Frozen Shoulder

What is Frozen Shoulder?

The medical term for frozen shoulder is adhesive capsulitis. The cause is not fully known, regardless, over time the shoulder begins to lose range of motion, or movement, and stiffness settles in along with pain. If it goes untreated, it will eventually resolve itself in about 2-3 years.

Adhesive capsulitis is rare as it occurs in less than 5% of the overall population and most commonly in people who are over the age of 45. Also, it more commonly affects women than men. If you have adhesive capsulitis on one shoulder, you are at a higher risk, approximately 20-30%, of it occurring in the other shoulder.

A complex and dynamic joint like the shoulder can sometimes be tricky in finding the primary cause of shoulder pain and loss of range of motion. So, to understand how a frozen shoulder occurs, a basic understanding of shoulder anatomy is important.

The shoulder is multi-jointed which allows for the ability to be multi-directional. The primary shoulder joint is where the shoulder blade (scapula) and upper arm bone (humerus) come together. The upper arm bone is a ball at the top which fits tightly into the shoulder blade bone where it is convex shaped. This joint is called a ball and socket joint due to its shape which allows for multi-directional movements.

The second joint within the shoulder is where the clavicle and the scapula bones join to form the acromioclavicular joint. This joint received its name because the clavicle bone fits together neatly with acromion, which is the bony structure coming off the scapula. The main purpose of the acromioclavicular joint is allowing the shoulder to raise above the head and to help with arm rotation.

To hold the upper arm to the body, within and around the shoulder exists soft tissue, a fluid sac, and cartilage-like structures. The most commonly known muscles, tendons, and ligaments within the shoulder is the rotator cuff-infraspinatus, supraspinatus, subscapularis, and teres minor. The rotator cuff allows for stability and movement of the shoulder.

A fluid-filled sac, called the bursa, exists within the shoulder joint to protect the rotator cuff. The main purpose of the bursa sac is the project shearing and compression of the tissue that passed through and/or connects directly within the shoulder joint itself.

In addition to the rotator cuff and bursa sac, your shoulder capsule has what is called the labrum. The labrum is what helps keep the joint “tight.” It stabilized the shoulder to ensure your arm stays connected to the body throughout the movement.

It is also within this capsular joint area where adhesive capsulitis can occur. There is a thin tissue lining the joint which can become inflamed and/or irritated causing scarring and thickening. The longer this goes untreated, the more scarring and thickening occurs which causes loss of range of motion and commonly progressive symptoms, especially with movement. The exact cause as to why this occurs is not clearly understood.

What causes a frozen shoulder?

Often the reason or cause of the condition is unknown. There is some debate whether the lining of the shoulder becomes inflamed which is known as synovitis, or there is an autoimmune reaction which “attacks” itself causing inflammation, irritation, and pain.

There are a few triggering events or conditions which may cause someone to be at a higher risk for developing a frozen and they include:

  • Arthritis
  • Bursitis
  • Diabetes
  • Parkinson’s
  • Post shoulder surgery
  • Rotator Cuff Tear
  • Stroke
  • Tendinitis
  • Thyroid disease
  • Tuberculosis

Symptoms of Frozen Shoulder

A typical frozen shoulder will have a gradual onset of loss of motion, stiffness and worsening pain. There are three main stages of a frozen shoulder, and they are:

  • Stage 1“Freezing”– This stage occurs within the first nine months of onset of symptoms. Gradually over time the shoulder becomes stiffer, and loss of range of motion begins. Pain progresses from a dull ache to sharp pain and it at night the pain may worsen when sleeping.
  • Stage 2 “Frozen”- This stage occurs typically within the first 3 to 12 months. Pain begins to subside; however, loss of motion worsens. All directional movements of the shoulder are impacted, but the external rotation is the most severely impacted. There is a significant impact on successfully completing functional activities due to a loss of range of motion and pain. During this phase, muscle atrophy, or wasting, begins due to lack of use.
  • Stage 3 “Thawing’ –This stage is full recovery of adhesive capsulitis takes anywhere from 1 to 3 years. Slowly movement returns to the shoulder allowing for improvement in function with daily activities.

