Postoperative Adhesive Capsulitis

[AikiPapi]

Hi, All. Thought I would take a shot and see if anyone had any experience with adhesive capsulitis following shoulder surgery, as I could certainly use some insight. I’m 52 years old and this is (very frustratingly) where I find myself stuck after about 10 years of training pretty consistently with the Starting Strength method.

Specifically, my surgery at the end of May was intended to evaluate and address subacromial outlet impingement syndrome with partial tear of the supraspinatus (including significant tendinopathy), and ended up including the following:

• Double row rotator cuff debridement and repair
• Subacroimuial decompression including bursectomy and acromioplasty with resection of acromial spur
• Glenohumeral debridement including type I SLAP debridement

By all measures, I was progressing very well getting out of the sling after 2-3 weeks and using rehabilitation methods along the lines of what Rip and others have mentioned here to be well ahead of the game. At the 6-week follow-up my surgeon both commented on my shoulder being in better shape than 90% of patients having a similar procedure and cautioned me against being too aggressive with the rehab. By week 9 I was pressing an empty barbell overhead, doing light pull-downs, and pulling deadlifts with 200 lbs. (I was typically pulling 325-350 x 5 prior to the setback), despite the advice to not lift anything more than 5 pounds between 6 and 12 weeks post-surgery. I was icing after workouts and sometimes taking OTC NSAIDS to help with sleep, but otherwise chugging along.

One morning, about 10 weeks post-surgery, I woke up with a very new kind of stiffness and pain that really had me thinking that I had somehow messed up the shoulder repair. A post-op MRI review with the surgical PA revealed that everything was structurally intact, but that the visible inflammation pointed to bursitis. The PA said that I had “dodged a bullet” and recommended 4 weeks of celecoxib (Celebrex) with no movement of the affected arm above eye-level to beat down the inflammation. This proved to be useless and at best a waste of time. At the next follow-up (with the surgeon) he acknowledged that there was more going on than just basic bursitis, including adhesive capsulitis. He then strongly implied that it was likely brought about by excessive use of the shoulder before the rotator cuff muscles were strong/secure enough to properly seat the head of the humerus in the glenohumeral joint and it’s “loose” movement in the shoulder capsule during my excessive usage had likely caused the inflammation. Sounds a little sketchy, but I don’t have an alternative explanation.

Unfortunately, from there the recommendation was simply for PT to focus on regaining ROM (as opposed to inflammation) where it seems to me there’s a lot of guess-work going on as to what combination of stretches and “strengthening” are going to help. I have learned that this is probably not what I want to hang my hat on, but I am stumped as to what to do otherwise (perhaps just continued aggressive stretching through the pain to gradually increase ROM on my own?).

I’m finding my current condition to be more debilitating and painful than the situation just a few weeks post-surgery, and the extensive layoff from lifting has me more than motivated to start making some progress. I’ve seen a few older posts with references to adhesive capsulitis or “frozen shoulder”, but not really enough to feel confident charting a path forward or even see a light at the end of the tunnel, having made very little progress with PT and aggressive stretching on my own over the course of 3 weeks now.


Apologies if this too much information, but I keep thinking that I’m overlooking something somewhere in terms of what I did wrong or could be doing now.


Thanks in advance to anyone able to share some insight, recommendations, or maybe just commiserate!

[Will Morris]

Hi, All. Thought I would take a shot and see if anyone had any experience with adhesive capsulitis following shoulder surgery, as I could certainly use some insight. I’m 52 years old and this is (very frustratingly) where I find myself stuck after about 10 years of training pretty consistently with the Starting Strength method.

Specifically, my surgery at the end of May was intended to evaluate and address subacromial outlet impingement syndrome with partial tear of the supraspinatus (including significant tendinopathy), and ended up including the following:

• Double row rotator cuff debridement and repair
• Subacroimuial decompression including bursectomy and acromioplasty with resection of acromial spur
• Glenohumeral debridement including type I SLAP debridement

By all measures, I was progressing very well getting out of the sling after 2-3 weeks and using rehabilitation methods along the lines of what Rip and others have mentioned here to be well ahead of the game. At the 6-week follow-up my surgeon both commented on my shoulder being in better shape than 90% of patients having a similar procedure and cautioned me against being too aggressive with the rehab. By week 9 I was pressing an empty barbell overhead, doing light pull-downs, and pulling deadlifts with 200 lbs. (I was typically pulling 325-350 x 5 prior to the setback), despite the advice to not lift anything more than 5 pounds between 6 and 12 weeks post-surgery. I was icing after workouts and sometimes taking OTC NSAIDS to help with sleep, but otherwise chugging along.

