Chances are many of us know someone who has gone through Frozen Shoulder, or even have gone through it ourselves. The term Frozen Shoulder is often erroneously used for any condition of the shoulder where it has become stiff and painful, but it more specifically refers to a condition where the main joint of the shoulder complex, the glenohumeral joint, has become contractured due to pathological inflammation.
Frozen Shoulder is also known as Adhesive Capsulitis, and also because of the demographics it affects, it has also been called ‘Fifty Year Shoulder’. Surprisingly, although it is common, its cause is still poorly understood.
This condition is characterized by deep and aching to sharp intense pain around the shoulder cap, often worse at night, affecting sleep and the ability to lay on the affected side. The shoulder becomes very stiff, with range of motion (ROM) becoming restricted in both active (self initiated) and passive (therapist initiated) movement. It is generally thought to go through three phases i as it goes from development to resolution, known as freezing, frozen and thawing- more about that later.
About 2-5 % of the general population can get it, with women being more often affected than men, at a ratio of 3:2 The average age of onset being late 40’s to sixty, but rarely after that. Besides the pain and disability, the most upsetting news is it can last, on average, just over two years. Some cases resolve in about a year while others linger on for three years.
People with systemic diseases such as diabetes, thyroid dysfunctions, and autoimmune disorders are at higher risk of getting frozen shoulder, but there are those who get it with seemingly no related health issues. This latter group are those who have been categorized as having primary frozen shoulder, whereas those with systemic diseases are categorized as having the secondary type, with generally a poorer prognosis for recovery and a greater incidence of developing it in the other shoulder. The secondary type of frozen shoulder can also occur in those that have had stroke, traumatic injury, and or surgical procedures (including mastectomy) with prolonged immobilization of the shoulder.
The shoulder is the most mobile joint of the body and paradoxically it is the only one that “freezes” like this.
The shoulder is made up of three connecting bones- the humerus, (upper arm bone) the clavicle, (collarbone) and the scapula (shoulder blade) There are four small but important muscles which originate on the scapula and attach around the head of the humerus, forming a cuff over the joint capsule. These muscles, as you might have guessed, make up the rotator cuff. They give support to the shallow ball and socket comprised of the head of the humerus and glenoid fossa of the scapula.
In normal shoulder movement, the humerus and scapula coordinate to move through a full range of motion. There are two degrees of humeral flexion/ abduction for every one degree of scapular upward rotation. This is called the scapular humeral rhythm, and it allows up to 180 degrees ROM. That’s in a healthy shoulder joint, but for those unfortunate to succumb to adhesive capsulitis, it’s a different story. As the inflammation process thickens the inner synovial lining, and the ligamentous capsule, it becomes harder to move. The most marked loss of ROM begins with external rotation, as the ligament that stabilizes the front of the shoulder becomes thickened and shortened. This is the coracohumeral ligament, which attaches from an anterior projection of the scapula located just underneath the outer end of the clavicle and connects to the humerus. Pressing on this structure can cause excruciating pain in those that have frozen shoulder. This reaction is so typical that it can be one of the diagnostic methods for adhesive capsulitis.
To confirm a diagnosis, first it must be differentiated from other conditions that have similar symptoms; for example, rotator cuff tendinopathy, calcific tendinitis, subacromial bursitis, and arthritis. This is necessary because treatment approaches vary with each condition.
Generally, a consideration of patient history, a physical exam, and a normal result on an X-Ray ruling out other conditions is enough to diagnose frozen shoulder. Other examinations using ultrasound, CT scan, and MRI arthrogram can be used, but usually not.
Frozen shoulder begins with an annoying ache, which is often worse at night. Moving your shoulder aggravates it, so you tend to avoid using it. This is the stage called ‘freezing’ where inflammatory conditions are changing the joint capsule, new blood vessel and nerve fiber growth into the joint damages the inner synovial lining and causes thickening of the outer ligaments. This stage typically lasts for up to 9 weeks and is usually the most painful.
At the ‘frozen’ stage, pain slowly begins to subside but the shoulder is now very limited in range of motion, and getting weaker. Normal activities of daily living are severely impaired, like brushing your hair, dressing yourself, putting dishes away, etcetera. This stage typically lasts about 4 to 6 months. These first two stages produce the highest amount of anxiety and distress.
The third stage, called ‘thawing’, is when the tide starts to turn for the better. Slowly the shoulder starts to improve as range of motion and strength begins to return to normal. This can take usually from 6 months to 2 years.
Identifying which stage the shoulder is in is important in order to determine the most effective treatment and rehabilitative program to consider.
In the freezing stage, the goal of treatment is the control of inflammation and the relief of pain. In this initial stage, intensive physical therapy should be avoided. Instead, the application of intra- articular corticosteroid, or sodium hyaluronate injections may help to reduce the pain and inflammation, enough to manage gentle ROM exercises like pendulum swing and wall crawl. Non-steroidal anti-inflammatories (NSAIDS) may provide some short duration pain relief, but not enough for some. TENS, cryotherapy, and activity modification education may also be given. Sufferers may also want to keep a hot/cold compress nearby at all times.
During the frozen stage, it is important to minimize capsular adhesions with gentle joint manipulations (particularly the posterior glide technique). Also considered, is the release of trigger points developed in the rotator cuff and larger muscles at the back of the shoulder, low level laser treatments as well as a stretching and strengthening program applied within the boundaries of discomfort. Exercise therapy performed in the pool is very beneficial as well. It is important at this stage not to get discouraged, even as the upper limits of your patience is being tested!
The thawing phase provides the widest window of opportunity for recovery. Further increases to range of motion as the joint capsule remodels, and the absence of inhibitory pain allows for more effective stretching and strengthening.
Adhesive Capsulitis is often cited as a self-limiting disorder, meaning the condition resolves on its own after a given time, but it is advisable to try and do the best you can to end up with a favourable outcome, even so, it has been noted that 10% of patients never recover full ROM. But remember, have patience and be gentle with yourself as you go through this process.
In the most stubborn cases, more invasive interventions are generally considered, like those of ‘hydrodilatation’ which is a saline solution, sometimes mixed with steroids, pumped into the joint to stretch it from the inside out. Surgical procedures like arthroscopic release to zap or cut away thickened capsular tissue are also commonly considered for these cases.
I have by no means covered all the treatment options possible for frozen shoulder. Ask your health professional for further information, or you can pop into Brio and ask me about any questions you have about this article.
On a personal note, I have recently gone through two phases of frozen shoulder and am currently living within the third phase. As you can tell, I take my work very seriously! I never took the corticosteroid injection option (maybe I should have?) But nevertheless, I survived on Tylenol 1’s, a prescription of Diclofenac (…meh) daily hot showers ( the miracle of home hydrotherapy!) and as well as, of course, the expertise of my colleagues here at Brio! I also found that float tanks provide a deeply relaxing experience, I try to follow a float with massage therapy. Daily stretching and strengthening with Therabands is a must as i It has been suggested that there are actually 4 stages, including a “pre-freezing” stage, where pain is predominant before any joint stiffening develops.