A Pandemic within a Pandemic: Frozen Shoulder
Michael Wilmink, MD
Crap, why does my shoulder hurt so much? It started about a couple of months ago, I might have tweaked my shoulder when I reached in the back seat to grab my wallet out of my bag, or was it when I pulled that heavy box off of the top shelf of the closet? Not sure, but frick my shoulder hurts now! It’s hard to put on my jacket/bra/shirt/blouse but I can still do it, just takes longer and some finesse. I wake up at night now when I roll over with sharp pain in my sleep. I took some ibuprofen regularly when this whole thing started and that helped some, especially at night, but it didn’t eliminate the issue, just made it more tolerable. My shoulder is not as sore as it was initially but it’s definitely not normal, like my other shoulder.
This my friends is the textbook description of how a patient finally presents to a physician/nurse practitioner/physician assistant and this is the story they tell when presenting with a frozen shoulder, which we call adhesive capsulitis in the medical world. Having a frozen shoulder sucks, it usually comes out of nowhere, and it has a massive impact on your life, especially when trying to get a good nights sleep. Most people have never heard of a frozen shoulder and therefore have no idea what is happening to their body when this occurs, and that is the purpose of this article. I am writing, to raise awareness, so that people can learn about this medical condition, and seek treatment earlier and get rid of their stiff, painful shoulder and sleep through the night again.
I feel compelled to write this article because during the last 2 plus years of the COVID 19 pandemic, I have seen a shockingly higher number of patients present to my orthopaedic practice with a frozen shoulder. Prior to the pandemic, on a monthly basis, I would see on average 1-2 patients with a frozen shoulder, now I see 1-2 per week. That is about an 400% increase in frequency of presentation. As a scientist, I have asked myself, “what the hell is going on in the world to be causing so much frozen shoulder?” My answer is, there is an increased baseline level of stress that has occurred due to the disruption of everyone’s normal life from all the negative consequences of this virus ripping through our society. More stress = more frozen shoulder, pretty simple. This is my opinion, not a study of 1,000 patients randomized to a control and placebo group (kind of hard to find a group of people in this world not affected by COVID) and this is my opinion is based on practicing orthopaeidic surgery for 20 plus years. In essence, medicine is pattern recognition, see enough clues (signs and symptons) that add up together, and you have a diagnosis. I am diagnosing society with a pandemic of frozen shoulder. The good news is, frozen shoulder is easily treatable and rarely will ever need a surgery to eradicate it.
So, what is adhesive capsulitis/frozen shoulder? Well, scientifically it is an inflammatory process that has gotten out of control and is like a snowball rolling down a hill, getting bigger and stronger until is stops moving because it has become so large. The actual cells that are the culprit here are the myofribroblasts. These are cells that live in the soft tissues of your body, primarily in the capsule of your joints- shoulder, knee, hip, etc. For some reason, these myofriboblasts get stimulated, and start having a party and producing excess amounts of collagen. The collagen accumulates in the surrounding capsule tissue, which makes the capsule extremely painful with movement, thicker, and stiff. The normal thickness of the shoulder capsule is about 1-5 mm in thickness, I have seen some patients have their capsule get to a thickness of 10-15 mm in thickness due to this disease process. So now that the drunk sailor myofibrolasts have gone on a bender and made all this extra collagen, you have a thickened shoulder capsule that is painful with every movement, and quite frankly does not move or function like it used to or like your other shoulder. Now here is a key take away, you have another shoulder to compare your painful/stiff shoulder to, so look in the mirror, raise your normal shoulder above your head, then watch yourself try and raise your frozen shoulder, pretty pathetic right? More than likely you just diagnosed yourself with adhesive capsulitis, nicely done. Can it occur in both shoulders at the same time? Yes, but very rarely, I have seen 3 patients with frozen shoulder in both arms over the course of 20 years of practice.