One morning, about 10 weeks post-surgery, I woke up with a very new kind of stiffness and pain that really had me thinking that I had somehow messed up the shoulder repair. A post-op MRI review with the surgical PA revealed that everything was structurally intact, but that the visible inflammation pointed to bursitis. The PA said that I had “dodged a bullet” and recommended 4 weeks of celecoxib (Celebrex) with no movement of the affected arm above eye-level to beat down the inflammation. This proved to be useless and at best a waste of time. At the next follow-up (with the surgeon) he acknowledged that there was more going on than just basic bursitis, including adhesive capsulitis. He then strongly implied that it was likely brought about by excessive use of the shoulder before the rotator cuff muscles were strong/secure enough to properly seat the head of the humerus in the glenohumeral joint and it’s “loose” movement in the shoulder capsule during my excessive usage had likely caused the inflammation. Sounds a little sketchy, but I don’t have an alternative explanation.

Unfortunately, from there the recommendation was simply for PT to focus on regaining ROM (as opposed to inflammation) where it seems to me there’s a lot of guess-work going on as to what combination of stretches and “strengthening” are going to help. I have learned that this is probably not what I want to hang my hat on, but I am stumped as to what to do otherwise (perhaps just continued aggressive stretching through the pain to gradually increase ROM on my own?).

I’m finding my current condition to be more debilitating and painful than the situation just a few weeks post-surgery, and the extensive layoff from lifting has me more than motivated to start making some progress. I’ve seen a few older posts with references to adhesive capsulitis or “frozen shoulder”, but not really enough to feel confident charting a path forward or even see a light at the end of the tunnel, having made very little progress with PT and aggressive stretching on my own over the course of 3 weeks now.


Apologies if this too much information, but I keep thinking that I’m overlooking something somewhere in terms of what I did wrong or could be doing now.


Thanks in advance to anyone able to share some insight, recommendations, or maybe just commiserate!

Well, first things first, surgery is one of the most prominent risk factors for the development of Adhesive Capsulitis. Outside of that, anything suggested as the potential "cause" of it is pure conjecture and most of the time, the surgeon will point towards something you did as the cause to mitigate their risk of you bringing a lawsuit against them (you'd never win anyways). It's funny because if you do too little, they will say that's what caused your AC, and if you move too much, that's what causes it. To be truthful, we really don't know, so when actual knowledge isn't there, we default to making things up to protect our licenses.

The bad news, there is nothing your PT can do to speed your progress up that you couldn't do for yourself. AC is great in the PT world because it is a ready made dairy cow for a therapist's office. We can bill insurance three times a week for months on end with virtually no risk to the practice, because, as I stated previously, if it gets worse, it is always your fault.

The aggressive stretching is not going to help, so stop that right now.

Train within your available ROM. Increase the ROM when there is available ROM. Increase the load incrementally on those lifts. Do what you can. Continually move the shoulder in the available range, and keep trying to get it to just short of the onset of pain. Nothing else you can do, no matter what your PT/PA/FNP/Ortho tries to tell you, outside of a manipulation under anesthesia, but that is offered only in exceptionally rare circumstances these days.

[Kansan]

A few years ago, when I was around 40, I had frozen shoulder on both sides. It was not after surgery, just started out of the blue.
I was offered surgery but chose only PT instead.
After a couple weeks I just did the ROM stretching at home in my free time, which was substantial since I couldn't really do much.
I refused to accept the conventional wisdom that it would resolve itself in a year or so and added my own ROM stretches/exercises.
My personality is such that I was aggressive with the stretching and I seem to have a pretty high pain tolerance.
The left shoulder resolved within 1-3 months. (don't remember for sure)
Once the left shoulder was almost resolved, I started having symptoms on the right.
I started the aggressive stretching immediately and the right shoulder resolved in a few weeks.
Stretches were just to increase the ROM, ie, I moved my arm until it hurt, then pushed a little farther and held it there as long as I could. Very painful and takes time.
NSAIDs also helped, especially for sleeping.
Not sure why stretching wouldn't help, especially since the "surgery" typically used for FS is moving the arm in full ROM under anesthesia. Sometimes the joint is opened and "cleaned out" but not always. Then PT after surgery to keep the adhesions from reforming

[AikiPapi]

Thanks so much for taking the time to share some insight here, Will. I’ve read quite a bit of your advice here over the years and can’t tell you how much I appreciate the candid, non-nonsense approach (in addition to all I’ve learned!).
You seem to have confirmed most of my suspicions with this mysterious affliction although, as mentioned, I was believing that I needed to “stretch” my way out of this since training seemed off the table with the limited ROM. If that’s the path forward, it does leave me with a few follow-up questions, if I may:

1) Would you recommend increasing the load on exercises/lifts before the complete (typical) ROM can be performed? I ask in light of recognizing that I currently can’t even press 5 lb. dumbbells over my head to the lockout I would expect with a proper overhead press, and I suspect that if I increased (for example) to 10 lb. dumbbells, it might even further limit the ROM possible or cause earlier onset of pain. So I could seemingly wind up pressing more and more weight over a shorter and shorter ROM. Perhaps you are telling me to just consider the onset of pain to be the end of the new effective ROM, wherever that might be (progressing 5 lbs. to pain-point, then 10 pounds to pain-point, etc.)?

