Frozen shoulder or adhesive capsulitis is something nobody wants to hear they have. If you've been diagnosed with this, then this video is for you. We're gonna walk through the definition, how we diagnose it, the timeline of the condition, and how we treat it. Welcome back team to the Building Life On Gathis Podcast. Thanks so much for stopping by, I really appreciate it. If we haven't met yet, my name is Jordan Reineke, and I'm a dual board certified physician in family and sports medicine. And the goal of this podcast is to keep you active and healthy for life through actionable evidence-formed education. Today we're diving deep into something that we see every once in a while in clinics, something called adhesive capsulitis, or what most people know it as frozen shoulder. This condition can be super frustrating for patients, so it's so important that we have a good understanding of what it is and how to educate patients about it. So let's dive into it here. So first things first, let's talk about the basics of adhesive capsulitis. What exactly is it? Well, it's not just shoulder stiffness, right? Some people say, "Oh, my shoulder's really tight." That's what it probably is like. I'm just saying as a clinician, when you see this, you will know it. It is not just like subtle, like, "Oh, that little stiffness," it is pronounced. So it's not just shoulder stiffness. It's serious. It's very insidious, though, kind of gradually comes on and starts with pain, maybe a little bit of loss of range of motion, but then eventually you have this big loss of shoulder range of motion, and that's the big thing. And the key thing here, kind of a big diagnostic criteria, is that the restriction's gonna happen with both active and passive range of motion, meaning the patient can't move themselves, and you as a clinician can't move them either. It's like hitting a wall. Honestly, when I teach people this, I say, "Hey, you have to feel like, it's like you're literally hitting a wall. You're trying to move their arm with external rotation or something, and you can't do it. You are hitting a wall." That's usually when you say, "Oh, snap, like this could be frozen shoulder." And that tells us the problem is going on deep, right? Deep into the capsule, into the shoulder joint itself, not just something else going on. And what is actually going on in there? Well, we're not entirely sure, but we think that initially it starts with inflammation, right, and that triggers a lot of the pain, right? So we have inflammation, the joint's angry, it hurts a lot, but then eventually it shifts towards fibrosis. So kind of think of like a scarring that's going on here, and the capsule tightens up and then contracts down. That's what limits the motion. When I step back and see the joint capsule, all of our joints have these synovial capsules, right? They have synovial fluid, so fluid inside these capsules. I kind of describe them as plastic bags. So plastic bags are kind of malleable, they move, they can hold stuff. That's kind of what a joint capsule is. In this condition, what's happening is that capsule is getting thick and contracting down. That's leading to that loss of range of motion. So when I think about that, I think of a tightened thick capsule that's leading to the loss in range of motion. And the names have changed over time. Used to be called periarthritis, then the catchy term frozen shoulder came on, and then more recently in terms of, I guess, you know, 1940s, not that recently, but they said adhesive capsulitis. They thought there were adhesions in there. Turns out when we look at things arthroscopically inside, there's no like real adhesions going on. It's more of like stiff, thick, and fibrosis. So, you know, a lot of people call this adhesive capsulitis in literature, and now actually people are making a push to say it's actually called frozen shoulder. It doesn't really matter. Don't really care what you call it. We use them interchangeably. So frozen shoulder, adhesive capsulitis, that's really what it is. And so that's kind of the big thing here though, is that it's going to be frozen shoulder or adhesive capsulitis. Don't care what you call it, but really what it is is that we're going to have this decreased range of motion, right? Significant changes in range of motion. And that's what you should be kind of cluing into the thing that, hey, this might be happening. So going into it though, not all adhesive capsulitis is created equal. We can break them down into two main buckets, primary and secondary. So primary is kind of idiopathic, meaning, I'm not sure. It's a fancy medical term for we don't know. I always say you're an idiot because it's idiopathic. We don't know what's going on. It just happens. But this is the big thing. We see strong links with other health conditions. Things like diabetes is a big one. I would say the vast majority of the patients that I see who have frozen shoulder happen to have diabetes. That's kind of what it goes to. Your risk of getting adhesive capsulitis goes way up. We're talking almost like 20, 30% of diabetics may experience at some point, compared to just a few percent in the general population. So a big thing. On top of that, they also lead to the more tough and more stubborn cases. And it's like most things, usually diabetes doesn't help anything. Any medical condition you have, if you have diabetes on top of it, usually that makes it worse. And it's kind of the same for adhesive capsulitis as