What is frozen shoulder? Symptoms, treatment and a possible pandemic connection.

What is frozen shoulder? Symptoms, treatment and a possible pandemic connection.
·8 min read

Sarah Noll Wilson started feeling the sharp pain in her right shoulder last July any time she would try to reach her arm behind her. "It got to the point where it was like take-your-breath-away pain," said Noll Wilson, 40, of Des Moines, Iowa. "I knew it wasn't right, but because it would only happen at certain times at that point, I didn't think it was as serious as it was."

That pain, Noll Wilson later came to learn, marked the beginning of a condition that would disrupt her life for months: frozen shoulder.

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"It was really debilitating for a long time," said Noll Wilson, who struggled to do basic activities such as washing her hair, getting dressed or sleeping comfortably because of her shoulder.

Noll Wilson isn't alone. Frozen shoulder, or adhesive capsulitis, is estimated to occur in about 2 to 5% of the U.S. population, according to the American Physical Therapy Association. While the exact causes of frozen shoulder aren't known, some shoulder specialists say they've seen an increase in cases among their patients over the past year and a half that may be connected to the pandemic.

"From a biological standpoint, there's some theories on how if you get covid, then your body is sort of in a heightened inflammatory state, and frozen shoulder fundamentally is an inflammation problem," said Michael Fu, a shoulder specialist and assistant attending orthopedic surgeon at the Hospital for Special Surgery in New York. Fu added that limits to access to care, such as in-person physical therapy sessions, during the pandemic and changes in people's daily activities might also be possible triggers.

"The shoulder capsule - it's a thin lining around the joint itself - has to maintain a delicate balance between flexibility, pliability and also integrity," Fu said. "Once you get into this cascade of a little bit of inflammation or microtrauma that leads to more inflammation, that just sets off the whole cycle of adhesive capsulitis, where the capsule, which is normally really thin like a piece of tissue paper almost, then becomes really thick and like cardboard, and that's how your shoulder gets tight and you lose range of motion."

Here's what Fu and other experts say you need to know about spotting frozen shoulder, what to expect if you're diagnosed and possible treatment options.

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Frozen shoulder often occurs when people are in their 40s to 60s and happens more often in women than men, experts said. Cases also appear to be more prevalent among people with certain underlying health conditions, including diabetes, particularly Type 1 or insulin-dependent diabetics, and thyroid disorders, said Julie Bishop, chief of the division of shoulder surgery at Ohio State University Wexner Medical Center. Additionally, Bishop said, frozen shoulder can be triggered by a minor injury, such as your dog yanking your arm while on a walk, or surgery that results in immobilization for an extended period of time.

Many frozen shoulder cases, however, "just come out of nowhere," Fu said.

Bishop agreed. "Most people are racking their brains to try to figure out what they did, and the reason that they can't figure anything out is, for most people, they didn't do anything," she said.

There are some theories that pandemic-related factors, including being infected with the coronavirus, could contribute to frozen shoulder. Researchers in Italy, for instance, studied 12 people who "reported shoulder stiffness and pain arising after COVID-19, with no apparent cause," according to a paper published in the peer-reviewed Journal of Shoulder and Elbow Surgery. The researchers suggested that "both direct and indirect effects" of having covid-19 may be involved in the development of frozen shoulder, with possible links to inflammation caused by the infection. They also noted that the condition could be the result of "the sedentary lifestyle forced on these patients by this disease."

Vaccines could be another potential cause, said Rajwinder Deu, a specialist in primary care sports medicine at Johns Hopkins School of Medicine. Deu said some of his patients have reported increased shoulder pain after receiving the flu or coronavirus vaccines, which may be the result of the shots being given too high in the upper arm, causing inflammation.

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Frozen shoulder typically progresses through several phases beginning with the inflammatory phase, which is characterized by pain, Bishop said. As the pain and inflammation worsen, stiffness starts to set in because the quality of capsule tissue is changing, Bishop said, likening the process to "tightening a belt around the shoulder."

This "freezing" phase is "the worst place to be," she said. "Any time they try to reach past what their range of motion is, everyone describes it to me like a knife or an ice pick in their shoulders. It can be excruciating."

Once the inflammation clears up, people enter the "frozen," or stiff, phase, Bishop said. The pain is gone, but they still have not regained their mobility.

Eventually, she said, frozen shoulders will "thaw" out, meaning the stiffness goes away, and the joint returns to normal.

The timeline of a frozen shoulder is "drastically different" depending on the person, Bishop said. While most people can go through the phases within a year, she said, the condition can take several years to resolve.

"Everybody wants to know, 'When is this going to end?' And I can't tell anybody that because it is very unique to just you and your biology," she said. People who are diabetic, for instance, are known to have longer, tougher courses.

"For a very benign process that almost never ends up in surgery, it is miserable for the people that have a really severe case of it," she said.

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To distinguish frozen shoulder from other shoulder ailments with similar symptoms, experts recommend getting a physical exam from a health care provider. If you have frozen shoulder, you won't be able to lift your arm yourself or with help from a clinician, Deu said. He added that he also often orders an X-ray to rule out other conditions that can cause a loss of active and passive motion, such as arthritis.

But experts cautioned against getting an MRI. As people age, it is common to see a little fraying or partial tearing of tendons, which will show up on the detailed image produced by an MRI and may complicate the diagnosis.

"Even if you have no shoulder pain, almost always there will be a line saying maybe you have a labrum tear or maybe you have a partial rotator cuff tear," said Joaquin Sanchez-Sotelo, chair of the Division of Shoulder and Elbow Surgery at the Mayo Clinic in Rochester, Minn. "That can be confusing because it's a red herring. It's not the real reason for shoulder pain in frozen shoulder."

A misdiagnosis, Fu said, could be problematic for a person's recovery.

"If you treat a rotator cuff tear with surgery, for example, in the setting where frozen shoulder is actually the primary problem, that's like pouring gasoline on a fire," he said. "That could make the frozen shoulder much worse."

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Frozen shoulder cases can resolve on their own without treatment, experts said, but it can take a long time.

Instead, Fu and other experts said early detection is important. If the condition is diagnosed in the inflammatory phase, Deu said a cortisone shot injected into the joint can help reduce inflammation and pain, allowing people to potentially start range of motion exercises sooner. Over-the-counter anti-inflammatory medications such as Advil or Motrin can also help people manage inflammation.

While the pain is generally at its worst when the shoulder is inflamed, getting surgery too early is widely discouraged. Surgery can't get rid of inflammation or stop the condition's natural progression to stiffness, Bishop said. What's more, even though a frozen shoulder operation - also known as a capsular release - is arthroscopic and minimally invasive, "surgery is traumatic," she said, and can amplify inflammation and stiffness if the joint is actively inflamed.

Shoulder specialists typically reserve surgery for people who are past the inflammatory stage and no longer seeing progress through physical therapy.

If the timing is right for a capsular release, the procedure can be highly effective, experts said. But they emphasized that a majority of frozen shoulder cases can be treated without surgery.

"The hallmark of treatment for frozen shoulder is physical therapy and stretching," Fu said.

Still, Deu said people with frozen shoulder should know that the various treatment options aren't guaranteed to speed up recovery. "It's a condition that requires patience."

After months of intensive physical therapy, Noll Wilson said she believes her shoulder is in the "thawing" phase.

"I still notice it," she said. "I'm still doing things to try to continue the recovery. But instead of it feeling like a barrier, it's like we're coexisting now."

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