2) If I forego the stretching and focus on getting back to training-based movements, should I be concerned that regaining ROM in movements that are not part of a basic lift (e.g. reaching behind my back or out to the side) will be in jeopardy more than they would otherwise? In other words, is it reasonable to expect that once the shoulder capsule decides to loosens up, it will do so similarly for all basic movements? I must say that since I‘ve started with the “aggressive stretching” (which is basically like putting myself or letting the PT repeatedly put me in different submission holds), I’ve seen some small progress in ROM and reduction in pain to the tune of ~2% improvement per week, if that makes sense. Of course, I have no idea if that would be happening on its own anyway.

3) Just generally curious what you’ve seen as far as typical or a range of outcomes from this condition as it seems easy to find information that points to a pretty daunting prognosis.

[AikiPapi]

Thanks for sharing your experience here, Kansan.

I'm glad you were able to resolve this on a much-reduced timeframe vs. what I'm reading elsewhere. As mentioned, I do feel like I'm on a positive (albeit very slow) trajectory, so I'm quite curious to get Will's take on the follow-up questions posed above. I'm not clear on what (if any) harm the stretching can do other than be a potential waste of time and/or distraction from actual training, so perhaps it's reasonable to continue stretching in directions not addressed with normal training/lifting/day-to-day activities?

[Will Morris]

Thanks so much for taking the time to share some insight here, Will. I’ve read quite a bit of your advice here over the years and can’t tell you how much I appreciate the candid, non-nonsense approach (in addition to all I’ve learned!).

You seem to have confirmed most of my suspicions with this mysterious affliction although, as mentioned, I was believing that I needed to “stretch” my way out of this since training seemed off the table with the limited ROM. If that’s the path forward, it does leave me with a few follow-up questions, if I may:

1) Would you recommend increasing the load on exercises/lifts before the complete (typical) ROM can be performed? I ask in light of recognizing that I currently can’t even press 5 lb. dumbbells over my head to the lockout I would expect with a proper overhead press, and I suspect that if I increased (for example) to 10 lb. dumbbells, it might even further limit the ROM possible or cause earlier onset of pain. So I could seemingly wind up pressing more and more weight over a shorter and shorter ROM. Perhaps you are telling me to just consider the onset of pain to be the end of the new effective ROM, wherever that might be (progressing 5 lbs. to pain-point, then 10 pounds to pain-point, etc.)?

If you did not do this, the only other option is to completely lay off all training until you get full ROM back which, as I said, it historically 12-18 months. You are welcome to do so, but that is not what I recommend, nor is that what I do for my patients in clinic. The prevailing theory, supported by MRI findings, is that adhesive capsulitis is caused by a calcification adhesion in the redundant folds of the shoulder capsule. The joint capsule being highly vascularized and well innervated is what causes the pronounced pain with movement, since the capsule itself is bound together and aggressively stretching leads you susceptible to tearing the joint capsule. If you believe yourself to be safer aggressively stretching instead of working resisted movements within the AVAILABLE range of motion, you are more than welcome to test that hypothesis at your convenience. But, I think you demonstrated understanding of my suggestion when you mentioned working to the onset of pain, so I think you have a working course of action here.

2) If I forego the stretching and focus on getting back to training-based movements, should I be concerned that regaining ROM in movements that are not part of a basic lift (e.g. reaching behind my back or out to the side) will be in jeopardy more than they would otherwise? In other words, is it reasonable to expect that once the shoulder capsule decides to loosens up, it will do so similarly for all basic movements? I must say that since I‘ve started with the “aggressive stretching” (which is basically like putting myself or letting the PT repeatedly put me in different submission holds), I’ve seen some small progress in ROM and reduction in pain to the tune of ~2% improvement per week, if that makes sense. Of course, I have no idea if that would be happening on its own anyway.

