Frozen Shoulder

Frozen Shoulder

Adhesive capsulitis is the medical term for frozen shoulder which is a condition causing pain and restricted movement in the shoulder joint.

There are three phases that the condition will pass through; a freezing phase where the joint tightens up, a stiff phase where the movement in the shoulder is significantly reduced and a thawing phase where the pain gradually reduces and mobility increases.

Symptoms

Painful (freezing) phase - The freezing phase of frozen shoulder symptoms start with a gradual onset of aching in the shoulder. The pain will often become more widespread and much worse at night making lying on the affected side difficult. This phase can last between 2 and 9 months.

Stiffening (frozen) phase - During the second phase the shoulder joint will begin to stiffen up. The shoulder is likely to be painful still and normal day to day tasks such as dressing or carrying bags become more difficult. Shoulder muscles may start to waste away through lack of use and this may be noticeable. Symptoms during the frozen phase can last between 4 and 12 months.

Thawing phase - During the thawing phase frozen shoulder symptoms begin to improve. Range of movement will increase and there is a gradual decrease in pain although pain may re-appear as stiffness eases for a time. The thawing phase can last 5 to 12 months.


Chiropractor Dr. Maria Madge explains how a chiropractor can help with treatment and mobility


What is frozen shoulder

Frozen shoulder or adhesive capsulitis is a condition which affects the ability to move the shoulder usually only occurring on one side. For approximately one person in five the problem spreads to the other shoulder.

The medical term adhesive capsulitis literally describes the condition where adhesive means sticky and capsulitis meaning inflammation of the joint capsule. It is thought that a lot of the symptoms are due to the capsule becoming inflamed and sticking, making the whole joint stiff and difficult to move. This is not the same as arthritis, and no other joints are usually affected.

It is extremely uncommon in young people, and is almost always found in the 40 + age group, usually in the 40-70 age range. Approximately 3% of the population will be affected by this, with slightly higher incidence amongst women, and five times higher prevalence in diabetics.

There are two classifications of adhesive capsulitis:

  • Primary - where there is no significant reason for pain or stiffness.  
  • Secondary - Which follows as a result of an event such as trauma, surgery or illness.

It is not known exactly what causes a frozen shoulder, however it is thought that the lining of the joint (the capsule) becomes inflamed, which causes scar tissue to form. This leaves less room for the humerus or arm bone to move, hence restricting the movement of the joint.

The increased prevalence among diabetics (particularly insulin-dependent diabetics) may be due to glucose molecules sticking to the collagen fibres in the joint capsule, which causes stiffness. For this reason, diabetics are more likely to have both shoulders affected. Hormonal changes may be responsible for the higher incidence among women, particularly due to the increased prevalence around the menopausal period.

Some studies have shown that poor posture, particularly rounded shoulders, can cause shortening of one of the ligaments of the shoulder, which may also contribute to this condition. Also, prolonged immobility (such as after a fracture) may cause this condition to develop.

Frozen shoulder treatment

What can the athlete do?

Seek medical advice if you think you may have this condition, as early treatment can help prevent really severe stiffness setting in. Follow any advice given by medical professionals, particularly with regard to a rehabilitation program.

Try to keep the shoulder moving even if it is just small pendular movements. If movement is very painful this should be only be done under the guidance of a qualified therapist. Mobility exercises can help keep the shoulder mobile and should be done regularly if pain allows.

What can a Sports injury professional do?

Frozen shoulder is usually managed conservatively, with surgery as a last measure if all other attempts fail.  Arrange a course of physiotherapy and exercises which will help maintain mobility and flexibility in the shoulder as best as possible.

A doctor may prescribe oral steroids or anti-inflammatory medication to reduce inflammation in the shoulder joint. Or a direct injection of steroid medication into the joint will also reduce inflammation. If conservative treatment fails to bring about any significant improvement then surgery may be recommended.

Rehabilitation program

The exercises and other treatment methods are dependent on which phase of rehabilitation the patient is at. We recommend seeking professional advice before attempting any rehabilitation.

Phase 1 - Freezing

This phase is usually the most painful phase of treatment and movement becomes gradually more and more difficult. The aim of the following treatments and exercises is to help control pain and maintain movement in the shoulder joint.

NSAID's (non steroidal anti inflammatory drugs) e.g. Ibuprofen may help reduce inflammation and pain although will be of less value in later phases of treatment. Check with a doctor before taking medication and do not take ibuprofen if you have asthma.

Electrotherapy modalities such as ultrasound, TENS and laser treatment may all help reduce pain and inflammation.

Exercises should be done as long as they can be performed pain free. Mobility exercises such as the pendulum and assisted shoulder exercises using a pole can help maintain shoulder mobility. See adhesive capsulitis exercises for more detailed information.

Shoulder stretching exercises for the muscles at the front and back of the shoulder can be done also to attempt to maintain as much movement as possible. Strengthening exercises are unlikely to be possible at this stage due to pain.

Phase 2 - Frozen

During the frozen phase of treatment is where there is least movement in the shoulder, but on the plus side pain tends to have reduced. This phase should be about trying to maintain strength and as much mobility as possible.

Mobility exercises such as pendulums and wand exercises should be continued. Stretching exercises for the chest muscles and muscles at the back of the shoulder should also be maintained.

Strengthening exercises can be performed to maintain muscle strength. Isometric or static contractions are exercises needing no joint movement and can be done without worrying about movement in the shoulder. Try to maintain good posture by working the upper back muscles. Poor posture could be a contributing factor in frozen shoulder helping to cause it or prevent healing.

A therapist may be able to help by performing some more advanced mobilizations on the shoulder to increase the range of movement at the shoulder joint. This is especially beneficial to patients who have very limited movement in the shoulder.

Phase 3 - Thawing

The final phase of treatment and rehab is where movement starts to return to the shoulder. This phase is all about getting the shoulder back to normal as quickly as possible by regaining full movement and strength. After a few months with little movement, the shoulder will be considerably weakened so strengthening exercises are important.

Mobility exercises and stretches can become more aggressive, but should still be within the boundaries of pain. Aim to restore full mobility in the shoulder joint.

Strengthening exercises can progress from isometric or static contractions, to exercises using a resistance band, then eventually free weights or weight machines.

Work the affected shoulder first, do as many reps as you can and then do the same number on the unaffected shoulder. This will help avoid a muscle imbalance.

Include rotator cuff exercises in treatment as well as posture exercises and exercises for the deltoid and chest muscles too. The shoulder joint is a complicated joint and correct biomechanical function between the shoulder joint and shoulder blade is important as other shoulder injuries may follow if the joint is not fully rehabilitated.

Surgery

Surgery is a last resort if normal treatment has failed. An arthroscopic capsular release is the technique most often used and is done via keyhole surgery. The technique involves dividing the thickened shoulder capsule to release it. It is important that surgery is followed by an aggressive rehabilitation program and the patient sticks to it.

Recovery time

Most cases will resolve on their own or with physiotherapy over a 1-3 year period, however it is a slow recovery process. Some studies have reported positive results following arthroscopic surgery to release the tight capsule, however this is currently only offered to patients who have not improved with conservative treatment. Many patients have reported persevering with mobility exercises as best they can but the condition just has to work its way through the three phases.

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