Is it a Frozen Shoulder

We are often asked this in the early stages of shoulder pain but at this time it is often hard to define it precisely and diagnose accurately.

Early arthritis, bursitis and rotator cuff pathlogy can all present with shoulder pain. Once frozen shoulder develops its familiar pattern of pain and stiffness due to the synovitis and capsular contracture, diagnosis is easier and can be confirmed by the absence of other conditions on US and xray

For reasons we do not understand, in frozen shoulder or idiopathic adhesive capsulitis, the lining of the shoulder capsule becomes very vascular and painful, and the capsule becomes thickened, fibrotic and contracted. Loss of the normal laxity of the shoulder capsule results in a loss of shoulder joint motion. Eventually, at an average of 2.5 years, this process reverses and shoulder motion is restored - although not always completely. We do not know why frozen Shoulder predominantly occurs in the 40-60 year old age group, is slightly more common in women (1.3:1) and in the left shoulder (1.3:1).

Symptoms

The main symptoms of a frozen shoulder are pain and later stiffness. All ‘true’ frozen shoulders are extremely painful, extremely limiting, and extremely disabling.

Initially the pain is usually a dull ache in the shoulder and upper arm then sharper pain with all movements. Most often there is no increase or unaccustomed activity that causes it and people will search for meaning in what might have brought it on but it is not a repetitive strain injury. In rotator cuff pathology people are more likely to report the activity that has aggravated their shoulder. Rest doesn’t seem to improve the pain, with it slowly getting worse and increasing at night.

After 6- 9 months the pain settles a little but true stiffness gets worse. True stiffness is when the shoulder joint wont move actively or passively by someone else. It is “ stuck” and the condition is frequently defined as loss of more than 25% of normal shoulder range of motion in at least two directions - lifting sideways, reaching behind our back and importantly rotating the arm outwards. To check this : stand with both arms at your side and keep your elbows bent to 90 degrees. While keeping your elbows tucked into your sides, rotate your arms out. This direction of motion is called external rotation. If you have a frozen shoulder, the painful side will significantly not rotate out as far as your non-painful arm.

Stiffness then progresses for 4-12 months, followed by gradual return to improved range over the next 6 months to 2 years.

Causes

Most Often there is no known cause (idiopathic), but can occur with other diseases, usually diabetes, or it follows traumas or periods of immobilisation like a stroke, or fracture. It may be more common with obesity, and thyroid dysfunction where there is low grade inflammatory processes occurring. Some argue there maybe tissue vulnerability from smoking , sleep deprivation and other chronic pain factors.

There is also a reported link with Dupuytren's contracture in the hand, so there could be a connective tissue disorder component. Unfortunately it is not uncommon for people to have both shoulders affected in their lifetime.

Treatment

The old idea that this is a self-limiting condition is now contradicted by modern evidence. It can thaw spontaneously but for many people it will be frozen to some degree for a long time, measured in years. There is strong evidence showing a considerable number of untreated patients are left with long-term disability and pain. Additionally, of available treatments, many can improve shoulder range of movement, increase function and decrease pain, however they cannot shorten the natural progression of frozen shoulder.

Understanding the condition can assist in reducing some of the fears and frustration that come with frozen shoulder. Education will also focus on activity modification to encourage functional, pain-free range of shoulder movement, and matching the intensity of stretching to a patient’s pain levels. Maintaining the functional mobility and strength of the surrounding joints and muscles is also an integral part a full recovery.

Physiotherapist’s management of frozen shoulder utilizes various joint mobilisations, soft tissue massage, assisted movements, stretching and exercises. The aims of the techniques are to relieve pain, increase joint range and improve function. These techniques are varied according to the stage of frozen shoulder and the sensitivity of the shoulder joint.

  1. Stage one is difficult as early diagnosis can be challenging. Very gentle shoulder mobilisation, muscle releases, dry needling and kinesiology taping for pain-relief can assist during this painful inflammation phase.
  2. Stage two : Overenthusiastic treatment in the early transition phase can aggravate your capsular synovitis and subsequently pain. Gentle and specific shoulder joint mobilisation and stretches, muscle release techniques, dry needling and exercises to regain your range and strength are used for a prompt return to function. Care must be taken not to introduce any exercises that are too aggressive. Slow eccentric loading exercises have been discussed as an appropriate way to strengthen without aggravation.
  3. Stage three is the stage that you can start to notice improvement and really benefit from specific physiotherapist-directed mobilisations, stretches and strengthening exercises.

Additional therapy

Intra articular steroid injections with or without hydrodilation are often administered with varying effects. An arthroscopic capsular release can also be performed under general anaesthesia during the second stage of the condition. Current evidence has been not able to clearly determine if one method is superior to another. Your Physio and GP can offer advice on these procedures.

Chronic loss of range in old frozen shoulders

We call this stage four. We often see patients who still have end of range limitations from frozen shoulders years ago. This is often painless but prevents them from throwing or reaching and they are unaware this can be improved. It is never too late to see a physio for your past frozen shoulder. Detailed assessment of the limitations and then targeted techniques and exercises will help regain residual deficits in range and strength.

Frozen shoulder is not to be taken lightly. Although self limiting, it is painful, frustrating and debilitating. Support through the process is an important part of management and optimal recovery. Speak with one of our Physios or make an appointment to get the right treatment for the right stage of your shoulder.

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