Adhesive Capsulitis is what we term a "self-limiting condition" with a "natural course", meaning, it will resolve on it's own in a predictable fashion. If you were something like a Special Mission Unit operator who needed to deploy to Israel for a hostage rescue mission, an orthopaedic surgeon would be willing to consider a manipulation under anesthesia to free up functioning of the shoulder immediately, but, it is risky, unbelievably painful, and most normal people do not tolerate it at all. Adhesive Capsulitis, in my decade or so of clinical practice, has always ended in 100% recovery, although it takes a long time. With somewhat routine regularity, adhesive capsulitis is given as a diagnosis with a less than stellar history and physical, and it is provided simply because the person has a painful shoulder and it hurts to move in several directions. True, legitimate adhesive capsulitis (frozen shoulder) is a war of attrition. Sports Medicine docs, primary care practitioners, and even physical therapists diagnose AC far more often than they actually see it. It was a weekly occurrence that I had a female patient in my clinic for an evaluation with a new diagnosis of AC, made by someone I mentioned, and it was just a painful shoulder with absolutely no physical exam findings consistent with AC other than a primary complaint of shoulder pain with movement.

[Kansan]

It is possible that I did not have true frozen shoulder, but it sure fit all of the descriptions I have read. It was also the most painful thing I have ever experienced, and that is saying something since I also have severe spondylolithesis and have been married for over 25 years, lol.
It is also possible that AkiPapi does not really have frozen shoulder, since it is so commonly misdiagnosed.
So why not try stretching it out and see if it helps?
Hanging from a chinup bar should be the goal.

I am not in the special forces but I did have two different orthopedic surgeons offer manipulation under anesthesia, one of which also wanted to open the joint and "clean it out", followed by aggressive PT, which was to start the DAY OF SURGERY, ie, wake up from surgery, go to PT.
Seemed excessive to me, so I just tortured myself at home until I could hang from a chinup bar.
At the time of my diagnosis my humerus movement was roughly 2-3 inches lateral and 2-3 inches anterior, no posterior movement at all, and essentially no rotation. It was rough.

[AikiPapi]

Thank you, Will.

I think I'm probably overly concerned about types of shoulder motion not explored during a typical training session because I never really regained full ROM following the surgery (before the onset of AC), when things like external rotation and reaching behind my back were emphasized during initial PT sessions, and may still be thinking about this along the lines of rehabbing from the procedure itself. That being said, I believe the perspective here was that even post-surgery, getting back to routine usage and loading (i.e. pressing, chinning, etc.) is the recommended path to regaining full function.

Would the absence of full recovery from the initial surgery change thinking at all about the need to continue exploring each and every shoulder-related movement regularly (even if not so aggressively)?

Last question for a while…I promise!

[AikiPapi]

Hello, Will and Friends –

I just wanted to report back my findings so far with the “frozen shoulder” thing as I continue to appreciate the guidance provided and am hopeful my situation and progress report can be helpful to others.
In line with Will’s advice, I did discontinue PT and the aggressive stretching that went along with it a couple months back and indeed the ROM in my left (affected) shoulder has continued to return at about the same rate (I would estimate 2-3% per week) as it was while doing the PT.

I have also resumed training as best I can including high-bar squats using straps to hold a bent bar on my traps, deadlifts, some ugly presses that are just starting to get locked out overhead where they should, and bench presses. All presses began with baby weights and higher reps (typically 3 x 10) but are getting back to at least near respectable intensity where I will soon start reducing the volume. Needless to say this has required some dedicated attention to keeping the shoulder stable and avoiding any sharp pain through the lifts. I’ve also worked through some assisted chin-ups enough to feel comfortable supporting my weight hanging from the bar now and can once again do them unassisted now. Of course, all the training limitations over the past few months mean there is a lot more dead weight to pull now

With respect to the types of shoulder motion not normally explored during a typical training session (i.e. isolated external rotation, reaching behind my back, etc.), that does appear to be slowly returning as well as evidenced by my improving ability to get a button-down shirt or belt on without squirming around too much and the ROM displayed with things like a sleeper stretch.

In sum, I’m about 5 months post-freeze (7 months post-surgery), continuing to make slow but steady progress, and remaining hopeful that somewhere down the road the shoulder will be back to its old self.

Best wishes to all for a happy and healthy new year!

[AikiPapi]

Just wanted to follow up here in case it might be helpful for someone else reading and thank Will and Friends again for the advice. I’m about 6 months out from the peak freezing of the shoulder and, true to Will’s prognosis, ROM has returned slowly without further PT and aggressive stretching, to the tune of about 2-3% per week. I resumed training a while ago, very carefully at first, using some higher rep ranges for bench and presses initially to get some training stimulus in without ratcheting up the weight too quickly and risking some kind of damage or debilitating pain. There’s still some pain involved, more so between sessions than during, and I still can’t get my hands up on the bar for a LBBS, but I have been successfully progressing squats holding a bent (buffalo-type) bar on my traps with lifting straps (SSB-style). So with about 80% ROM returned and a willingness to scratch and claw my way back to some respectable level of strength, I am hopeful for a full recovery at some point in the not-too-distant future.