well. We're not sure why that happens, but that does seem to be the case. Additionally, there's thyroid problems that can be attached to this, both overactive and underactive thyroid. So hyper and hypothyroidism, both of those can be linked to having this as well, but we're not exactly sure why. Could be a metabolic change going on, maybe autoimmune things are going on. Definitely not sure as well. And there also may be some connections to heart disease and Parkinson's, other things like that. But the biggest things are usually thyroid and diabetes. Secondary adhesive capsulitis is more straightforward. It happens because of something else. Maybe there was an injury directly to the shoulder, like a rotator cuff tear, or maybe we had trauma to it, something like that. A lot of the times what I see is, is following a fracture or surgery, right? So after a fracture or shoulder surgery, you have a pronounced period of immobilization. And that's kind of the big thing. When you immobilize your shoulder after a trauma or for whatever reason, there's a chance of it kind of contracting down, getting tight and you get this frozen shoulder. And so that is something that can happen. It has also seen other serious conditions like stroke and heart attacks sometimes after, can cause frozen shoulder. But the big thing is usually a trauma or something like that. And once again, when we're talking frozen shoulder, we're talking like big range of motion loss. So when we're looking at it, it can be upwards to 50% of range of motion loss specifically. So I just wanted to mention that that's a really big thing. And so what are these clinical phases? Well, typically frozen shoulder goes through some distinctive phases. So you have to remember the timeline's not set in stone, though, right? It's gonna vary quite a bit between people. Think of it as kind of like four main ones. So it used to be three, not gonna be as four. So the first is pre-freezing. So this lasts anywhere up to about three months. It kind of starts subtly, right? The patient feels the ache and it's bugging them more and more, maybe at night it's starting to hurt. And then you start to lose a little bit of motion specifically when you're trying to turn that arm out, right? The biggest thing when we're looking at this clinical history is, hey, external range of motion. That's usually the first one to go. So when I have patients in clinic, I'm checking if they have great external range of motion, I'm not that concerned for frozen shoulder. But once again, that's a big thing. You're gonna take the patient and you're gonna bring them through external range of motion. And if they have a great range of motion on both sides, probably not frozen shoulder. But then if you hit the wall and you're like, oh shoot, they can't do anything, then I definitely think this could be going on. And eventually over time, it'll become where it's globally, where abduction, you know, internal rotation, flexion, all those things are limited, but external rotation is the first one. And so that's the big thing when testing, if we see decrease there, you start to think, ah, could it be, this is early. But in this early, you know, pre-freezing stays, it's not that bad, right? At this point, it's kind of easy to mistake this for something else. And this happens all the time, right? People come in, little bit of shoulder pain, little bit of loss of range of motion. Think, hey, maybe this is rotator cuff related pain, labor, who knows what, I'm not too worried about this, but hey, go to physical therapy and come back. This happens all the time because it's almost impossible to differentiate something else from early pre-freezing stage. That's, you know, unfortunately, but that's kind of what happens. Then we move on to the next phase, which is the freezing phase. And this is where things start to get real and get nasty. Usually this is between around three to nine months and the pain really ramps up here. And that stiffness really starts to increase as well. And you start to lose range of motion. You get that big loss of range of motion in multiple directions, right? So both actively and passively, meaning they can't move it and the clinicians can't move it either. And the capsule is getting more and more fibrotic, more scar down, and the pain is typically the worst at this stage. It feels like the shoulder's literally freezing up. This is one where I tell all my learners, hey, it's under differential of like, when everything hurts, when the shoulder just doesn't make sense and everything hurts, you have to think of frozen shoulder 'cause it can be incredibly, incredibly painful. And so I just, some have to consider that someone comes in, you're like, oh, this doesn't really make sense. Like there's no trauma to this and they're having decreased range of motion and it just hurts everywhere. We have to think about frozen shoulder. So this is that freezing phase of the second one. Really, really painful, kind of happening anywhere from about three to nine-ish months can be variable, you know, depending on the person, but super painful, does not look like a good time. Then we move in from the freezing, right? Here we're going from, first one's pre-freezing, then freezing, and then now we're into frozen. This is why they are stuck. And this is usually from around, you know, at nine to 15 months. And here it's kind of, things change a little bit, right? So the intense pain starts you back off a little bit, especially