I have a Frozen Shoulder, What Now?

Have you been struggling to lift your arm for an extended period of time? Do you feel like your shoulder is ‘frozen’?

You might be experiencing ‘Frozen Shoulder’ or ‘Adhesive Capsulitis’, a common and complex problem that affects many individuals.

What is Frozen Shoulder?

Frozen Shoulder (FS) is a condition where your shoulder gradually becomes stiffer and less mobile over time.  It is often accompanied by shoulder pain and reduced function, which can be severe and significantly impact your daily life. FS affects a significant proportion of people, between 2-5% of the population, and is most common in those aged 40 to 60. It also has a slightly higher prevalence in women, especially around menopause. The condition has also been linked to stress levels, though this is not definitive.

As the technical name ‘Adhesive Capsulitis’ suggests, FS occurs due to the chronic inflammation and contracture (shortening and hardening) of the strong connective tissue that surrounds the shoulder joint (the joint capsule). This can also occur in other surrounding structures, such as tendon attachments. This stiff and thickened joint capsule is what restricts shoulder joint movement.

What causes Frozen Shoulder?

While the exact cause of FS is unclear, we are starting to understand the condition more. FS is generally classified into two categories: primary (idiopathic) and secondary.

Primary FS occurs spontaneously, without any known cause, whereas secondary FS is associated with a defined event and often observed after shoulder surgery, injury or trauma.

Risk factors that are thought to be linked to the development of FS include:

  • Age (between 40 to 60 years)
  • Gender (slightly higher prevalence in females)
  • Chronic conditions (i.e. type 2 diabetes, hyperthyroidism and obesity) due to systematic inflammation and reduced tissue healing.

How does Frozen Shoulder progress?

Historically, frozen shoulder has been sub-divided into four distinct phases:

  1. Painful

  2. Freezing

  3. Frozen

  4. Thawing

In the ‘Painful’ phase, pain gradually worsens with very little shoulder stiffness. Pain is often vague and felt over the outside of the shoulder or upper arm. It is typically described as a ‘constant ache,’ although can be sharp with fast movements or at the end of range, for example, when reaching overhead. Pain is worse during the night, and so, can impact sleep quality and duration.

The ‘Freezing’ phase typically consists of a gradual loss of shoulder mobility as well as severe pain. This occurs both at night and during end-range shoulder movements. In this phase, the loss of active moment (the ability to move the arm yourself) is equal to the loss of passive movement (the ability for your arm to be moved by other means, for example, by a physiotherapist). This is unlike other shoulder conditions and is an important sign used to diagnose FS. This phase can last anywhere from a few weeks to 6 months.

In the ‘Frozen’ phase, people usually experience a reduction in pain, particularly at night, but experience significant joint stiffness. People will struggle to move the shoulder in this phase. This can last up to 6 to 9 months.

In the final ‘Thawing’ phase, the condition begins to resolve! The range of movement in the shoulder joint gradually begins to improve and function is restored. Minimal pain is experienced throughout. This also occurs over the course of several months.

The four phases above often overlap and people with FS will often describe only two phases, based on how much their shoulder hurts, and how much their movement is restricted. They might describe that:

  1. Pain > stiffness: Pain is worse than stiffness. This will then progress to…
  2. Stiffness > pain: Stiffness is worse than pain.

When does Frozen Shoulder fully resolve?

As discussed, FS resolves eventually, and the stiffness will greatly reduce with time. The process of full symptom resolution, however, can take an average of 12 months to 3.5 years.

With this in mind, approximately 20-50% of patients can have enduring symptoms, such as pain and reduced mobility. These symptoms can last for several years from diagnosis.

If left untreated, symptoms have been observed to persist in a significant proportion of people at an average of 7 years following help manage symptoms and improve long-term outcomes.

How is Frozen Shoulder managed by a Physiotherapist?

Physiotherapy is an integral part of FS management and should be considered a first-line treatment.

While it is not possible to avoid the stages of frozen shoulder, effective Physiotherapy management is aimed at addressing symptoms early on. The goals of management are to help with the understanding of the condition, address contributing factors, reduce pain, reduce shoulder stiffness, and maintain and improve shoulder strength.

Different approaches to management will be used depending on the stage of presentation so that treatment can be directly tailored to your needs at the time. This might include:

  • Education regarding the nature of the condition.
  • Manual (hands-on) therapy (including shoulder joint mobilisation, soft tissue massage/release).
  • Exercises to maintain mobility and strength in the shoulder.
  • Exercises to maintain mobility and strength in surrounding joints such as the neck, elbow, wrist and hand.

What other interventions may be useful?

There are different procedures that may be necessary and can be helpful in reducing pain and improving movement. In addition to seeing a physiotherapist you may be referred to see a specialist, to assess whether it is necessary for you to consider:

  • Hydrodilatation (where fluid is injected into the shoulder joint to stretch the tightened structures) with or without including hydrocortisone is an option as your shoulder becomes stiffer.
  • Arthroscopy to surgically release the tight structures.
  • Manipulation under anaesthetic to stretch the joint, and the tight structures is another option.

The research suggests that capsular release that is controlled is safer and more effective than manipulation under anaesthetic.

 

If you have more questions about Frozen Shoulders, or need help managing your shoulder pain, feel free to get in touch with our team to discuss your options.

 

References:

Lewis 2015 ‘Frozen shoulder contracture syndrome – Aetiology, diagnosis and management’, Manual Therapy, vol. 20, no. 1, pp. 2-9.

Kingston, K, Curry, EJ, Galvin, JW and Li, X 2018 ‘Shoulder adhesive capsulitis: epidemiology and predictors of surgery’, Journal of Shoulder and Elbow Surgery, vol. 27, no. 8, pp. 1437-1443.

Ryan, V, Brown, H, Lowe, CJM, Lewis, JS 2016, ‘The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review’, BMC Musculoskeletal disorders, vol. 17, no. 1, pp. 340.

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