The Modern Treatment of Adhesive Capsulitis or “Frozen Shoulder”
Timothy J. Mazzola, MD, CAQSM, RMSK
Breakthrough Regenerative Orthopedics, Boulder CO
Adhesive capsulitis is a condition that not only limits shoulder motion but can cause exquisite amounts of pain in the early stages. It is caused by a robust inflammatory response, usually to a flare of rotator cuff tendinosis. It has three phases and can lead to significant shoulder impairments for up to 2-3 years if left untreated.
Sadly I’ve had the “opportunity” to personally experience adhesive capsulitis and do not remember it fondly. Prior to this, I had taken an interest in treating this condition after seeing a number of patients that weren’t responding to the typical treatment options of anti-inflammatories, physical therapy and even surgical intervention, such as manipulation under anesthesia and capsular release surgery. After spending much time learning about the basis of the condition, the anatomic structures involved, and the clinical studies of its treatment, I developed my own treatment algorithm that has led to incredible and consistently good outcomes.
What we do for frozen shoulder depends on the stage that the patient is in. The phases are as follows:
1) The “freezing phase” is characterized by lots of inflammation, pain, difficulty sleeping on the shoulder and exquisite pain with sudden movements
2) The “frozen phase” which is typically less inflammatory and painful, but characterized by a very limited range of motion for the shoulder
3) The “thawing phase” which is when the shoulder begins to slowly loosen up as the inflammation and scarring or fibrosis resolves
I prefer to see patients as soon as possible in the acute inflammatory “freezing” phase, as these patients can be greatly helped by a combination of ultrasound-guided precision injections that may include a small dose of corticosteroid medication. This is the “cortisone” injection often discussed in lay terms. While at Breakthrough Regenerative Orthopedics, we don’t typically like to use steroid or “cortisone” injections, in this early phase of frozen shoulder they have proven helpful. More important than the medication is HOW we do the injections- we typically provide an ultrasound-guided joint distension (to fill the joint up and stretch it open) along with injections around the inflamed and fibrotic tendons, bursae and capsule. Once numbed up, we can do some gentle osteopathic techniques to get the shoulder motion to improve. Occasionally we have to provide an ultrasound-guided nerve block for patients that are in too much pain, or have too much nerve upregulation in this phase of frozen shoulder.
If patients come to us in the “frozen phase”, we can still help. We don’t typically need to use the steroid or “cortisone” shots in this phase as the inflammation has subsided and patients are just “stuck” with very limited shoulder range of motion. In this scenario, we still provide the ultrasound-guided joint distension injection as well as injections to free up scar tissue around the inflamed and fibrotic tendons, bursae and capsule. We also provide the gentle osteopathic mobilizations to help get the joint moving.
If patients arrive in the “thawing phase” or have regained their motion after we’ve provided the “freeing up” injections, they commonly will have some ongoing pain with activity. This is due to the underlying problem that caused the frozen shoulder that we talked about at the beginning- usually a degenerative or partially torn rotator cuff tendon. In this situation, we perform a physical examination as well as a complete diagnostic ultrasound to look at and evaluate the tendons for problems and tears. Ultrasound is much easier for patients to tolerate than MRI and is about 10-20% the cost! If we find degenerative tears, we typically offer a regenerative injection to treat them.
Regenerative injections are also performed under ultrasound-guidance where we can directly inject and treat the injured rotator cuff tendon in real-time under local anesthesia. We can provide options of Dextrose Prolotherapy, Platelet Rich Plasma (PRP), bone marrow concentrate or fat-derived injections that contain your own stem cells. You can have confidence knowing I've performed regenerative injections since 2009, teach nationally and authored a book chapter on how to perform these injections.
In the end, our goal at Breakthrough Regenerative Orthopedics is to get you back to the active life you love. In the case of frozen shoulder, this first requires getting back your range of motion, so after these injections we advise getting with your physical therapist 2-3 times in the first week or two to “lock in the gains” we get from our treatments. It can take as little as a few days to a few months to get the shoulder functioning well again, but we’re committed to ensuring you as good of an outcome as possible.
Our success with treating frozen shoulder has been nothing short of revolutionary and I sincerely hope that any patient suffering with this condition will allow us the opportunity to join their treatment team.
Cheers and best of health to you!
-Updated April 3, 2021