when the resting, maybe sleeping's not as bad, but the stiffness is still really extreme. So I kind of think about, initially you had huge amount of pain and freezing's kind of getting there and then eventually they kind of cross. Now we have a frozen shoulder and pain is getting better, but still bothersome for them, right? You're really gonna be limited in range of motion and movement. And when you try to push it, there's this hard, once again, wall, it's like you're running into a wall, they can't do it. It's a firm end point. That's a big thing. I say, hey, does this have a firm end point? Talk about that with other orthopedic tests, but hey, it's like running into a wall. The capsule is thick, tight, and it's really challenging. It can be upsetting for them 'cause it's tough to do even just your daily activities when you can't move your arm. And we're talking about literally, people can't lift their arm up at all, like to the side or anything, they can't use it. And so it's really challenging to do your daily living of things when you can't use your arm. And then finally, after we have that, the last phase is the thawing phase. And this usually starts around ish, 12 months maybe. Who knows? It can take up to two years or three years to fully heal. That's the big thing. And so if you take a timeframe in this, it takes a long, long time. But in this thawing phase, motion gradually starts to come back. Pain is mostly getting better or gone, and the capsule starts to remodel itself again. And the cool thing is that most people do get better. They often get back too close to their normal function, but it can just take a long, long time. And so the biggest thing is that when you're talking to patients, you have to say, hey, this may take a long time, and set up expectations. Like, hey, this is gonna be the long haul. Like I've literally seen sometimes it takes up to two to three years for some people to get kind of back to where they be. And other people don't get fully back to where their baseline was, and that can happen. So it's not unheard of though, to have a little bit of stiffness, or occasional ache and pain for a very, very long time. But the biggest thing I would say, out of everything in this lecture and understanding is that, hey, this can be in it for the long haul, so you have to counsel patients appropriately. 'Cause if you think, hey, we'll be better in four weeks, it's gonna be a hard time when they're at six months, and like, why am I not better? It's like, well, 'cause you were never gonna get better at six months, we didn't have that expectation set. So just something to think about. And as I mentioned, the natural history of this is that it's usually self-limiting, meaning it'll just go away on its own, usually within one to three years. And yeah, it does happen for some folks, but there's definitely not the case for everyone. Just waiting it out sometimes may not be the best strategy, 'cause it can lead to other morbidity. So what I mean by that is if you just did nothing, right? So hey, like just have benign neglect. So you're fine, it'll get better, no worries. That can work for some people, but not for everyone. Because while spontaneous recovery is the natural course, a pretty significant chunk of people actually end up with lingering issues for a long time if they don't get treatment. So we're talking about persistent pain, stiffness that just won't go away, and trouble with daily functions even years down the road. And so that's why I'm always a big advocate of we want to treat this. And yes, is it like a life-threatening we need to treat? No, we don't need to do that, but it's helpful for their long-term prognosis to do that. Some studies suggest that patients still had some pain or stiffness seven years after this. That can happen. And another study showed that 40% still had range of motion limits after several years as well. So self-limiting doesn't always mean a perfect recovery for everybody. That's why we wanna kinda use all the resources that we have. And what makes the difference on these people? Some people have better outcomes than not. Well, there's a couple of different things. First is diabetes, right? Diabetes is a big one that often means that you're having a longer, tougher road. And how long you've had symptoms before getting it, getting help also may matter. Meaning if you wait too long, that could potentially lead to worse outcomes. Though the data is a bit mixed about that, I'll say as well. But, and also how bad the stiffness was initially seems to play a role. If it's really, really bad to start, odds are it's probably gonna be a little longer in recovery or may have a worse recovery, something to think about. And on top of that, if it's secondary, adhesive capsulitis, caused by something like a trauma or surgery, the recovery path might look different depending on the original problem as well. So it's not like a simple A to B, everyone's gonna follow this course. We're just understanding that we probably wanna get involved with physical therapy and treatment modalities, whatnot to help improve the long-term outcomes. But even then, it may not matter. We could do an intervention and it may not help you, or we can do nothing and you're fine, who knows? But we just have to offer things to patients and have options for everybody. And so on top of that, moving on, let's talk about the clinical diagnosis, right? So how do we do it? It doesn't, as we talked about here, it is a