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Frozen shoulder, also known as adhesive capsulitis, is characterized by limited movement, stiffness, and pain in your shoulder. The symptoms typically start gradually and worsen over time, and eventually recede after a period (this period can last for one or two years!).

What Causes Frozen Shoulder?

When any problem causing pain in the shoulder persists, it can lead to a frozen shoulder. The prevalence of frozen shoulder in the population is between 3-5%. It is more commonly seen in women than men. The incidence of frozen shoulder increases with age, especially after the age of 40.

The majority of frozen shoulder cases have an unknown cause. The most commonly implicated disease among known causes is diabetes. Other factors include prolonged shoulder immobility, trauma, thyroid disorders, stroke, and heart attack. However, it is important to note that the cause of frozen shoulder is often unknown. When any problem causing shoulder pain persists, it can lead to a frozen shoulder.

Symptoms of Frozen Shoulder

Why Does Frozen Shoulder Occur?

In some patients, the condition can cause severe pain that may occur even at rest or during sleep, disrupting sleep. Increasing loss of movement in the arm is noticed, especially in female patients, who may have difficulty reaching behind their back (e.g., fastening a bra) or raising their arm overhead (e.g., reaching for an object on a shelf). The patient may experience pain not only in the shoulder but also in the neck and back.

The restriction of movement in frozen shoulder occurs in all movements, unlike other shoulder conditions that limit specific shoulder movements. The symptoms manifest primarily in three phases:

  1. Painful freezing phase (lasts approximately 3-4 months)
  2. Frozen phase (12 months)
  3. Thawing phase (6 months)

 

 

Treatment of Frozen Shoulder

The standard treatments for frozen shoulder can be summarized as follows:

• Physiotherapy (physical therapy) • Painkillers and anti-inflammatory drugs (to reduce pain and stiffness) • Cortisone injections (to reduce pain and stiffness) • Surgical treatment.

The majority of frozen shoulder cases can be successfully treated with non-surgical treatment methods.

Surgical Treatment

Treatment of Frozen Shoulder

Patients with frozen shoulder are rarely subjected to surgery. Surgical treatment is only performed in cases where non-surgical treatments mentioned above and 3-6 months of physical therapy have failed to provide improvement. In such cases, arthroscopic (minimally invasive) technique is used to release the thickened capsule and adhesions in the shoulder joint. At the end of the surgery, in order to achieve normal range of motion, the patient undergoes ARTROSCOPIC AND manipulation under anesthesia to fully open the shoulder. It is important to ensure complete relaxation achieved by anesthesia, allowing the doctor to perform gentle manual intervention after the minimally invasive procedure without causing harm to the patient.

Below, the range of motion after arthroscopic capsular release and manipulation under general anesthesia is demonstrated in a patient with frozen shoulder who was unable to move their arm in any plane.

General causes of the tear in your shoulder: the natural loss of strength and degeneration of muscles with advancing age – repetitive strenuous movements due to household chores or work (such as cleaning windows, excessive cleaning efforts, knitting, repetitive heavy lifting, etc.).

Unfortunately, my only recommendation for this would be for the patient to determine the position that they feel most comfortable in. Each individual may have different preferences and comfort levels when it comes to sleeping after surgery. It is important to listen to your body and find a position that minimizes discomfort and supports the healing process.

The tear in your shoulder occurs due to the compression of the shoulder tendons or the abrasive effect of friction and/or inflammatory tissues over time. When a tear occurs, you may experience weakness in shoulder movements, such as dropping objects (e.g., a glass), and especially nighttime pain (inability to sleep on the shoulder and being awakened when changing positions). These are common symptoms associated with a shoulder tear.

rom the first day after surgery, you can comfortably eat your meals with the shoulder sling on.

Considering that you will be using a shoulder sling for approximately 6 weeks and then undergoing about 6 weeks of physical therapy, it is advised not to return to your routine daily tasks until 3-4 months have passed. However, you can still comfortably perform your own light tasks that are not too strenuous (without actively lifting your shoulder)

A tear in the shoulder occurs due to the compression of the shoulder tendons or the friction and abrasive effect of inflamed tissues over time. When a tear occurs, you may experience weakness in shoulder movements, such as dropping objects (e.g., a glass), and especially nighttime pain (difficulty sleeping on the affected shoulder and waking up when changing positions), among other symptoms.