Okay, one more boring scientific paragraph about the causes of frozen shoulder and some anatomy, before we get the fun part, treatment and getting rid of it. Grab a sip of coffee, matcha, highly caffeinated sugar drink, and please read on. Frozen shoulder is a bit of a mystery, but we know that it can be caused by trauma, surgery, burns, and diabetes and few other rare conditions. The underlying science here is that your bodies inflammatory process starts in reaction to an unknown event, and the inflammatory process takes off and will not stop. The initial symptoms of frozen shoulder is the painful inflammatory phase where you have immense pain, but the stiffness is not that bad yet. Eventually the shoulder capsule fills up with collagen, gets stiff, and the severe pain settles down. Now you have a shoulder that doesn’t hurt quite as much as it did initially, but now you can’t move your shoulder worth a darn. A lot of people get to this stiff phase of a frozen shoulder and just adapt and learn to live with it. The body can accommodate for a stiff glenohumeral joint (true shoulder joint between the glenoid portion of the scapula the head of the humerus- see photo) by firing up your scapulothoracic articulation. Basically, you use your shoulder blade to be able to lift your arm over your head because you have lost the ability to move your true shoulder joint (glenohumeral). You typically will tilt your head to the left and use your right shoulder blade to raise your right arm above your shoulder to get the dish you want off of the top shelf. Sound familiar? Go look in the mirror again.
Okay, so now you have figured out that you have a frozen shoulder, how do you get rid of it? Just to start things off, it is rare to need a surgery to get rid of this process. My estimate is that only 5-10% of patients presenting with a frozen shoulder within 6 months of onset of symptoms will need a surgical solution, presenting with a well-established frozen shoulder of more than 6 months of duration, not so lucky. The majority of patients can be treated with the following treatment work flow:
1. Regular Non-Steroidal Anti-inflammatory medication like Ibuprofen 800 mg three times a day/Naprosyn 500 mg twice a day
2. Physical therapy three times a week until normal motion returns
3. A shoulder capsular stretching injection of steroids/cortisone
a. An injection from back side of the shoulder into the glenohumeral joint that has lidocaine, marcaine and steroid like Kenaolog, DepoMedrol, Betamethasone, or MethylPrednisone
b. The injection stretches the shoulder capsule, and the steroid shuts down the myofribrolast party and stops further production of collagen tissue.
4. A manipulation under anaesthetic
a. This is a surgical procedure where you go to sleep, and the shoulder is gently (not so gentle actually) manipulated so that the capsule is stretched to the point where it tears or ruptures and shoulder motion is regained. Then you go to physical therapy that day, and every day for 5 days in a row, then three times a week for as long as it takes to get back to normal.
5. Arthroscopic capsular release.
a. This is for the very resistant frozen shoulder, typically patients with diabetes or the shoulder has been frozen for over 6-9 months and there has been no improvement with medications, therapy and a capsular stretching injection.
b. You go to sleep, and then the shoulder capsule is cut/released with an arthroscopic instrument under direct visualization with a camera. This typically involves three small 1 cm incisions around your shoulder and takes about an hour. Then you go to physical therapy that day, and every day for 5 days in a row, then three times a week for as long as it takes to get back to normal.
Well, there you have frozen shoulder in a nutshell. I hope you made it through this public service notification and have a better understanding of what a frozen shoulder is and how to rid of it. There is a pretty simple fix for a very painful and exhausting condition that has become all too common out there in this world of heightened anxiety and stress. Most patients I see need an NSAID, and a capsular stretching injection to start with. I see patients back 7-10 days after the injection and I would say that 60% of patients get better with these two treatments, the other 40% need to go on and have physical therapy to get their full motion back. Curing someone of a frozen shoulder is one of the most gratifying things I do as an orthopaeidic surgeon. I get countless hugs from patients all the time when they come back to the office a week later after the injection, and they are sleeping again and the pain is gone! So, if all this sounds familiar to you, find your local orthopaeidic surgeon, sports medicine physician, or physiatrist and get started on the mend, you don’t need to live with a painful, stiff shoulder.
Sincerely,
Michael Wilmink, MD
Great article Dr. Mike and very timely too. A friend of my parents is having trouble with his shoulder but because he’s over 80 he was told he has to live with it 😡. I’m going to forward your article to him.