clinical diagnosis. So before I kinda mentioned that, clinical diagnosis means like you can just see them in clinic and make that. It's not just this run of the mill stiffness that I mentioned before, it is really, really serious. It's going on and it's gonna take quite a bit of time. And the big thing for diagnosis is there's gonna be clinical exam, right? So history and clinical exams can be like the big thing. When I say it's a clinical diagnosis, that means it's clinical and that you talk to a patient and understand. They're gonna give you this history of, hey, it's been coming on for a while, have this vague shoulder pain, it's getting worse, I'm losing some range of motion. Those are the big things we're looking at here. And specifically, they may have already had contact with the healthcare system. A lot of times they come in and say, "Hey, I had shoulder pain." They get sent to physical therapy, they don't get any better. And quite frequently, I'll see people in my sports clinic who were in physical therapy and PT sends them back saying, "Hey, I think they have a frozen shoulder." Our physical therapists are wonderful at that. They recognize it, they know to look for it. But in primary care, we should also look for that saying, "Hey, if we have this vague shoulder pain, it's not getting better, come on back and we can think about adhesive capsulitis or frozen shoulder." So we have to kind of think about those things as well. And maybe they have, when you're on the exam, you're going there and decrease range of motion in general. So you think about your external rotation, that's the first one to go, they're gonna have decreased external range of motion. It's feeling like that end point if it's really laid on in that frozen stage is like it's like a hit in a wall. But I always check that first and see how that's going. Then you'll check the other ones. So abduction, flexion, and then internal range of motion as well. Global usually you're decreased there. That's kind of what we see. From a palpation standpoint, they may have tenders kind of all over the shoulder. There's not like one specific spot that says, "Hey, like you have frozen shoulder 'cause it hurts here." That's not the case at all. But it sometimes have diffuse pain. And then with special tests, if they're able to do special tests, looking for other rotator cuff testing, those might be positive as well, just 'cause the whole shoulder hurts. And so it's one of those ones where there's not like a one test gives you this. It's more of a, "Hey, I rule out other things." Almost a diagnosis of exclusion, but can definitely be clinical and they have to think about that as well. And so those are the big things when I think about making a diagnosis is that it's gonna be clinical. So talking with the patient, get their history, that's so, so important. Don't just brush through them and move their shoulder and say whatever, listen to their history. Usually that gives it away in terms of the range of motion losses. Check for range of motion losses on exam. You can palpate if you want to, but a lot of times those are the big things. And then moving on imaging. As I mentioned before, this is a clinical diagnosis. A clinical diagnosis means that we don't need imaging. And so we don't need to do that, but a lot of time it's done to rule out other stuff as well, right? 'Cause when people come in and their shoulder hurts so bad, you don't want to be like, "Oh yeah, it's just a frozen shoulder," if you don't know for sure, 'cause there can be a lot of other stuff that mimics it. And so we always get x-rays first to start. That's just kind of how all radiology works. Or the main thing here is that we're looking to make sure they aren't missing anything big, bad, or scary, right? Like really profound arthritis can look like this. You can lose range of motion with really bad arthritis and it'd be foolish to say, "Oh, you have a frozen shoulder. We have really bad glenohumidular arthritis." So that's a bad look. So always look for that. Also, you can see calcium build-ups, so calcium tendinopathy, that presents with a lot of pain as well. Maybe you see a fracture or you can see a tumor. The reason we get x-rays is just 'cause we don't miss big, bad, scary things. But however, in straightforward frozen shoulder, the x-rays are usually completely normal. Maybe just showing a little bit of osteopenia 'cause of not using it as much, but usually pretty normal. And then MRI, sometimes MRIs are got, just 'cause the range of motion is so bad, you're like, "Oh gosh, what's going on here?" So you can definitely get it. Not needed, but can be helpful. And what you'll see here is if you do that, you're essentially once again trying to rule out stuff like a big rotator cuff tear. If you have ultrasound, we'll talk about in a second, that can replace that. But if you do get an MRI, you might see a couple of things. You might see thickening of the joint capsule, usually thickening over four millimeters is kind of suggestive of maybe adhesive capsulitis. And you may also see thickening of a specific ligament called the coracohumeral ligament. And so if you see those reports in the MRI, they'll probably say concerning for adhesive capsulitis. But if you see thickening of the capsule or thickening of the coracohumeral ligament, think about potentially what's going on there. You might also see signs of inflammation, especially if they use contrast, which I don't know why anybody's getting an MR