John-Paul Rue, MD, an orthopedic surgeon at Mercy Medical Center in Baltimore, Maryland, talks about a condition that comes on with little warning and may mimic arthritis.
Interview conducted by Ivanhoe Broadcast News in December 2016.
We’re talking about frozen shoulder syndrome; can you tell us what you’re talking about?
Dr. Rue: Sure. Frozen shoulder, the medical name is adhesive capsulitis. It’s actually a relatively common condition it affects about two percent of the US population. It’s more common in women than men. It is a very painful condition whereby the patient will often lose significant motion. It’s a very, very painful condition and sometimes it just develops out of the blue overnight. It may be associated with some other medical conditions, those conditions such as diabetes or thyroid conditions. In fact, people with diabetes up to ten to twenty percent of patients with diabetes may develop adhesive capsulitis at some point during their life. It’s more common in the forties, the fifties, the sixties and it’s a very painful condition.
Do you know what the cause is?
Dr. Rue: There are a variety of causes. Some causes may be due to prolonged immobilization for example, after an injury, after a fracture. Sometimes it can happen in association with specific injuries to the rotator cuff or other structures around the shoulder. It can often be associated with someone who may have had surgery maybe even unrelated to the shoulder and they might be immobilized. Sometimes it just comes out of the clear blue with no warning to just happen. Those are the ones that scare people the most because you can often just wake up with severe shoulder pain and over the course of a few days to weeks can often develop severe loss of motion which is quite debilitating to people.
How do you diagnose it?
Dr. Rue: The diagnosis is really based on exam. Based on talking to the patient, hearing that they may or may not have had an injury, timing on the onset of it and then it’s on a physical exam. The physical exam is really important to show range of motion limitations. You know the shoulder is a little different than the rest of the body. If you have pain in the knee or pain in the hip you’ll limp and if you limp your loved ones or your family members might say hey, go get your hip or knee checked out. But your shoulder you can kind of hide and cheat or compensate to move it and you can actually develop pretty profound loss of motion before it really comes to someone’s attention as a problem.
What kind of treatments are there?
Dr. Rue: Frozen shoulder goes through phases. It goes through the freezing or inflammatory phase and that’s the initial onset where it’s very, very painful. That can take six weeks up to six months to kind of go through. The frozen phase is where the shoulder starts to get socked in, the capsule of the shoulder becomes rigid and the patients lose motion with that. That’s a very concerning time. That’s when patients are very concerned with their motion. Then it goes through a thawing phase, which again can take six months to come through. The mainstay of treatment is pain control, maintaining, regaining range of motion, and then eventually getting back to some strengthening exercises. The vast majority of patients are going to get through this without surgery. In fact, ninety percent or more will get through this process without surgery. But if you do the math on each of those segments, each of those three phases, from the freezing, to the frozen, to the thawing phase can take up to two years to sort of get through to the other side. Most people will get through without significant limitation but every once in a while there will be people who have some mild residual stiffness from the underlying condition.
Can you have permanent injury or permanent disability from this if you don’t get treatment?
Dr. Rue: You can. One of the main concerns is if it will continue and if you’ll never regain that motion. That’s why the mainstay is really physical therapy, medications to control pain and to try to get your motion back. Most people will get through it without significant limitations or disability. But there is a good chance that you may not have the full motion that you had before.
Talk to me about the surgery, for which patients is this and how long does it take, what does it involve?
Dr. Rue: There are a group of patients; either they present late to us with severe pain or severe loss of motion, or those who just plateau and are just not making any progress. In that setting surgery has a role. The role of surgery is to break the cycle to help regain motion and control pain. We do that through a variety of means. The most common way is we do it through an arthroscopic approach. A couple small band-aides incisions around the shoulder through which we insert an arthroscopic or fiber optic camera and instruments to literally cut the scarred down tissue; what that does is allow the joint to move. Then we do a gentle manipulation of the shoulder to stretch the capsule which is the primary restraint to the motion of the shoulder.
What’s the recovery like, because you’re going in through those keyhole it’s not major, you don’t have major incision.
