Pain Management: Visual Guide to Frozen Shoulder

What's Frozen Shoulder?

It is pain and stiffness in your shoulder that happens slowly.

It's pain and stiffness in your shoulder that happens slowly. It can worsen until your shoulder seems "frozen" in one position. Your doctor might call it "adhesive capsulitis." Although it may take as much as a few years to get completely better, it can improve long before then, especially if you do physical therapy to help with recovery.

Causes

Doctors don't know exactly what causes it, though some things make you more likely to have it. For example, it can happen if you can't move your shoulder very well because of an injury or surgery, or if you have diabetes, which can worsen symptoms and make them last longer. Thyroid problems, Parkinson's disease, heart disease, and certain HIV medications also seem to raise your odds of getting frozen shoulder.

What Happens

Strong connective tissue called the shoulder capsule surrounds the ball end of your upper arm bone and holds it to the socket. Frozen shoulder causes this tissue to get thicker in parts (adhesions) and inflamed. This may limit the "synovial" fluid that normally lubricates the area and prevents rubbing. The result is pain and stiffness. There are three stages.

Stage 1: Freezing

Over a period of 2 to 9 months, the shoulder capsule gets more and more inflamed. This ramps up pain and stiffness, and starts to limit your range of motion (how well you can use the joint). And these symptoms often get worse at night.

Stage 2: Frozen

As you might have guessed, this is when your shoulder is stiffest and hardest to move. It usually lasts somewhere between 4 months and a year. Pain often starts to improve in this stage. But your range of motion may be so limited that you find it hard to do basic things like eat, dress, and go to the bathroom.

Stage 3: Thawing

Your shoulder pain should continue to ease during this stage, and now you start to regain some of your range of motion, too. It happens slowly, taking 6 months to 2 years. In some cases, you may get back all or almost all of your strength and mobility.

Who Gets It?

It is most common if you're in your 50s or 60s, and it is rare for anyone under 40. Women get it more than men.

It's most common if you're in your 50s or 60s, and it's rare for anyone under 40. Women get it more than men. And if you get frozen shoulder on one side of your body, you're up to 30% more likely to get it on the other side.

Physical Exam

Your doctor will ask you about your symptoms, injuries, and medical history. Then she'll check your shoulder. She'll move it herself to see where the pain and stiffness start. This is your passive range of motion. Then she'll ask you to move it yourself. That's your active range of motion. At the limit, it may feel like your arm is stuck. If you have frozen shoulder, your passive and active range of motion will be less than normal.

Tests

An "injection test" may help narrow down the cause of your symptoms. Your doctor gives you a shot in your arm that dulls the pain. With most shoulder problems, this gives you a bigger range of motion, but it won't change it much if you have frozen shoulder. Doctors typically only use imaging tests like X-rays, ultrasounds, and MRIs to rule out other conditions.

Exercises

Once your frozen shoulder pain starts to ease up, your doctor might suggest arm exercises. A physical therapist can give you moves to do as homework. Take it easy at first. If you "push through the pain," you could make things worse. You'll likely start with range-of-motion exercises for a couple of months. After you feel better, you can safely begin to build strength.

Medicine

NSAIDs like aspirin, ibuprofen, and naproxen may curb pain and swelling.

NSAIDs (non-steroidal anti-inflammatory drugs) like aspirin, ibuprofen, and naproxen may curb pain and swelling. More powerful drugs called steroids are sometimes injected directly into the joint. But it can be tricky to get them into just the right spot, and even these will only provide temporary relief of your symptoms.

Hydrodilatation

Your doctor might suggest this method if physical therapy and medication have not helped.

Your doctor might suggest this method if physical therapy and medication haven't helped. She'll use pictures of the inside of your body to guide a shot of fluid into your shoulder joint. The goal is to stretch out the joint capsule and give you better range of motion.

Surgery

Your doctor may suggest this, usually in the "frozen" stage, if nothing else works. There are two methods, sometimes used together. The first is manipulation while you're "asleep" from general anesthesia. The surgeon moves the joint until it stretches or even tears the tissue. The second method, called arthroscopy, cuts the affected tissue directly. Your surgeon works through small cuts in your skin, using special tools.