arthrogram necessarily for this. That's usually not the first line. But sometimes if you see that, you might see additional dye into the space called the axillary recess, which is kind of under the arm. That can be filled in more on MRI. You might see that more fluid there. And then also you could see even kind of how the capsule responds to fluid may also indicate that I have the adhesive capsulitis as well. But once again, those usually overkill for most cases. If you're getting an MR arthrogram, it's usually 'cause you're looking for like labral or something, but usually an MR without contrast is acceptable. And then finally, we also have the ultrasound. Ultrasound is getting more popular. It is convenient, it has no radiation. You do need to have a sealed operator in this though. So you have to really, it's kind of subjective. You may see an ultrasound thickened coracohumeral ligaments. You can check the axillary recess to see if it moves when you rotate the arm, stuff like that. Maybe able to see some changes on Doppler. Regardless, that's not necessarily, I think the main role of most people unless you're specialized in that, but the big thing that it's really good for is it can rule out big rotator cuff tears, right? That's like the big thing I use it for a lot of times is I'll look at those other things as well to try to see. But really what I'm trying to see is man, I think this is a frozen shoulder. I want ultrasound and make sure, okay, the rotator cuff is not torn, great. It's not a huge tear, then it's frozen shoulder. We can go from there, save people an MRI and save them time as well. So those are the big things. Once again, you don't need any of those. You can make this clinical diagnosis on your own, but that is what we do and can be helpful. And so now let's talk about treatment, right? We usually start with conservative approaches and trying to avoid more invasive measures unless we need to, right? So the first thing first, as I mentioned before, is education, and this is huge. Patients need to understand what's going on. And it's important to explain the stages, right? That this is a known condition and importantly, that this typically does get better, but it's gonna take a lot of time. The biggest thing from patient education is understanding those expectations. I say it all the time. When I'm telling people about rehab, I actually tell them, "Hey, you've been having pain for a while, it's gonna take multiple months to get better." You know, a lot of times people think, "Oh, not better in four weeks in physical therapy. Oh, why not?" If you set that expectation that I wouldn't expect you to be better in four weeks, that's really helpful. Same thing here, telling them, "Hey, this is going to be a while." It does get better, but it's gonna take a while. Months or maybe even a couple of years. So setting realistic expectations from the get-go is crucial to keep them engaged and prevent frustration, right? And we also need to talk about modifying activities as well in this process. So I always tell people, don't push into sharp pain. Like you have like take your breath away pain, like, "Ah, ooh." Like don't do that. You don't have to push into that. It's not helping it. You know, you're not gonna necessarily change the course of the condition. So just pull back a little bit. But I also don't want you to immobilize completely. Like you're sitting in a sling. I want you to use it. Kind of gentle emotions that you can tolerate is really key. And I just kind of say motion is lotion. In this situation, it's very, very true. We wanna keep moving as best we can, but we don't wanna push through like crazy amounts of pain. On top of that, we can take medications to help with pain. You know, obviously I prescribe those judiciously. I don't do a lot, but when you're in a lot of pain, sometimes it can be helpful. Things like NSAIDs can be helpful and can take the edge off the pain, maybe calm down a little bit of inflammation. The evidence isn't super strong that they dramatically change the course of this condition or improve range of motion at all, but they may just make you feel better. And sometimes that's worth it, just feeling better. So we have to think about that. But once again, anytime with NSAIDs, just gotta think about the other side effects, you know, GI issues, kidney issues. If you have a heart disease, probably wouldn't take those. So don't just be popping Advil, talk with your physician first, obviously. And then oral steroids, sometimes they can be indicated. So a short course of steroids, like a taper there, may be helpful for some patients, particularly early on when things are really inflamed and painful. So it can offer a pretty dramatic short-term pain improvement, and maybe might speed up initial range of motion improvements. The catch though is that obviously the benefits don't last forever. Once you stop the meds, a lot of times the pain improves for a while and it may come back, may or not, we'll see. But also it has other side effects of steroids, right? So you can mess up blood sugars for patients who are diabetics, can lead to mood swings, sleep problems, technically increases risk of infections. And so these are kind of reserved for people with really severe pain that's really wrecking their sleep or making it possible to even start therapy. So that's kind of how I think about oral steroids, systemically have a place, but they're a big gun and I try not to use them if possible, but