Dr. Rue: You don’t have major skin incisions but the work on the inside is still very significant. It’s still very important for physical therapy, rehabilitation, and for range of motion exercises following this. It’s still going to take three to four months at a minimum to get through that. It’s a very painful operation because we are literally cutting the capsule and then moving the shoulder to separate those cut edges.
About what percentage of patients who need this surgical step?
Dr. Rue: A very small number of the total number of patients who have this condition actually need surgical intervention, a very small percentage. The reason is the vast majority of people are going to get through it, ninety percent plus without surgery. Somewhere in the ten percent range might ultimately need some surgery for the condition. The vast majority are going to get through this without needing surgery, it just takes a long time. It’s one that’s very frustrating for patients and for physicians alike because it takes a lot of discussion and education to really understand the principles of why it takes so long to get through.
Is there anything new that you are doing surgically or any new techniques or procedures that you’re doing on the shoulder in these cases?
Dr. Rue: I think the biggest advance is to try to figure out what is going on with the inflammatory or freezing phase and really recognizing that phase early.
What’s the newest right now?
Dr. Rue: I think the biggest advances are in recognizing it as a condition affecting people early on in the course of it, to try to alter the outcome earlier. Surgically, our advances are in the techniques and the instrumentation, to allow us to do this surgery through smaller and less invasive type procedures, and to hopefully enable it to help the patient with hopefully a quicker and less painful recovery.
The push is to really recognize this early?
Dr. Rue: Yes. I think the key is education, understanding it, and to know that if you know someone that has a sudden onset of shoulder pain when nothing happened, there may be a very significant reason for why that happened. To catch that person early, to educate them, to get them under control from a pain standpoint, and to get them in to therapy for range of motion exercises, is really the key for this condition.
For people who are sitting out there, what do they need to be aware of to catch it early?
Dr. Rue: You really need an awareness of it and you really need to have someone evaluate you, to really isolate and show the loss of motion. Because as I said, you can compensate; I can have a very severely contracted shoulder joint but still move my hand around in space by moving my spine, by moving my shoulder girdle, by moving my elbow, and sort of cheating or compensating. Then to get the pain under control, so that you can be doing therapy and not having excruciating pain that is truly affecting your life and all those in your life.
So don’t shrug off sudden pain?
Dr. Rue: Absolutely.
Is there anything I didn’t ask you that you want people to know?
Dr. Rue: One thing that we’ll talk about with Suzanne is that there are a variety of conditions that may be associated with frozen shoulder. There are a variety of conditions that may be associated with frozen shoulder or may in fact mimic the condition of a frozen shoulder. It may in fact lead to a frozen shoulder. Those are calcific tendonitis, which is where this calcium deposits in the rotator cuff which can be exquisitely painful, especially when they start to resorb. The concern is if you have someone who has a very painful shoulder they won’t move it. If someone doesn’t move their shoulder with prolonged immobilization they can absolutely develop a frozen shoulder. That compounds the condition and so we really want to get involved early, control the pain, encourage motion, and help that patient through that painful cycle at the same time as maintaining their motion so that they don’t develop a severe frozen shoulder.
You had also mentioned diabetes.
Dr. Rue: Right. It’s not clear what the exact association is, but certainly patients with diabetes, thyroid conditions, hypo and hyperthyroidism are associated with a much higher incidence of frozen shoulder. A patient who is female, in her forties to sixties with diabetes or a thyroid condition, who presents with severe shoulder pain that then has stiffness, is absolutely the poster child for frozen shoulder and somebody who really should be getting treatment for that for both pain control and regaining their motion.
Tell us a little bit about Suzanne and her situation.
Dr. Rue: Sure. Calcific tendonitis or calcific tendinosis is a very painful condition. It’s not a hundred percent clear why the condition starts, but at some point, calcium deposits form in the rotator cuff. The rotator cuff is the big muscles around your shoulder that moves your shoulder. That calcium deposit can be painful in and of itself just from a volume standpoint by causing pressure on the rotator cuff. It can also be painful as it starts to resorb or go away. It is also typically a self-limited condition where it will improve with time but it can go through this restoration phase which is very painful.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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