What is Frozen Shoulder?
Frozen shoulder or adhesive capsulitis is a common source of shoulder pain. It occurs in about 2% to 5% of the population and commonly presents in 40 to 60-year-olds. It is more prevalent in women (70%). (Sheridan et al 2006)
While frozen shoulder is commonly missed or confused with a rotator cuff injury, it has a distinct pattern of symptoms resulting in severe shoulder pain, loss of shoulder function and eventually stiffness.
The more precise medical term for a frozen shoulder is “adhesive capsulitis”.
In basic terms, it means that your shoulder pain and stiffness is a result of shoulder capsule inflammation (capsulitis) and fibrotic adhesions that limit your shoulder movement.
What Causes Frozen Shoulder?
Unfortunately, there is still much unknown about frozen shoulder. One of those unknowns is why frozen shoulder starts. There are many theories but the medical community still debates what actually causes frozen shoulder.
Health conditions such as diabetes, cardiac disease, hyperthyroidism and hypothyroidism conditions do increase the prevalence of frozen shoulder. For example, the incidence of frozen shoulder in diabetics can be 10 to 38%. Researchers are unsure why the risk is increased in these patient groups.
Post-surgery is another potentially preventable cause of frozen shoulder. Patients who are more protective of their arm and avoid post-operative exercises appear more likely to develop frozen shoulder. It is recommended that you comply with your physiotherapist’s post-operative instructions to avoid post-operative onset frozen shoulder.
What is Known about Frozen Shoulder?
Frozen shoulder causes your shoulder joint capsule to shrink (to < 5 cm3) and significantly thicken (from ~1mm to ~5mm!), which leads to pain and a stiff shoulder joint capsule resulting in a reduced range of shoulder movement. Your shoulder capsule is the deepest layer of soft tissue around your shoulder joint and plays a major role in keeping your humerus within the shoulder socket.
What are Frozen Shoulder Symptoms?
Frozen shoulder has three stages, each of which has different symptoms.
The 3 Stages are:
- FreezingPhase one is characterised by pain around the shoulder initially, followed by a progressive loss of range of movement. Sometimes referred to as the RED phase due to the capsule colour (inflammation and bleeding) if you undergo arthroscopic surgery. This usually lasts anywhere from 3 to 9 months! Aggressive treatment should be avoided in this phase. See more about treatment during the phase later in this article.
- FrozenPhase two is where stiffness is dominate. The early transition from phase one to two can be painful. Late phase two is generally pain-free but functionally limiting due to the stiffness. Referred to as the PINK phase due to the capsule colour if you undergo arthroscopic surgery. This stage can commonly last from 9 to 15 months.
- ThawingPhase three. During this final phase, there is a gradual return of range of movement. Known as the WHITE phase due to the capsule colour if you undergo arthroscopic surgery. The stage can last 15 to 24 months.(Kelley et al 2009, Walmsley et al 2009, Hannafin et al 2000)Research has shown that some interventions are helpful in certain phases. Treatment focuses on pain relief in the initial freezing stage with increasing emphasis on physiotherapy to regain lost range of motion in the later phases. (Hanchard et al., 2011)The average course of natural resolution is 30 months. So any improvement on that timeframe should be deemed a bonus. Treatment options that appear to improve, hasten the reversal of stiffness and quicken your return to normal function will be discussed shortly.
How is Frozen Shoulder Diagnosed?
Frozen shoulder can be diagnosed in the clinic from your clinical signs and symptoms.
A clinical diagnosis of frozen shoulder can be determined by a thorough shoulder examination. Your physiotherapist will ask about what physical activities you are having difficulty performing.
Common issues include:
- Unable to reach above shoulder height
- Unable to throw a ball
- Unable to quickly reach for something
- Unable to reach behind your back eg bra or tuck shirt
- Unable to reach out to your side and behind. eg reach for seat belt
- Unable to sleep on your side.
Frozen shoulder is commonly misdiagnosed or confused with rotator cuff injury by inexperienced shoulder practitioners. It is important to get an accurate diagnosis. Your treatment plan and recovery period will vary considerably to other shoulder conditions such as shoulder arthritis or rotator cuff tears.
Frozen Shoulder Physical Examination
Your physiotherapist will ask you to perform shoulder movements. Frozen shoulder has a distinct capsular pattern of stiffness:
Lateral Rotation > Flexion > Internal Rotation.
Normally, your rotator cuff strength will still be normal with the exception of pain inhibition. Frozen shoulders are commonly non-tender on palpation examination due to the pathology being quite deep.
Quick movements are very painful in phase one with patients very keen to avoid any fast movements such as reaching or throwing and catching.
(Walmsley et al., 2009)
Frozen Shoulder Investigations
In some cases, you may be referred for X-rays or MRI to rule out other causes of shoulder pain. X-rays are not able to diagnose frozen shoulder. MRI or preferably MRA can provide a definitive diagnosis. A double-contrast shoulder arthrography is the traditional diagnostic method, although this is usually not required if you have a skilled shoulder practitioner assessing you.
Who is Likely to Suffer from Frozen Shoulder?
Frozen shoulder is more likely to occur in people who are 40 to 60 years old. It can be primary, with no known cause, or secondary, associated with an underlying illness or injury.
There are a number of risk factors predisposing you to develop frozen shoulder.