Recovery

Frozen shoulder gets better for a lot of people within a year if they do physical therapy and use pain medicines and steroid shots if needed. Even without those methods, most people get better within a couple of years, though if you have diabetes, it may be harder to recover. Surgery works pretty well as long as you stick with your physical therapy afterward to rebuild and keep up your strength and mobility.

Reviewed by Tyler Wheeler, MD on 6/18/2018

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Rotator Cuff Tear: Symptoms, Causes, and Surgery

Rotator Cuff Injuries

A woman looks at a man’s injured shoulder.

Rotator cuff tears can be career-ending for professional athletes and are one of the most common causes of shoulder pain for everyday folks. So, what is a rotator cuff and how can it tear?

Shoulder Anatomy: The Rotator Cuff

An illustration of the shoulder joint and tendons.

The rotator cuff refers to a group of four tendons and muscles that form a "cuff" to stabilize the shoulder joint and keep the arm in the shoulder socket, while allowing it to move in different directions.

The shoulder joint is stable because of the rotator cuff, but it is also relatively weak. Acute injuries or repetitive stress and strain on the joint can cause swelling and tears in the tendons.

What Are the Causes?

Most of the time, rotator cuff injuries are caused by repetitive stress on the rotator cuff, or degeneration caused by aging. Such repetitive stress can include injuries sustained from sports, particularly those that require a lot of shoulder movement such as baseball, tennis, swimming, weightlifting, and football.

As we age, reduced blood supply to the rotator cuff tendons means damage does not repair itself as well, and bone spurs (bony overgrowths) can also weaken the tendon and lead to tears.

Acute injuries caused by falling, using an arm to break a fall, or lifting heavy items with a jerking motion can also lead to rotator cuff tears.

Acute Rotator Cuff Tear

A man injures his shoulder lifting heavy stones.

An acute rotator cuff tear occurs when there is excessive force exerted on the rotator cuff tendon. The amount of force needed to tear a rotator cuff tendon varies from person to person and the condition of their rotator cuff tendon prior to trauma. In a person with a healthy tendon, it could require the stress of a fall, landing on an outstretched arm to tear the tendon. But if the tendon has pre-existing degeneration, the force require for it to tear may be modest, such as lifting a moderately heavy object.

Chronic Tear

Chronic rotator cuff tears are commonly seen in people whose occupations or sports require them to reach their arms overhead frequently, such as in baseball pitchers, tennis players, or even painters. Use of the arm in such a position causes repetitive trauma to the rotator cuff muscles and tendons.

Tendinitis

A senior tennis player grips an aching shoulder.

As we age, the blood supply to the tendons is reduced which can lead to longer healing times after injury. In addition, muscles degenerate. All this can lead to tendinitis (tendon inflammation), which can make a person more prone to a rotator cuff tear.

What Are the Symptoms?

A man explains his shoulder pain to a nurse.

Symptoms of rotator cuff injuries are due to inflammation and swelling in the rotator cuff and include:

Pain in the shoulder and arm. Pain is felt often at night when lying on the affected shoulder.
Pain may also be felt when moving the arm in certain ways. The pain stops before the elbow.
If the injury is acute (sudden) pain will be intense and immediate.
If the injury is degenerative (damage occurs over time) the pain may be mild at first.
Weakness or loss of motion in the arm or shoulder.
A grating or snapping sensation or cracking sound when moving the shoulder.

When to See the Doctor

Any time you have an acute shoulder injury, or chronic shoulder or arm pain, you should see a doctor for a diagnosis and treatment. If your shoulder pain persists despite rest, ice, and anti-inflammatory medications, if you can no longer perform your daily activities, if you cannot reach overhead, or you can no longer participate in a sport you used to, see a doctor. Early diagnosis of a rotator cuff tear can make a big difference in recovery and prevent loss of strength and motion.

Should You Go to the ER?

A sign points to the emergency room entrance at the hospital.

If your injury is acute (sudden) such as from a severe fall or accident, go to a hospital's emergency department. If you suspect a bone is broken, if you have an open wound or a bone protruding from the wound, if you experience any numbness in the arm or hand, or if you cannot move your shoulder, go to an emergency department.

Exams & Diagnosis

A rotator cuff injury is diagnosed first with a physical exam where a doctor will move your arm in different directions to assess your pain levels and range of motion. Tests for a rotator cuff tear may include:

X-ray
MRI (magnetic resonance imaging)
Ultrasound
Arthrogram - a special type of X-ray that uses dye injected into a joint to more clearly see detail in the tendons and muscles

Treatment Options

A woman uses exercise bands for physical therapy on her shoulder.