Unless instructed otherwise by your doctor, the shoulder sling will typically stay in place for an average of 6 weeks (1.5 months) following rotator cuff repair. The sling should not be removed for approximately 6 weeks unless your doctor advises otherwise. This period is a standard accepted time frame for the repaired tissue to heal to the bone.

The shoulder-arm sling is often cited as a discomfort by patients. However, this sling helps the anchoring (screw) we use to secure the repaired tendon to the bone during the healing process and also aids in preventing the development of permanent stiffness in the shoulder to some extent. Therefore, unless instructed otherwise by your doctor, the sling should not be removed for approximately 6 weeks.

You will be put under general anesthesia. Your surgery will be performed in a seated position called the beach chair position. After you enter the operating room, the surgery may start approximately 1-1.5 hours later due to the anesthesia and positioning requirements.

After the surgery, ice application for a duration of two days will be started immediately, along with the administration of pain medication. Following a closed or arthroscopic repair, the majority of our patients (unless there is a medical obstacle) can be sent home in the evening of the same day, walking with a shoulder-arm sling. Your wounds will be dressed every other day, or every two days. Generally, stitches will be removed around the 9th-10th day. Subsequently, the post-operative rehabilitation program will be initiated in accordance with your doctor’s recommendations starting around the 4th-5th week. The timeline mentioned above is a standard one and can be modified by your doctor.

The small screws, called anchors, that are placed inside are micro-sized and take up very little space in the bone. These screws serve the purpose of reattaching the torn tendon to its original position on the bone. Due to their small size and remaining within the healed tendon, there is no harm in leaving them in the body. In some cases, absorbable anchors that can dissolve within 6-9 months may be used, depending on the surgeon’s decision.

The topic of re-tear is still controversial. There is a chance of re-tear, especially in individuals of advanced age, with low tissue quality, and those who have accompanying conditions such as diabetes or rheumatism. Smokers and individuals who have experienced a significant shoulder trauma are also at risk of re-tear. It is important to emphasize that smoking, or tobacco use, not only delays the healing of the tear but has also been proven to be a contributing factor in the recurrence of the tear.

 

If you have a tear that is accompanied by symptoms and has been visualized on an MRI, the torn tendon cannot heal on its own. In the future, the tear is highly likely to enlarge. Additionally, scientific studies have shown that this can lead to negative effects on other intact tissues, the continuation and exacerbation of your symptoms, increased weakness, and even calcification in the shoulder joint.

Another point I want to emphasize is that tears that occur especially after trauma (such as falling or sudden movements) tend to rapidly expand within 4-6 months.”

The postoperative physical therapy process is essential for the continuation of your treatment. In other words, the success of your surgery significantly decreases if physical therapy is not performed or cannot be performed. Physical therapy, or postoperative rehabilitation, is applied based on the principles of regaining range of motion and strengthening the shoulder. The stages of rehabilitation follow each other. The patient’s compliance and contribution to rehabilitation are the most important keys to success. Strength training begins after 3 months. Lifting weights and participating in contact sports (such as football or basketball) are strictly prohibited before the 6th month. In conclusion, the rehabilitation program recommended by your doctor plays a key role in the success of your treatment.

In general, most patients experience noticeable improvement in pain and daily activities. In other words, approximately 90% of our patients report significant benefits and satisfaction when asked about their progress one year after the surgery. The restoration of the shoulder’s strength depends on the quality of the tendon, complete healing of the tendon, and the completion of the physical therapy process if required again.

The answer to this question depends on the condition of other shoulder muscles and the age of the patient. Many elderly patients can continue their lives without pain or disability despite having a torn rotator cuff, as they may not experience any symptoms. In a study, although 40% of patients over 70 years old were found to have a rotator cuff tear, no symptoms were observed. However, in younger age groups, especially when the tears occur due to sudden injury, surgical treatment is recommended.

Steroid injections performed in limited numbers (3-4 injections) into the structure known as the bursa are generally safe and often effectively reduce local inflammation (non-infectious inflammatory condition) and pain. These locally administered steroids do not pose the same risks as orally administered steroids, as they are not systemically absorbed by the body. However, repeated steroid injections have been shown to negatively affect the quality of tendons, potentially leading to the need for surgery later on.