Frozen Shoulder - What you need to know! | Back In Motion

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Frozen Shoulder - What you need to know!

You may have heard this term from a friend, a colleague or even in your favorite medical show.

So, what exactly is frozen shoulder?

(In case you were wondering – it actually has nothing to do with how cold it is where you live!)

What is Frozen Shoulder?

Clinically known as adhesive capsulitis, frozen shoulder is a painful condition where movement of the shoulder becomes restricted due to contracture or secondary fibrosis around the shoulder capsule. The term is used to describe what it feels like in the shoulder joint; characterized as stiffness and pain in the shoulder joint which gradually gets worse over time.

The shoulder is a ball-and-socket type of joint, where the head of the humerus fits into a socket in the shoulder blade.  

There is also a network of ligaments surrounding the joint, holding it all together – this is called the shoulder capsule.

Like with all joints they need free-moving ligaments, free from any scar-tissue or adhesions - but this is especially the case with the shoulder joint.

Frozen shoulder is when the ligaments that make up the shoulder capsule become contracted through an enzyme driven process. Adhesions start to form in the tissue which impacts the ability to move the joint and causes pain.  We still have very little understanding as to why this enzyme driven process occurs in some people

What causes frozen shoulder?

There is no clear explanation of why frozen shoulder happens. To this point, there hasn’t been a clear connection to any specific medical conditions or circumstances that lead to this.

There are, however, a few factors that may increase risk of developing frozen shoulder:

  • Diabetes
    Frozen shoulder affects an average of 2-4% of the general population, however it seems to impact up to 25% of people with diabetes. Doctors are unsure of the exact reason why this is the case; however some theories suggest that glucose molecules may affect the collagen (a key protein that makes up your connective tissue).

It is also understood that people with diabetes tend to experience more severe cases of frozen shoulder.

  • Recent shoulder injury or surgery

Any recent shoulder injury or surgery, can potentially increase an individuals risk of developing frozen shoulder due to limited mobility.

Symptoms

Frozen shoulder is divided into three key stages. If you’re experiencing frozen shoulder, you’re likely to experience the following:

  • Stage 1 - The “freezing” stage
    In this stage, pain starts to develop in the shoulder joint, and it slowly intensifies. As time goes on, the pain gets worse, and range of motion starts to deteriorate. This stage generally lasts between 6 to 9 weeks.
     
  • Stage 2 -The “frozen” stage
    During the frozen stage, shoulder pain sometimes improve however range of motion is at its worst and doing daily activities can be difficult. This stage usually happens 4 months after your pain starts and can last a few months.
  • Stage 3 – The “thawing” stage
    During the “thawing” stage, range of motion starts to slowly improve, and pain is usually manageable. Strength can also start to return as the muscles start to move freely. The thawing stage typically takes anywhere between 6 months to 2 years for patients to get back to full strength and range of motion.

Diagnosis

Diagnosis of frozen shoulder is often done by a physical exam, performed by a Physiotherapist.

Your Physio may also recommend imaging such as an MRI, Ultrasound or an X-ray to obtain a better understanding of what is happening in the shoulder capsule and rule out any other conditions.

Frozen Shoulder treatment:

The good news is that frozen shoulder generally gets better as time goes on! However, it can take up to 2 to 3 years for it to completely heal. There aren’t many aggressive treatments to address frozen shoulder, as the main objective is to restore range of motion and manage pain.  

Depending on the extent of pain and restriction of motion, surgery may be an option in consultation with your doctor. However, most cases are effectively treated with non-surgical (conservative) treatments.

Conservative treatment

Most cases of frozen shoulder show a significant reduction of pain, and an improvement in range of motion with conservative treatments. Remembering that the main objective of treatment is to slowly improve range of motion while managing pain, conservative treatments are a suitable way to meet that objective.

  • Anti-inflammatory pain relief
    Using anti-inflammatory drugs such as Nurofen or Advil, can help you manage your pain while your body recovers.
     
  • Cortisone injections
    Cortisone shots (also known as steroid shots) are injections that can help relieve pain and inflammation in the shoulder.
     