sometimes when people are miserable, we gotta do what we gotta do to help people live a normal life and get some sleep. And then moving on to the real workhorse here of treatment is physical therapy. So physical therapy is pretty much essential, especially once you're past that initial super painful phase into the freezing and frozen stages. So what are we trying to achieve in physical therapy? Well, the goal really is to get that motion back, maintain the motion we do have, right? If it is still freezing, trying to hold on to what we got and then help people function better in daily life and keep their pain manageable. Main component of physical therapy here is stretching. I think a lot of times you'll hear me rag on stretching, saying stretching is a little bit overrated. In this situation, like that's what we gotta do. We're gonna have to stretch because we've lost so much range of motion, we're trying to get that back. So it's this gentle low load stretches held for a decent amount of time, right? So kind of passive stretches where either the therapist or gravity does the work to start, then active assist where the patient helps and eventually the patient can take over and do all the stretches themselves, but it's kind of this gradual, slow progression. And we really want to be gentle here in these end ranges of motion, right? So external range of motion, abduction, flexion, internal range of motion, all of them are there, we're gonna be gentle and hold it there. The key is consistency though, right? We're doing these regular, right? These kind of little doses of stretching and it's gonna be way better than just one aggressive time per week. So really kind of slowly doing that. And as I mentioned before, don't be too aggressive, especially early on, trying to force motion when it's really irritated can just make things worse and set you back. And so gentle persistence is gonna really be our key here. And there's also things that physical therapists can do called joint mobilizations. This is where the therapist uses their hands to glide or move the joint. These are definitely helpful at times. They can be nice 'cause you get a little more range of motion there. It might give a little bit of extra boost to that stretching program. And yeah, it may help with pain as well. So yeah, there's multiple studies that show a benefit, but however others show, maybe it's not as important in the long-term. Either way, it's one of those things where we're just kind of seeing how it goes, seeing if it helps with the progress, helps with their pain, and it's generally safe and we just gotta be smart about it. And what about things like heat and ice? Sure, they can definitely help make people feel better and maybe relax the muscles more, but overall it's not gonna change anything. I tell people that all the time. They're like, "Should I do heat or ice?" I don't care. Not to be mean, but it doesn't matter. Whatever feels better to you is fine 'cause neither of those things are gonna heal this process, but it's gonna help you tolerate things better, then great. Things like therapeutic ultrasound intends you to as well. Evidences that they actually don't really do much. They don't speed up the recovery. They don't change the underlying condition. So you can use them if it's helpful. So if you're in a lot of pain, intends or ultrasound makes you feel better, then great. That's fine, we can do that, but just something to consider. And then finally, strengthening comes later. Once the emotion starts to come back and pain's under control, then we can start adding exercises back to build strength, the strength that we lost from not using it. So we focus a lot on the rotator cuff muscles and scapular stabilizers as well. And so those are a couple of the big things, but that's the general way that we think about physical therapy. And then what if that doesn't work? So we did a bunch of stuff, all the conservative stuff, took some meds, did PT, didn't work. Then we start thinking about interventions. And they're a bit more involved. The first is a steroid injection. So this is probably the most common injection from an intervention from a physician standpoint. We're talking about injecting some sort of steroid medication into the actual glenohumeral joint. So the ball and socket joint. Think about that ball and socket, that's where we're gonna inject that medication. And what does it do? Well, it's pretty good at providing significant pain relief for several weeks, maybe even a few months. And if I calm things down, it may sometimes lead to faster improvements in range of motion compared to just doing PT alone. The big advantage here though, is that it's reducing pain and allowing patients to actually tolerate and participate more in therapy. That's what I say all the time. Steroids are almost never like a curative injection. That's not always the case. Sometimes it actually may be, but in these situations, the real reason I use this is to help patients tolerate therapy when they can't sleep, when they're in pain all the time, a steroid injection sometimes just calms things down so you can like get out with your normal life, get some sleep and start to do your therapy. And that's what I use it for predominantly. I don't think I'm ultimately fixing it. And if it has the benefit of maybe shortening it, great. And that's wonderful, but I'm not convinced by that data, but it's something to think about. However, the evidence does generally back it up for