patients have great difficulty with daily activities such as combing their hair, reaching behind their back, or putting on a jacket.
3. Stage 3: Thawing Stage (Recovery Period):
   
   • Duration: Usually lasts from 6 months to 2 years or longer.
   • Symptoms: Shoulder stiffness gradually resolves and range of motion progressively increases. Pain steadily decreases. This can be the longest stage, and regaining full range of motion may not always be possible, especially if left untreated.

How Is Frozen Shoulder Diagnosed?

Frozen shoulder is diagnosed primarily on a clinical basis, meaning through the patient’s history and the doctor’s examination findings.

• Patient History: Your doctor will ask in detail how your symptoms began (suddenly or gradually), when and how the pain occurs, the degree of restricted movement, and whether you have risk factors such as diabetes or thyroid disease. It is typical for pain to begin first and gradually give way to stiffness.
• Physical Examination: This is the most important step for diagnosis. Your doctor carefully measures both the active (movement you perform yourself) and passive (movement the doctor performs) range of motion of your shoulder. In frozen shoulder, a marked restriction of passive range of motion in every direction is typically found. External rotation of the arm in particular is one of the earliest and most affected movements. This finding helps distinguish frozen shoulder from other conditions, such as a rotator cuff tear, in which passive movement is usually better preserved. There may be tenderness around the shoulder.
• Imaging Methods:
  
  • X-ray: Usually normal in frozen shoulder. However, it may be requested to rule out bone problems, fractures, or shoulder osteoarthritis.
  • Magnetic Resonance Imaging (MRI) or Ultrasonography (USG): Generally not necessary for the diagnosis of frozen shoulder. However, if clinical findings are unclear or another pathology, such as a rotator cuff tear, is suspected, it may be requested to rule these out. On MRI, findings suggestive of frozen shoulder, such as thickening of the joint capsule or reduced volume of the axillary recess, may sometimes be seen.

Frozen Shoulder Treatment Options: Patience and Physical Therapy Come First!

The primary goal of frozen shoulder treatment is to control pain and regain the lost range of motion in the shoulder. Treatment is planned according to the stage of the disease. The vast majority of patients recover with non-surgical (conservative) treatment methods, but this process requires patience and time.

Non-Surgical (Conservative) Treatment (Main Treatment Approach):

• Pain Control:
  
  • Medications: Under a doctor’s supervision, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) or simple analgesics (Paracetamol) may be used to relieve pain. Pain control is especially important in Stage 1 to make participation in physical therapy easier.
  • Heat/Cold Application: May help reduce pain and discomfort.
• Physical Therapy and Exercise: The cornerstone of treatment.
  
  • Gentle Stretching Exercises: The most important part of frozen shoulder treatment. Exercises aimed at stretching the shoulder capsule (e.g., pendulum exercises, wall climbing, external/internal rotation with a stick, back-scratch movements), performed regularly with a physiotherapist or at home, aim to gradually increase range of motion.
  • Important Note: Exercises should be performed patiently and gently. Particularly during the painful “freezing” stage, overly forceful or painful exercises should be avoided, as this can increase inflammation and worsen the condition. Exercises should be kept within the pain limit. In Stages 2 and 3, stretching exercises can be intensified.
  • Strengthening Exercises: As range of motion is regained, strengthening exercises for the muscles around the shoulder are started.
• Intra-Articular Corticosteroid (Cortisone) Injections:
  
  • Particularly in Stage 1, when pain is very severe, or in the early part of Stage 2, a cortisone injection into the shoulder joint can be quite effective in reducing inflammation and pain. Reduced pain allows the patient to perform physical therapy exercises more comfortably and can speed up the recovery process. Usually 1 or 2 injections are sufficient.
• Hydrodilatation (Distension Arthrography):
  
  • This procedure involves injecting a large volume of sterile saline (sometimes with cortisone and a local anesthetic added) into the joint capsule under imaging guidance (usually ultrasound or fluoroscopy) to stretch and expand the capsule. Although it may be beneficial for some patients, its effectiveness varies and it is not a routinely applied method.

