Frozen shoulder, or adhesive capsulitis, can give you an extremely painful shoulder. Typically, the pain you feel will begin gradually in the shoulder and can often, seemingly start, with no particular cause. It’s common for you to be unable to identify any specific injury or trauma to your shoulder. This can make it hard to explain why your shoulder suddenly hurts.
How Does It Start?
When frozen shoulder starts, pain can persist for over three months with little improvement. However, the most noticeable sign of a frozen shoulder is a gradual feeling of stiffness and loss of range of motion. So, what causes it? Frozen shoulder is initially an inflammatory condition that causes fibrosis within your shoulder or glenohumeral joint. This leads to progressive stiffness and a loss of movement in your shoulder. Range of motion is normally reduced in internal and external rotation (Mezian et al, 2023). This means that putting your hand behind your back to put your coat on or to do up your bra can soon feel restricted and difficult to do. It can also mean that throwing a ball overhead, for example when dog walking, starts to become increasingly hard.
What Causes a Frozen Shoulder?
The cause of frozen shoulder is not entirely understood. However, numerous risk factors have been identified. This means, that if you have any of the following, you may be more likely to develop a frozen shoulder:
- Diabetes mellitus (with a prevalence of up to 20%)
- Stroke
- Thyroid disorder
- Shoulder injury. Often, people may suffer a fall and put their arm out to save them, jarring their shoulder as they do so. This doesn’t always cause a shoulder injury at the time. However, frozen shoulder can often be kickstarted and can develop from this mechanism of injury
- Dupuytren disease
- Parkinson disease
- Cancer
- Complex regional pain syndrome
(Mezian et al, 2023)
Frozen shoulder is a somewhat common condition, affecting up to 5% of the adult population. It’s evident that women are four times more likely to develop a frozen shoulder than men. Notably, the non-dominant shoulder is also more likely to be affected than the dominant shoulder (Kingston et al, 2018).
The Underlying Pathophysiology of Frozen Shoulder:
When looking at what actually happens within the body during a frozen shoulder, numerous changes occur. Frozen shoulder is frequently described as a fibrotic, inflammatory contracture of the rotator interval, shoulder joint capsule and the surrounding ligaments. However, the development of frozen shoulder is still not fully understood. Whilst various proposals exist, the most recognized pathology is what’s known as cytokine-mediated synovial inflammation with fibroblastic proliferation.
Inflammation, Adhesions & Contraction:
The inflammatory response within the shoulder essentially leads to a thickening and stiffening of the shoulder joint capsule. These changes have been observed using arthroscopic techniques. Here, the shoulder joint has been examined internally using a small camera to assess for any changes.
Additional findings also include adhesions within the shoulder joint, caused by increased collagen and nodular band formation. Overall, the physical changes which occur within the shoulder, lead to thickening and contraction of the shoulder joint. This quickly begins to reduce your shoulder range of movement (Cho et al, 2018; Mezian et al, 2023).
Signs and Symptoms of Frozen Shoulder:
Frozen shoulder will typically only affect one shoulder. This means that when it develops you will have unilateral pain, usually in the front of your shoulder. As the shoulder joint contracts and stiffens, loss of movement into mainly external rotation and abduction will occur. This means that reaching overhead and taking your arm out to the side will become increasingly difficult and more limited. As we use our shoulders and arms so much, the loss of range of movement can make daily activities and sport extremely challenging. This includes for example, hanging up washing, doing up a seatbelt, brushing your hair and getting dressed. Not only do these movements cause shoulder pain, but neck pain can also commonly develop. This is because your neck or cervical muscles will often work harder and will compensate for the loss of shoulder motion.
The Stages of Frozen Shoulder:
When you develop a frozen shoulder, its development can be split into three separate stages: freezing, frozen and thawing (Mezian et al, 2023).
1) Freezing
The ‘Freezing’ phase is the initial stage and occurs over the first 2-9 months. You will start to notice mainly pain in the shoulder which can be particularly worse at night-time. Gradually you’ll start to notice a reduction in your shoulder range of movement.
2) Frozen
The second or ‘Frozen’ stage, develops over months 4 to 12. Here, the main symptom you’ll feel is increasing stiffness and a persistent loss of shoulder movement. However, the level of pain you experience will reduce.
3) Thawing
The third or final stage of a frozen shoulder is the ‘Thawing’ phase. This occurs over 12 to 42 months where you’ll start to notice a gradual improvement and restoration of your shoulder range of motion (Mezian et al, 2023).
Throughout the course of the three stages above, the typical duration of a frozen shoulder will be 1-3 years, with a mean time of 30 months (Hubbard et al, 2018; Xiao et al, 2017). In about 15% of patients, the contra-lateral or opposite shoulder will be affected with the same problem within five years.
Treatment for Frozen Shoulder:
If you develop a frozen shoulder, physiotherapy input, in conjunction with pain relief is normally the first step. Only in a small number of cases will a frozen shoulder result in surgical input (Wong et al, 2018). The following treatment options are the best options available for frozen shoulder, with some being more effective depending on what phase your shoulder is in. Being strategic with your treatment input is therefore important.