short-term gains. Some studies even suggest it's better than taking oral steroids or just doing PT initially. I like this over oral steroids because it's gonna be more localized instead of just taking steroids, it gets everywhere. This is gonna stay a little bit more in the joint. We know there's some absorption of any injection systemically throughout the body, but it's more targeted here. But yeah, do I think it makes a huge difference in the final outcome compared to just sticking with PT and at a year plus time, who knows, not necessarily, but it maybe provide valuable relief early along the way that people need. And so that's what I think about. And from an injection standpoint, you can do this. You can try this landmark. Ultrasound is just gonna be a way better way to go. Ultimately, we know that medication is getting into the joint capsule where it needs to be instead of actually going somewhere else there. And you can still do a subacromi injection there and that may get some benefit. That's actually not a, that's what you know, and you can help them, that's fine. But ultrasound, if we have it to get actually inside the joint, that'd be ideal. And as we mentioned before in previous podcasts and videos, we've talked about that, yeah, when you have injections of steroids or anytime you can have complications, the biggest thing is that you can weaken the tendons with steroids, especially if you do lots and lots of injections. May also get some thinning of the skin or loss of skin pigment as well. And then can also spike blood sugar levels with diabetics as we've talked about before. Also increases your risk for infection around that area. So there's just some things to think about there. I have additional modules on injections and all that stuff there, but that's worth mentioning. Another thing I wanna talk about is called the hydrodilation or something called a hydro distension. This is kind of the next level up, kind of intense. And what is it? Well, it's basically just injecting a lot of fluid into the joint capsule. Usually it's a mixed, kind of like a cocktail of a steroid, some normal saline or mixed with some sort of local anesthetic. So a lot of times it can be steroid, anesthetic, saline, dextrose, it could be lots of different things, but we're injecting some mixture into the actual joint capsule. And the goal is to physically stretch the tight capsule down from the inside out. Almost like we're inflating a stiff bloom. That's kind of how we think about it. And for this one though, you're gonna absolutely need imaging, right? You can't just do that landmark, you're not gonna know. Usually you can do ultrasound or you can do fluoroscopy. I do ultrasound, but we're going in there with literally just putting fluid in there, trying to just pop open that little plastic bag a little bit, not necessarily pop it, but you kind of make it a little more space, not quite as thick. And the idea is that how does it work? Well, partly it's that we're physically stretching or maybe even causing some small micro tears in the capsule in the tightest parts. But it may also wash out some of the inflammatory molecules that are in there. That's another idea that's going on. And that's why maybe the steroid may be beneficial. I don't do a huge amount of steroid, but you could do a little bit there. And what does the evidence say? Well, several big reviews, including meta-analyses have looked at this and they generally suggest that hydrodilation can be quite effective for both pain and improving motion. And some research indicates it made me better than just a standard steroid injection or PT alone, particularly for those earlier in the process as well. But the quality of these studies varies and there's lots of debate on this and how much fluid to use. That's another big thing is people don't know what's going on. It is an office-based procedure though. So it's usually not on the or or anything, but it's done under some sort of guidance and it can be very uncomfortable though, right? So when you have a fixed amount of space in your body and you're putting more fluid in there, it just leads to a lot, a lot of pressure. And so it can be very painful and uncomfortable. And there's no one cocktail that people use. It could be anywhere from 10 milliliters. So I've seen people say 30 plus. And so literally just putting tons and tons of fluid in there, I don't go that far, it's barbaric. I've even seen some people say that, "Hey, you should inject until you break the capsule." And for me, I'm not trying to do that, but that's how much volume we're talking here. It can be a lot. But the big thing is after we do this, we definitely still wanna get physical therapy afterwards to maintain this. So if you stretch out the capsule, get a little bit of range of motion, we really wanna get you to PT fast so we can keep that range of motion. And as I mentioned before, not that comfortable for patients, it can be uncomfortable. And so this is one you definitely talk with them and say, "Hey, it's an option." But if you're sitting there in your primary care office and saying, "Hey, I don't know what options I have. You can send us to sports. We can absolutely do these things." So I just wanna mention that it's definitely out there and the data seems to be supporting that it can be helpful for patients. And so what happens though now if you've gone through months of physical therapy, tried a couple injections, maybe destroyed, and a hydrodilation, and