The first line of treatment for rotator cuff injuries that are mild to moderate includes rest, ice, and anti-inflammatory medications such as NSAIDs including ibuprofen (Advil, Motrin). Avoid using the shoulder if it hurts.

Physical therapy for rotator cuff injuries is used to make the shoulder stronger and more flexible. In some cases, steroid injections such as cortisone may be used to relieve pain and inflammation.

Most of the time, surgery is not needed to repair a rotator cuff injury, except in severe cases where the tendon may be completely torn, the injury is acute, or the pain is chronic and has not been helped by other treatments. Following surgery, physical therapy is still needed.

Surgical Treatments

A torn rotator cuff (left), and a repaired rotator cuff tendon following surgery (right).

Surgery may be recommended for a torn rotator cuff in severe cases. If pain does not improve with medical treatment and rest, or if you are an athlete or use your arms and shoulders a lot for work you may need surgery. Surgical options include an open repair, which involves a traditional surgical incision. This method is used for large or complex tears. Arthroscopic repair is less invasive and involves a smaller incision in which the surgeon inserts a small camera (an arthroscope) into the shoulder joint allowing the surgeon to see the shoulder anatomy and to guide surgical instruments.

Either type of surgery involves an extensive rehabilitation period. This consists of immobilization of the shoulder joint, such as with a sling, for four to six weeks. Once the sling is off, physical therapy begins with passive exercises where a physical therapist will move the arm and shoulder for you. Beginning 8 to 12 weeks post-op you may start doing active physical therapy exercises to strengthen the arm.

Can Rotator Cuff Injuries Be Prevented?

A woman stretching her shoulders before exercise.

You may not be able to prevent all causes of rotator cuff injuries. Accidents happen and muscles and tendons degenerate with age. But there are some things you can do to decrease the likelihood of a rotator cuff tear.

Proper warm-ups before sports or other tasks involving the shoulder joint can keep it flexible and may prevent injury.
Exercise the shoulder to maintain strength.
Avoid lifting heavy objects over your head.
If you are using your arms and shoulders a lot, take frequent breaks.

Recovery & Prognosis

A father and son enjoy playing football in the backyard.

In about half of patients with rotator cuff injuries, nonsurgical treatment is sufficient to relieve pain and restore shoulder function and movement. Conservative treatment generally consists of a minimum of six weeks of physical therapy and sometimes cortisone injections.

If surgery is required, the recovery time is longer. The shoulder will need to be immobilized for four to six weeks, followed by physical therapy. Patients usually need to wait about three months before using the shoulder for light activities above shoulder height, and about six months to return to vigorous activities.

Reviewed by Aimee V. HachigianGould, MD on 6/21/2016

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This tool does not provide medical advice. See additional information:

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Leg Pain: Causes and Treatment for Leg, Calf, and Thigh Pain

What Is Peripheral Artery Disease (PAD)?

Peripheral artery disease causes cramps in the lower legs.

Peripheral artery disease is a condition where there is inadequate blood flow to reach your limbs due to narrowed arteries. It is one cause of leg pain. People with PAD suffer from leg weakness, numbness, and cramps when they walk. Symptoms typically occur with walking and other types of physical exertion and they resolve with rest. The condition may cause color changes in the legs and may make you feel cold when they do not receive enough blood flow. Smoking contributes to PAD, so if you have the condition and you smoke, you should stop. Medications may help, but some people need surgery for the condition. Another name for PAD is peripheral vascular disease. People with PAD are at increased risk for heart attack, stroke, and coronary artery disease. The pain caused by inadequate blood flow during exercise is called claudication.

Deep Vein Thrombosis (DVT) Is Painful

DVT may cause pain and redness in the affected leg.

DVT (Deep Vein Thrombosis) is a condition that occurs when a blood clot forms in a vein in the lower leg or thigh. It may or may not cause symptoms. If symptoms are evident, they include swelling, skin redness and warmth, and leg pain. DVT may lead to a potentially life-threatening condition called pulmonary embolism (PE). This occurs when part of a blood clot breaks off and travels to the lungs. Blood clots located in the thigh are more likely to lead to PE than those in the lower legs. Seek medical attention right away if you are experiencing symptoms of DVT. Medications are available that inhibit clots from forming, growing, and breaking off and traveling to other locations in the body.