How is a frozen shoulder diagnosed?

First and foremost, if you are experiencing ongoing shoulder pain, it is recommended you visit with a health care provider like a physical therapist. Early intervention and treatment are always best.

With a thorough physical examination, a PT, or your physician, can often determine if you have a frozen shoulder, by conducting a review of your medical history, examining the shoulder, and performing a few special tests.

Your PT will test the integrity of the joint as well as each muscle and tendon of the shoulder. During this exam, you will perform certain arm movements like lifting your arm away from your body, rotating your arm, and reaching behind your back.

Your PT will also perform some resistance during arm movements, but don’t be alarmed as they are checking for muscle strength. This testing may cause mild discomfort, but don’t be concerned as they are not doing any further damage to the shoulder. They are trained experts in the musculoskeletal system.

During your examination, your PT will ask specific questions related to your symptoms and how they impact your function. The question may include:

  • When was the onset of your symptoms?
  • What activities make the pain worse?
  • Where is your exact point of pain?
  • Was there any trauma to the shoulder? If so, what was it?
  • Was the onset of your symptoms gradual or immediate?
  • Do you perform repetitive activities?

If you seek medical care from a physician, they too will go through a medical history and examine the shoulder. They may order an image like an MRI (magnetic resonance imaging) to look internally at the shoulder structure. The MRI will look closer at the shoulder structure along with images of the tissue, which will provide information about swelling and/or damage to the tissue, like a tear.

Treatment of Frozen Shoulder

As a consumer of health care, you have a choice in finding the right provider for you. Do your homework and search for a health care provider with excellent outcomes, great customer reviews, and can provide you the care you need for a reasonable cost.

Conservative treatment, such as physical therapy (PT), is recommended for frozen shoulder. Even though the shoulder will be most likely to recover on its own within 2-3 years, a physical therapist can shorten the recovery time. Proper training and treatment in movement, strengthening, and returning to activities are critical for a full recovery.

After the examination, a PT will create a customized treatment plan with you to help return movement, strength, and function back to your shoulder. The goal of treatment will begin with managing your pain, start gentle range-of-motion exercises, and when appropriate your PT will advance you to strengthening exercises. Throughout your treatment, your PT should keep track of your progress with an outcome tool such as FOTO.

Sometimes beyond therapy, during this time pain or anti-inflammatory meds may be needed. If this is the case, your PT will make the appropriate recommendation to you and your physician. A PT cannot prescribe drugs, but he or she can establish a plan with you and your physician. The main goal is to help manage the pain while increasing the range of motion and introducing the return of daily activities.

It is rare, but in some cases, capsular release surgery is indicated. Your surgeon will decide what technique is best used, but most commonly a manual manipulation or arthroscopy procedure is done. Immediately after surgery, your arm will be in a sling for comfort measures, but the goal is to get you using your arm sooner rather than later. The goal is to improve mobility.

After surgery, physical therapy is recommended and usually starts within a few days. The goal is to help return you to functional activities and prevent the shoulder from freezing up again. Most commonly, you can return to sedentary work within 1 to 2 weeks after surgery. If you have a more labor intensive job, it may be months before you can return, which should be discussed thoroughly with your health care provider before surgery.

Next Steps

If you are experiencing persistent shoulder pain, more than one week, and it is impacting your daily activities such as work, hobbies, or sleep, seek medical attention. Early intervention and diagnosis are critical to managing a frozen shoulder. Remember, you have choice in your health care provider.

A medical provider such as a physical therapist can be seen directly without a physician’s order, which is called direct access. Most states have some form of direct access, so to determine what the rules are within your state, please visit the American Physical Therapy Association’s website Physical Therapy Direct Access By State.

To find a qualified physical therapist near you, click on Find A Clinic. A highly qualified PT will not only take the time to evaluate you, review your history, listen to your goals, and exam the shoulder, but also a top-rated PT will track his or her outcomes like FOTO. Tracking your progress is part of integral care and treatment of the shoulder.

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