Surgical / Interventional Treatment (When Conservative Treatment Fails):

In a small proportion of patients, if severe pain and restricted movement persist despite effective conservative treatment usually lasting 6 months or longer, more interventional methods may be considered:

• Manipulation Under Anesthesia (MUA):
  
  • While the patient is under general anesthesia (fully asleep with relaxed muscles), the surgeon moves the shoulder joint in a controlled and careful manner in different directions to “tear” or “stretch” the adhered and hardened joint capsule. The aim is to achieve a sudden increase in range of motion.
  • A cortisone injection is usually given into the joint after the procedure.
  • Risks: Although rare, it carries risks such as bone fracture or muscle or tendon injury.
• Arthroscopic Capsular Release:
  
  • This is a minimally invasive (closed) surgical method. A camera (arthroscope) and special instruments are inserted through small incisions made in the shoulder.
  • Viewing the interior of the joint, the surgeon releases the thickened and contracted joint capsule by controlled cutting or freeing of specific areas (particularly the anterior, inferior, and sometimes posterior portions responsible for the restricted movement).
  • It generally provides a more controlled release than MUA and offers the opportunity to see and treat other problems within the joint (if present) at the same time.
  • It can often be performed together with manipulation under anesthesia.

In cases where conservative treatment fails, Prof. Dr. Murat Bozkurt evaluates and applies manipulation under anesthesia or arthroscopic capsular release, depending on the patient’s condition.

Risks, Benefits, and Recovery Process

• Non-Surgical Treatment:
  
  • Benefits: No surgical risks, effective for most patients, allows the body’s natural healing process to take place.
  • Risks: The recovery process can be very long (months, sometimes years), full range of motion may not be regained, and it requires patience and continuous adherence to physical therapy.
• Surgical / Interventional Treatment (MUA / Arthroscopic Release):
  
  • Benefits: Allows range of motion to be regained much faster than the natural course, and can relieve pain more quickly.
  • Risks: Carries the risks of general anesthesia and surgery (infection, bleeding, nerve damage – rare). There is a risk of fracture during manipulation (rare) and a risk of stiffness recurring after surgery (if rehabilitation is not performed properly).
• Recovery Process (After Interventional Treatment):
  
  • After manipulation or arthroscopic release, the key to success is PHYSICAL THERAPY that is started IMMEDIATELY and continued INTENSIVELY to maintain the range of motion gained.
  • Physical therapy is started immediately after surgery or the next day. The goal is to prevent the capsule from re-adhering and hardening.
  • Pain control is important.
  • Recovery can still take several months, but regaining range of motion is generally faster than with conservative treatment.

Frozen Shoulder Treatment in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Frozen shoulder can be a highly frustrating condition for patients that restricts daily life. For patients experiencing this condition in Ankara, Prof. Dr. Murat Bozkurt adopts the following treatment approach:

• Accurate Diagnosis and Staging: He first carefully evaluates the patient’s complaints and examination findings to confirm the diagnosis of frozen shoulder, rules out other shoulder problems, and determines which stage the condition is in.
• Patient Education and Emphasis on Patience: He informs the patient in detail about the natural course of the disease, its stages, and the fact that recovery may take time. He emphasizes the importance of patience and adherence to treatment.
• Priority to Conservative Treatment: He usually begins treatment with pain control, cortisone injections (at the appropriate stage), and gentle, progressive physical therapy exercises. He works in close collaboration with physiotherapists.
• Decision for Interventional Treatment: In cases where conservative treatment is insufficient (usually severe restriction persisting for 6 months or longer), he discusses the risks and benefits with the patient and evaluates the options of manipulation under anesthesia or arthroscopic capsular release.
• Focus on Rehabilitation: Both in conservative treatment and in the post-surgical period, he is aware of the critical importance of rehabilitation for a successful outcome, and he closely monitors and guides his patients throughout this process.

Frozen shoulder is a condition that requires patience and proper treatment management. With early diagnosis, timely application of appropriate treatment methods, and especially active participation in physical therapy, most patients can recover successfully. If you have frozen shoulder complaints in Ankara, you can consult Prof. Dr. Murat Bozkurt to create the most appropriate treatment plan.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.