Peripheral Neuropathy and Pain

Diabetic neuropathy is one kind of peripheral neuropathy.

Peripheral nerves are nerves are those that are outside of the brain and spinal cord. Damage to to peripheral nerves causes a condition called peripheral neuropathy. Diabetes is the most common cause of peripheral neuropathy. This is known as diabetic neuropathy. Other conditions can cause it. So can infections and the use of certain medications. Peripheral neuropathy in the legs can cause sensations of numbness, weakness, and tingling (pins-and-needles sensation). Diabetic neuropathy can also cause foot pain. Treating the underlying cause may resolve the condition. Medications are available to treat nerve pain.

Keep Electrolytes Balanced

Electrolyte imbalance is one potential cause of leg pain.

Potassium, sodium, and calcium are electrolytes, or salts that help conduct electric current in the body. Electrolytes are necessary for muscles and other systems in the body to work properly. We lose electrolytes when we sweat and physically exert ourselves. Treatments like chemotherapy cause us to lose electrolytes, too. If you lose too many electrolytes, your legs may cramp. You may even experience numbness and weakness. Drink sports drinks to replenish electrolytes. Mineral water and certain foods that contain electrolytes can also replenish these important compounds. If you experience frequent cramps that are not relieved when you replenish electrolytes, see your doctor.

Spinal Stenosis

This condition causes spaces within the spine to narrow. This, in turn, puts pressure on spinal nerves. This results in symptoms like numbness, tingling, weakness, and pain. Some people also experience balance problems. The lower back and neck are the areas most commonly affected by spinal stenosis. Certain inherited conditions, degenerative diseases, tumors, trauma, and bone conditions may cause spinal stenosis. The condition may be treated with over-the-counter pain medications, steroid injections, restricted activity, prescribed exercises, and physical therapy. Surgery may be needed in some cases.

Spinal stenosis may occur when the spine is injured and tissue swelling puts pressure on the nerve roots or spinal cord. An injury to the spine may cause a bulging disc, or herniated disc. This can protrude into the spinal canal. When a herniated disc puts pressure on a nerve root, this is known as a pinched nerve. This results in numbness, tingling, and pain in areas where the nerves travel. Some cases of disc herniation are treated surgically.

Radiculopathy is a condition that happens when a nerve is compressed in the spine. When this occurs in the lower back, or lumbar region of the spine, this is known as lumbar radiculopathy. Lumbar radiculopathy is also known as sciatica. The condition is known as cervical radiculopathy when it occurs in the neck and thoracic radiculopathy when it happens in the middle of the spine.

Do You Have a Pinched Sciatic Nerve?

A pinched sciatic nerve, or sciatica, may cause leg pain.

The sciatic nerve is the largest nerve in the body. You have two sciatic nerves. Each one runs from the lower spine down through the buttock, the back of the thigh, and down to the foot. Sciatica is a condition that occurs when the sciatic nerve is compressed. This results in pain in the hip, back, and the outer leg. Some people experience cramps and shooting pain that may interfere with the ability to sit or stand. A slipped disc, a herniated disc, spinal stenosis, or a slipped vertebra may may cause sciatica. The condition may be treated with pain meds, exercise, physical therapy, stretching, massage, and ice packs. Severe cases may be treated with steroid injections or surgery.

Arthritis and Leg Pain

Arthritis is a condition that causes pain and inflammation in the joints. People may also experience symptoms like joint stiffness and swelling. Arthritis of the knees, ankles, and hips may make it difficult to walk and do other activities throughout the day. Arthritis cannot be cured but daily exercise and maintaining a healthy weight can help. Over-the-counter pain relievers may ease pain. Heating pads can diminish aching while ice packs diminish pain and swelling.

Pulled Muscles Ache

Pulled muscles commonly occur in athletes.

A pulled muscle is a muscle that has been overstretched. Pulled muscles are a common occurrence in people who play sports. A pulled muscle will cause pain instantly and the pain is described as intense. The area is painful to the touch. If you pull a leg muscle, it's a good idea to apply ice packs to the area several times a day for 20 minutes at a time. Take a break in between icing the area. Lightly wrap the pulled area and elevate the affected limb, if possible. Rest and take over-the-counter medications to ease pain from a pulled muscle.

