National Post (National Edition)
Frozen shoulder — a painful and enigmatic ailment
YOU CAN WAIT FOR THE THAW OR SEEK TREATMENT
The pain sneaked up on me — my shoulder hurt though I didn't remember doing anything to injure it. I would reach behind my back to rearrange a throw pillow and feel a painful twinge in my shoulder. I had to turn my whole body around to plump that pillow.
Over time, my pain-free arm movement became more limited and my repertoire of workarounds increased. I switched arms to back the car out of the driveway.
I did my best to rest the shoulder and let it recover. But then I'd do something and be met with a jolt of pain that brought tears to my eyes. Eventually, I went to the doctor.
My doctor sent me to a physical therapist, who diagnosed me within minutes. I couldn't raise my arm over my head and she couldn't either. It's the classic test for frozen shoulder. (If I'd had a rotator cuff injury, which is more common, she'd have been able to move my arm all the way.)
Frozen shoulder is painful, aggravating and inscrutable. Sometimes it occurs after a shoulder injury, but more often, “It just happens,” says Todd Schmidt, an orthopedic surgeon in Atlanta.
An inflammatory process causes the ligaments that hold the shoulder together to contract and tighten up.
“It's like a shrink wrap around the joint,” Schmidt says.
The condition affects women more often than men, and tends to occur between the ages of 40 and 60. People with diabetes, hypothyroidism or lipid disorders have elevated odds of getting frozen shoulder. These characteristics hint at some hormonal contribution, but precisely what triggers frozen shoulder is unknown. It can happen to someone who's physically active and it can happen to someone who is sedentary.
Here's another curiosity: The shoulder freezes, and then it thaws. That's the natural course of the condition, even without treatment. “It might take two years,” Schmidt says. “But it will resolve on its own.”
Still, treatment helps. Physical therapy and corticosteroid injection into the shoulder are typical first-line treatments for frozen shoulder.
My physical therapy sessions began with 10 minutes of transcutaneous electrical nerve stimulation, or TENS, and a very warm heating pad. Next, the therapist would stretch me, moving my arm to the point of resistance repeatedly. After that, I'd head out to the gym for a customized series of stretches and exercises with various pieces of equipment.
Being stretched by another person was painful — there's no other way to say it. But by the end of the hour-long session, I always felt better — I gained more range of movement and more confidence. Some of that confidence came from an unexpected place: Learning that inadvertently triggering pain with an unwise reach was not reinjuring myself, it was not going to set me back.
My physical therapist also advised me how to stretch at home, and she measured my progress.
“Physical therapy is all about function — increasing mobility and managing pain,” says Brian Eckenrode, associate professor of physical therapy at Arcadia University near Philadelphia. In addition to monitoring your progress, therapists alter stretches and exercises as needed and they can help you find a more comfortable position for sleep. “They can fine-tune everything.”
The evidence for physical therapy alone tends to be scientifically wanting in that studies often don't have a placebo group. And because physical therapy sessions are multi-dimensional and customized, it's hard to pinpoint precisely what is most helpful.
In the clinic, Eckenrode says, success is measured by “reduced pain, improved function, increased motion and satisfied patients.”
Steroid injections into the shoulder joint may improve both pain and mobility. A 2014 review of studies found more improvement when steroid injections were combined with physical therapy compared with physical therapy alone.
Although, Eckenrode points out, the improvements were measured over the course of weeks. “It's not clear that it improves long-term outcomes,” he says.
A 2020 review of studies reported that steroid injection may be more effective as the shoulder is in the freezing stage, while physical therapy manipulation may be more effective once the joint is frozen.
If you don't see progress after three to six months of physical therapy and steroid injections, the orthopedic surgeon can offer more invasive treatments, Schmidt says. One puts the patient under general anesthesia while the doctor forces the arm beyond the frozen position. Another option is arthroscopic surgery to cut through the tightened joint capsule. Both of these treatments would typically be followed with more physical therapy.
How do you know what doctor to see first? A general practitioner, a physical therapist or an orthopedic surgeon?
“If you have a good relationship with your primary care provider, that's a good place to start,” says Schmidt, the orthopedic surgeon. “But we're here when needed.”
A final note. Most people recover from frozen shoulder, although recovery may not be complete. A 2013 paper highlighted several studies in which researchers could measure lessthan-full arm mobility while at the same time noting that subjects were satisfied with their recovery. That means, my left arm's range of movement may never match my right arm's, but if I can do everything I could do before, I'll be happy.
IT MIGHT TAKE TWO YEARS, BUT IT WILL RESOLVE ON ITS OWN.