- shoulder trauma,
- inflammatory conditions,
- inactivity of the shoulder,
- autoimmune disease,
- cervical cancer, and
Approximately 20% of people who have had a frozen shoulder will also develop frozen shoulder in their other shoulder in the future. (Kelley et al., 2013)
Frozen Shoulder Treatment
Treatment for frozen shoulder depends on what stage you are in and is tailored to your specific needs.
Pain relief and the exclusion of other potential causes of your frozen shoulder is the focus during this phase.
Pain relieving techniques may include pharmacological medications as prescribed by your doctor. Intracapsular corticosteroid injection may be considered in this phase but it does seem to be ineffective after the first few weeks have passed. Intracapsular corticosteroid injection is considered on a case by case basis when pain is unbearable. Please seek the prompt advice of your shoulder specialist.
Very gentle shoulder mobilisation, muscle releases, acupuncture, dry needling and kinesiology taping for pain-relief can assist during this painful inflammation phase. The application of a TENS machine was shown reduce pain and increase range of motion. (Page & Labbe 2010).
It is important not to aggravate your frozen shoulder during this phase, which is, unfortunately, a side effect of an overzealous practitioner or patient.
Overenthusiastic treatment in the early transition phase can aggravate your capsular synovitis and subsequently pain. A quality shoulder physiotherapist will know how much is enough and how much is too much.
Gentle and specific shoulder joint mobilisation and stretches, muscle release techniques, acupuncture, dry needling and exercises to regain your range and strength are used for a prompt return to function. Care must be taken not to introduce any exercises that are too aggressive. In particular, mobilisation with movement (MWM) style techniques appears the most effective and more effective than stretching exercises alone. (Doner et al., 2013, Yang et al., 2007) MWM’s are specific-techniques performed by suitably-trained shoulder physiotherapists.
Wiles J (2005) found that specific massage techniques increased shoulder range of motion, so the effectiveness of shoulder girdle soft tissue massage should certainly be considered as a treatment option.
Hydrodilation is a procedure that involves injecting saline along with cortisone and local anaesthetic into the capsule to inflate and stretch the capsule. It is thought that this helps to stretch and break down capsular scarring and adhesions. Researchers have not found hydrodilation plus physiotherapy is no more effective than physiotherapy alone. (Hseih et al., 2012)
Phase three is the stage that you can start to notice improvement and benefit from specific physiotherapist-directed mobilisations, stretches and exercises. Researchers have reported that well-prescribed shoulder mobilisation and stretches are your best chance of a quicker prompt return to full shoulder movement and daily function.
As your range of motion increases your physiotherapist will be able to provide you with exercise progressions including strengthening exercises to control and maintain your newly found range of movement. Physiotherapy is most effective during this thawing phase. (Jain et el., 2014)
Frozen Shoulder Surgery
Frozen shoulder is a condition that resolves over an 18 to 24 month period in most cases. 60% to 80% of frozen shoulder patients will respond favourably to non-surgical treatment.
Shoulder surgery may be considered where there is insufficient recovery after an appropriate physiotherapy program. During the “late frozen or thawing” phases your shoulder surgeon may consider an arthroscopic release in combination with a manipulation under anaesthetic plus some intensive post-operative physiotherapy to maintain your newly gained range of motion. This combination of treatment can improve your stiffness by up to 80% in most cases. Post-capsular release surgery can see most patients return to work within 6 to 12 weeks.
For specific frozen shoulder surgery advice, please consult with your shoulder surgeon.
(Grant et al., 2013, Castellarin et al., 2004)
Can You Prevent Frozen Shoulder?
While the spontaneous onset frozen shoulder is of unknown origin, you can prevent frozen shoulder caused by disuse by avoiding a long period of shoulder inactivity. eg post-surgery or shoulder injury.
If you do have a shoulder or arm injury, it is always advisable to seek the professional advice of someone such as your shoulder physiotherapist about exercises to help prevent a secondary frozen shoulder developing. This is especially important if you are in a high-risk category.
For more information, please contact your physiotherapist or doctor.
Common Shoulder Pain & Injury Conditions
- Rotator Cuff Syndrome
- Shoulder Tendinopathy
- Rotator Cuff Calcific Tendinopathy
- Rotator Cuff Tear
- Bicep Tendinopathy
- Shoulder Impingement
- Swimmer's Shoulder
- Shoulder Dislocation (Instability)
- Subacromial Decompression
- Shoulder Arthroscopy
- Rotator Cuff Repair
- SLAP Repair
- Biceps Tenodesis
- Biceps Tenotomy
- Total Shoulder Replacement
Researchers have discovered that managing your shoulder injury with physiotherapy is usually successful. Typically, you have two options: non-operative or a surgical approach. Your condition will dictate which option is best for you at this time. Non-operative care is conservative rehabilitation.
If shoulder surgery is required, then your physiotherapist may undertake:
- Pre-operative rehabilitation - to either try a non-operative treatment approach or to condition and prepare your body for a surgical procedure.
- Post-operative physiotherapy - to safely and methodically regain your normal range of movement, strength, speed and function.
PhysioWorks physiotherapists have a special interest and an excellent working relationship with leading shoulder surgeons. Our physiotherapy team provide you with both conservative and post-operative shoulder rehabilitation options. We aim for you attaining the best possible outcome for your shoulder injury.