  • Shoulder distension / Hydrodilatation
    This procedure involves injecting sterile fluid into the shoulder joint to expand and stretch the shoulder joint. This alleviates tightness and promotes movement of the ligaments.
     
  • Physiotherapy
    Depending on which “stage” the injury is, improving range of motion in the shoulder will be possible with the help of a physiotherapist. Therapy will include a combination of stretching, manipulation and loosening of the shoulder joint.   

    The main goal with Physiotherapy will be slowly introducing a bigger range of motion in the shoulder joint while avoiding any increase in pain.

Surgery

If symptoms don’t improve with conservative treatment, doctors may look into surgery. Like with any surgery, there are risks involved, so it’s important to talk with your doctor.  

Surgery is usually considered while a patient is in the second stage (Frozen stage), as this is the longest stage with the most impact on mobility. The end goal of surgery is to stretch the ligaments of the shoulder capsule and release any adhesions.

Although surgery is rarely required to treat frozen shoulder, the 2 most common options are:

  • Shoulder arthroscopy
    A small incision is made around the shoulder joint, and a surgeon will use small tools to remove any scar tissue and release ligament adhesions in the shoulder capsule. Recovery can take anywhere between 1 to 6 months, depending on the extent of the repair.
     
  • Shoulder manipulation
    A doctor will forcefully move, stretch and manipulate the shoulder while the patient is under general anesthesia. The purpose is to tear apart any adhesions formed in the shoulder capsule and introduce a wider range of motion with force, which would otherwise be extremely painful to achieve with a patient being awake.  

    There isn’t a recovery from surgical intervention involved, however, there will be recovery from the manipulation itself as the ligaments were stretched. Naturally, there will be pain after the procedure, and this usually lasts anywhere between 1 to 10 weeks.

    Studies have shown that shoulder manipulation has an 85% satisfaction rate in patients, leading to a significant reduction in pain and an increase in range of motion.  

Once either procedure is complete the shoulder needs time to heal. Doctors will commonly prescribe a rehabilitation program that includes stretches and exercises to introduce flexibility and range of motion.

How can physiotherapy help Frozen Shoulder?

Studies have shown that 90% of patients experiencing frozen shoulder achieve great results using non-surgical treatments [2] (Cho et al, 2019). Physiotherapy is arguably one of the most essential factors in treating frozen shoulder and regaining mobility. During stage 3 (or the “thawing stage”) range of motion starts to slowly come back and the goal at this point should be to increase the range of motion while managing pain levels.

To achieve the best results, a physiotherapist will provide you with a structured and tailored program to help you achieve full range of motion and strength. Physiotherapy treatment can include:

  1. Manual therapy:
    Your physiotherapist can help treat frozen shoulder using a combination of different treatments such as hands-on treatment, stretching, soft tissue massage or joint mobilization. Physiotherapists are experts in the structure of the body and its movement, and your physio will work with you on the best course of action to achieve your results.
     
  2. Stretches and exercises for shoulder pain:
    Your physiotherapist will be able to provide you with specific stretches and exercise progressions to ensure that your range of motion improves. These exercises will allow your shoulder muscles to stay strong, flexible and overall increase your chances of a return to full shoulder movement.
     
  3. Education and advice:
    Physiotherapists are great at helping you with the physical improvement of your frozen shoulder, but they’re also great at helping educate you about the condition. The better your understanding of what’s happening, you’ll both have a better understanding of your goals and outcomes.

Back In motion is always here to help you!

With practices Australia-wide, we’re Australia’s leading provider of physiotherapy and related services. Contact us on 1300 859 981 to organize a booking with one of our physiotherapists to help you with your frozen shoulder pain today!

References:

  1. EFORT Open Rev 2019;4:98-109. DOI: 10.1302/2058-5241.4.180044
  2. Treatment strategy for Frozen Shoulder – Chul-Hyun Cho MD, Ki-Choer Bae MD and Du-Han Kim MD 2019. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6695331/)