they're still stuck and miserable, and we're six plus months out from this. Well, then we have to consider, should we have this patient talk with a surgeon, right? They're not the first line treatments. This won't be there. We reserve them for really stubborn cases. One option is manipulation under anesthesia. And here the patient gets completely under general anesthesia. And then the surgeon potentially carefully moves the shoulder around. We're just kind of breaking up adhesions is kind of the way I think about it. The scar tissue kind of literally just like stretching, aggressively stretching them is what we're doing. I'm trying to open up that capsule a little bit. And it can be pretty dramatic and it can sound awful if you're in the OR and you hear this, like you can make a crazy sound. That's pretty intense. But yeah, a lot of times when you do this, it does have risks. So the first thing's first is that like, if you just did it and go back to normal life, like you'll go back to being scarred on. So we have to once again do it and then go right to physical therapy to keep those gains. And on top of that though, it's definitely risky 'cause you have to put a lot of force into it. And if you put a lot of force, you could theoretically break someone's arm or shoulder. That would be bad. You could potentially dislocate the shoulder, tear the rotator cuff, cause a nerve injury. And because it's kind of pseudo barbaric, a lot of times this is not taken lightly, right? If we're gonna do this, we've really thought about that, but it's not necessarily a huge one that I see all the time, but it's an option that we have. And then another surgical option we have is an arthroscopic capsular release. And this is a minimally invasive surgery, where essentially you make tiny incisions into the shoulder joint, put something inside and inside there use special instruments to kind of cut and work through these tightened thick areas of the capsule. And usually they're focusing on the anterior and inferior parts of the capsule in kind of area called the rotator interval. And these are like wherever they see the tight spots there, it's kind of where they go in there and try to break that up. And yeah, it's cool cause you're using the camera to see you're along the whole way. Surgeons feel this is a little bit safer, more controlled way to kind of restore motion, but it's still a surgery. So you have your standard risks of infection, bleeding, nerve injuries, anesthesia risks, all that stuff. And once again, we'll need physical therapy after, but these can be the tools that we have if we've been doing things for a while and not getting any improvements. And so that's kind of where we're at. I just wanna wrap up the main points here, right? This is a lot that I've been talking about here, but just kind of take home points, 20,000 foot view. First, remember that frozen shoulder, it's this insidious onset, gradual locking the shoulder. It's painful. You're gonna have loss of range of motion in both active and passive ranges of motion. That's a big thing. And so we're gonna see in both sides. And there's two different types, right? Primary, the kind that just shows up sometimes associated with diabetes, but not sure. And then secondary, which is linked to an injury or trauma or something like that. And to make the diagnosis, it's clinical. Listen to the patient's story and then exam findings of globally reduced range of motion may kind of cinch the deal for you. And you can use imaging. I think it's probably wise to get an x-ray first just to make sure we're not missing anything big, bad, or scary, but don't necessarily have to do it. And then the duration of this, it's long. And it will get better on its own or it should get better on its own, but may take up to one to three years. And just telling people to wait it out probably is not ideal. We wanna get them rolling with physical therapy and kind of get going. And from a treatment perspective, we work it step-by-step, right? So start with education so they understand, then you can work in some NSAIDs or oral steroids potentially if they need to. We can also really get them involved early physical therapy to focus on gentle stretching and kind of improving their range of motion if possible. And then if we need to escalate, think about steroid injections, right? So hopefully ultrasound guided, but at least steroid injections into the glenohumeral joint or a hydrodilation may be helpful. And if, you know, at last case that's not working, we can refer to surgery to see if there's a surgery that needs to be done. But the bottom line is often it takes a combination of these things. And maybe most importantly, we need to help our patients understand that this is a marathon, right? This is not a sprint. It's gonna take a long time. We need to have some patience, persistence, and just kind of realistic expectations will be really, really helpful. And that's a wrap on adhesive capsulitis. Thanks so much for tuning in and sticking with me through a lot of that nerdy stuff. I hope this breakdown was helpful and gave you some practical insights you can use. If you did enjoy this, it would mean the world to me if you shared this with a friend, gave it a five-star review in your podcast, platform, or choice, or subscribed on YouTube. And so that's gonna be it for today. Thanks so much for stopping by. Now get off your phone and get outside, have a great rest of your day, and we'll see you next time.