What About Sprains?

Sprains are injuries to soft tissue areas (ligaments) where a muscle connects to a bone. Ligaments that are overstretched or torn are called sprains. The ankle is a common location for this type of injury. If you have a sprained ankle, you cannot put weight on it and the area is swollen and painful. The recommended treatment for a sprained ankle is Rest, Ice, Compression, and Elevation (RICE). This involves resting the swollen ankle, icing it for 20 minutes several times per day, compression of the area by wrapping the ankle in a bandage, and elevating the lower leg to minimize swelling. See a doctor for injuries to make sure you do not have a broken bone.

Do You Get Muscle Cramps?

Dehydration is a risk factor for muscle cramps.

Muscle cramps are involuntary contractions of muscles. You cannot relax a muscle that has cramped up. Muscle cramps commonly occur in the calves and either the front or the back of thighs. Muscle cramps come on suddenly when the muscle gets tight. It may cause a sharp pain and you may be able to feel your muscle in knots under the skin. Risk factors for cramps include older age, dehydration, and being out in hot weather. Cramps usually are not a cause for concern, but you should see your doctor if you suffer from them regularly.

Shin Splints Cause Leg Pain

Shin splints cause pain in the front of the lower legs.

Shin splints are pains that occur along the inside edges of the lower leg, the shinbone (tibia). Shin splints occur when tissues and muscles in the area become inflamed during physical activity. Runners are frequently affected by shin splints. Risk factors for the condition include wearing ill-fitting shoes and having flat feet or rigid arches. Treat shin splints by resting your legs, applying ice packs to sore legs in 20 minute intervals several times per day, and taking over-the-counter pain relievers to combat pain and inflammation. See your doctor if shin splints do not resolve or if you suffer from them frequently to make sure nothing else is medically wrong.

Stress Fractures Are Painful

$Stress fractures are a type of overuse injury.$

One cause of leg pain in the lower legs is a stress fracture. A stress fracture is a small crack in your tibia (shinbone). When shin splints do not feel like they are getting better, it may be because you have a stress fracture. These injuries are overuse injuries because they occur when muscles surrounding bone are overworked and they do not protect the underlying bone as they should. Treatment for a stress fracture involves staying off the affected limb and resting. It may take between 6 to 8 weeks for the bone to heal completely. It is important to rest if you have a stress fracture. Exercising while the fracture is present can make the injury worse.

Tendinitis Hurts

Tendinitis is one potential cause of leg pain.

Tendons are tissues that connect muscles to bones. Tendinitis is a condition where tendons become inflamed due to overuse. The ankles, hips, and knees are frequent sites where tendinitis occurs. Treat tendinitis with RICE (rest, ice, compression, elevation). Over-the-counter anti-inflammatory medications can help relieve pain and inflammation. Ibuprofen and naproxen are good choices. If the pain persists or is severe, see your doctor for an evaluation.

Are Varicose Veins Painful?

Varicose veins can cause leg pain and other symptoms.

Veins are blood vessels that deliver blood back to the heart. Veins have valves that assist the one way flow of blood. When these valves weaken or become damaged, blood may pool in the veins and cause them to stretch. Bulging, swollen, purple, twisted varicose veins result. Varicose veins may cause leg pain, throbbing, cramping, burning, and heaviness. Risk factors for varicose veins include being overweight, sitting or standing for long periods of time, and exercising. Wearing compression stockings can give your legs extra support and decrease the risk of varicose veins. Rarely, varicose veins may be associated with blood clots or skin ulcers. Treatments are available to get rid of varicose veins.

Do You Have Burning Pain in Your Thighs?

Meralgia paresthetica causes burning leg pain in the thigh area.

Meralgia paresthetica is a condition in which a nerve in the thigh becomes compressed. This leads to painful burning, tingling, and numbness in the upper thigh. Risk factors for the condition include wearing tight clothes, being overweight or pregnant, or having scar tissue due to surgery in the groin region. Over-the-counter pain relievers like ibuprofen and acetaminophen may provide relief of symptoms. If the pain is severe or lasts for more than a couple of months, see your doctor who can prescribe stronger medication.

Reviewed by Charles Patrick Davis, MD, PhD on 3/13/2018

Sources:

This tool does not provide medical advice.