Treatment in the Early Stages:
Anti-Inflammatories
In the early or ‘freezing’ stage of a frozen shoulder, there is a degree of inflammatory change. This becomes less apparent in the later stages. Therefore, in the first few months, anti-inflammatories can help to reduce inflammation within the shoulder joint, together with pain (Mezian et al, 2023).
Pain Relief
This is important as when a frozen shoulder starts to develop, the pain is noticeable and can be quite severe. Taking regular pain relief is necessary for pain control, particularly before bed at night-time when the pain can increase (Mezian et al, 2023).
Hands-On Physiotherapy
Soft tissue therapy, mobilisation and gentle stretching can be extremely beneficial. This helps to alleviate associated muscle tightness and pain around the neck and shoulder. It also helps to maintain shoulder mobility. Ultrasound treatment, cryotherapy and the use of a transcutaneous electrical nerve stimulation (TENS) unit can also all help to alleviate pain. In the early stages, exercises to help maintain mobility and reduce your loss of shoulder movement can also be given. Sometimes, these sorts of exercises can be too painful to begin with. In which case, focussing on neck and thoracic mobility can be extremely important. Ultimately, the aim is to keep you moving as much as possible without forcing the shoulder into too much pain (Mezian et al, 2023).
Patient Education
Educating people regarding frozen shoulder should not be underestimated. Developing a frozen shoulder can be extremely worrying. This is because the pain and loss of movement you experience can often seemingly come out of nowhere. Understanding what the condition is and what to do to help maintain the movement your shoulder has is critical (Mezian et al, 2023).
Corticosteroid Injection
If pain relief is not sufficient in providing adequate pain control, a corticosteroid injection can be administered. This type of injection can be extremely pain relieving. Notably however, it will not fix or resolve a frozen shoulder and will not do anything to improve your range of movement. Despite this, it remains a common and excellent option for helping to alleviate the level of pain you may feel in the early stages (Mezian et al, 2023).
Treatment in the Developed Stages
After the inflammatory stage in the early few months, a frozen shoulder will progress to a ‘frozen’ and then subsequent ‘thawing’ phase. Treatment objectives in the more advanced stages should focus predominantly on regaining shoulder range of motion. In these stages, a degree of pain may still be felt but the main symptom you’ll experience will be stiffness. It will commonly feel as if you physically can’t move your shoulder any further than it wants to go. This means that physiotherapy exercises can become far more intensive.
Physiotherapy:
When you have a frozen shoulder, you shouldn’t and indeed can’t force your shoulder to move beyond a certain point. However, shoulder range of motion exercises are critical to help maintain the movement you have in your frozen shoulder. These exercises will also increase your range of movement. This is critical as you progress to the ‘thawing’ stage. Ongoing hands-on treatment including shoulder joint mobilisation and soft tissue therapy can be extremely beneficial (Mezian et al, 2023). Treating the shoulder together with the neck and upper back can also help. It helps to increase mobility and greatly reduce muscle tightness and pain. As your shoulder regains its movement and you show signs of good improvement, progression to gentle strengthening work is important. This is because, you lose shoulder function throughout the duration of a frozen shoulder. This will cause muscle loss and weakness which must be restored.
Surgery:
Your frozen shoulder will generally resolve over time, with physiotherapy input and home management alone. However, you may need to consider surgical input. This relevant if you have a refractory case of frozen shoulder which does not improve after six months of non-operative treatment. A technique, known as manipulation under anaesthetic can be used. This will tear and release your contracted shoulder joint capsule under anaesthetic to help improve your shoulder movement. Treatment in the form of capsular hydrodilatation can also be used. This stretches your joint capsule by injecting saline into the shoulder joint. You can also consider an arthroscopic capsular release (Mezian et al, 2023).
What Should I Expect at The End of a Frozen Shoulder?
In the majority of people, your frozen shoulder will recover over a period of 1-3 years with a very good prognosis for most (Hubbard et al, 2018; Xiao et al, 2017). However, approximately, 10% of people may show signs of ongoing shoulder stiffness and disability on an ongoing basis. Frozen shoulder is a difficult and somewhat protracted condition. Therefore, ensuring you embark on a good robust physiotherapy plan is imperative. Whilst physiotherapy exercises are extremely important, beware the physio who only gives you a sheet of exercises and doesn’t touch you.
Be Patient…
Hands-on treatment can be extremely beneficial to help alleviate associated neck and shoulder muscle tightness and spasm. It can also reduce pain and help promote shoulder movement and mobility. A frozen shoulder requires patience but over time, it’s a condition which normally has a very good result. This means that at the end of it, you will be able to get back to doing everything you enjoy.
If you or anyone you know is struggling with shoulder pain, please contact us for an appointment or for more information. Our clinic in Byron Bay provides local and comprehensive physiotherapy assessment and treatment in Byron Bay and the surrounding areas.
