Frozen Shoulder

Frozen shoulder is the stiffening of the shoulder due to thickening and contraction of the capsule that surrounds the shoulder joint which results in painful movement and loss of motion. Other common names used to describe this condition include:

  • Adhesive capsultis
  • Contracture of the shoulder

Frozen shoulder occurs in about 2% to 5% of the American population. 70% of those diagnosed are women, and primarily affects those who are over the age of 45. It is estimated that 20% to 30% will get it in the other shoulder as well.

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Causes of Frozen Shoulder

There is no clear reason for the occurrence of frozen shoulder, and it has been a topic of debate for quite some time. Some believe it is caused by inflammation or thickening of the capsular lining of the shoulder joint (synovitis). Others attribute it to autoimmune reactions, where the body essentially attacks its own tissues. Other causes might include:

  • Reaction After an Injury or Surgery
  • Pain From Other Conditions: Arthritis, