When the shoulder becomes ankylosed…

doctor checking patient's shoulder

Dr. Dominique-François Gazielly

Orthopedic surgeon, Head of the Shoulder Centre Clinique de Genolier, Genolier

August 2, 2022

Shoulder injuries are no joke. It takes 27 different muscles for them to function normally. Once the shoulder gets injured, it can spiral into a vicious cycle of pain and stiffening. When the shoulder becomes ankylosed, the joint becomes stiff due to abnormal adhesion and rigidity of the bones. Normally, only precise rehabilitation and functional therapy help to loosen up the shoulder joints, rather than surgery. The loosening of the shoulder to restore mobility usually takes around 3-4 months. However, you’d have to dedicate yourself to properly exercise and attend physiotherapy, or else it would take longer.

Want to learn more? Keep reading the article by Dr. Dominique-François Gazielly.

The shoulder joint is very complex: 27 muscles ensure that it functions harmoniously and ensure its stability and mobility. Numerous bursae allow it to glide between the different muscle levels, giving it great mobility on all spatial planes. Overuse above the horizontal, a contusion, a fracture, or an operation can disrupt this perfect harmony: Pain inhibits movement, the gliding planes become blocked, the shoulder stiffens, and gradually becomes completely paralyzed.

In the case of the shoulder, there is a danger that a vicious circle of pain and stiffening begins, which can only be broken with efficient rehabilitation to loosen the shoulder joint. This is all the more effective the sooner it is initiated.

It is important to distinguish between shoulder stiffness, which affects “only” anterior elevation (lifting of the shoulder girdle), and internal rotation (inward rotation of the hand onto the back), where the shoulder is therefore only partially blocked and only these two movements are restricted, and adhesive capsulitis, complete paralysis of the shoulder, also known as “frozen shoulder”. This distinction is not only theoretical but also has practical consequences, as it takes on average 3 to 4 months to restore full mobility to a stiffened shoulder where the limitation of movement was limited to anterior elevation and internal rotation (inward rotation of the hand onto the back), whereas the treatment of adhesive capsulitis takes on average 12 to 18 months.

Painful and stiffened shoulder during anterior elevation and internal rotation (inward rotation of the hand onto the back)

The arm cannot be raised higher than 120 to 150 degrees and internal rotation (inward rotation of the hand onto the back) is only possible up to waist level. Gradually, a vicious circle of pain and stiffening sets in due to the gradual development of inflammatory adhesions in the gliding areas. To illustrate this, one can imagine a kind of spider’s web that spans the shoulder and insidiously encloses it more and more. The 2 main causes of painful shoulder stiffness are:

  • overuse of the shoulder above the horizontal, which often occurs at work or in sports (overhead work or overhead sports);
  • or resting the arm too rigorously and for too long after an accident or shoulder surgery.

The pain in the shoulder becomes insidiously noticeable after the shoulder has been overused. It can come on unexpectedly when you wake up one morning. The pain is usually on the outside, but sometimes on the front.

of the arm. Initially, he does not prompt the affected person to take further measures. He only pays further attention to it when he is awakened by pain at night and can no longer sleep on his side.

The diagnosis is made by a comparative clinical examination of both shoulders and a conventional X-ray examination, which can detect anatomical causes for the stiffness (calcification, bone spur). Treatment of a painful and stiffened shoulder is usually done through functional therapy, not surgery. It is the only way to relieve shoulder pain and restore normal mobility, thus breaking the vicious cycle of pain and stiffness. Physiotherapy exercises for loosening the shoulder joint enable one to go back the way that gradually led to the notorious vicious circle of stiffness and pain. These loosening exercises must be done with a physiotherapist who has experience with this form of rehabilitation, and the patient must also do them regularly on their own. Initially, the loosening exercises ensure that the pain at night gradually subsides. The loosening of a painful and stiffened shoulder to restore mobility and health to the shoulder usually takes 3 to 4 months.

If the painful shoulder stiffness is due to an anatomical cause, such as a bone spur, arthroscopic microsurgery may be required. The bone spur must be removed to stop the wear and tear of the tendons in the shoulder. In any case, surgery must not be performed until full mobility of the shoulder has been restored.

The adhesive capsulitis or “frozen shoulder” Adhesive capsulitis is an inflammation of the capsule that coats the two bony parts:

– the humeral head (caput humeri) and the glenoid

– of the shoulder joint. This joint capsule thickens and contracts, resulting in a severe and very painful restriction of mobility of the shoulder.

Adhesive Capsulitis or Frozen Shoulder

Clinically, adhesive capsulitis, which is also called “frozen shoulder”, manifests itself by severe pain in the stiffening phase, associated with a complete restriction of shoulder movement. Not only is the anterior elevation (lifting the arm forward) and internal rotation (inward rotation of the hand onto the back) restricted, as described in the first clinical picture, but external rotation (outward rotation of the arm) is also completely blocked. The shrinkage of the capsule prevents any movement of the joint.

Adhesive capsulitis occurs predominantly in two cases:

  • In people who have suffered severe emotional trauma, for example in a relationship, in the family (bereavement, divorce), or at work (dismissal), it can occur brutally from one day to the next. In this case, it is a reaction to excessive stress, usually observed in young adults.
  • The second cause may be the final developmental stage of a painful and stiff shoulder in anterior elevation and internal rotation (inward rotation of the hand on the back), which gradually worsens until complete paralysis occurs. Certain diseases can also promote adhesive capsulitis of the shoulder joint: Diabetes, heart attack, lung disease, hemiplegia, Parkinson’s disease, or hypothyroidism. It can also occur as a result of thoracic surgery or breast removal for breast cancer.

The treatment of adhesive capsulitis is long and complicated. It is based on manual physiotherapy to loosen the shoulder joint, which takes an average of 12 to 18 months to restore normal joint mobility and achieve permanent healing. Each physiotherapy session requires manual massage of the neck and the entire shoulder girdle and passive stretching exercises for the shoulder to gradually loosen the contracted capsule. Balneotherapy in 35-degree water can be combined with the rehabilitation exercises “in the dry.”

Sometimes the time needed for healing can be shortened by arthrographic distension. In this procedure, a radiologist injects an iodine-containing, radiopaque agent into the joint under pressure and X-ray fluoroscopy. Arthrographic distension allows the inflamed, contracted capsule to be loosened. At the same time, a corticosteroid is also injected to fight the inflammation. The arthrographic distension procedure, which is performed by certain interdisciplinary teams in a center specializing in the shoulder, is only effective in combination with appropriate physiotherapy.

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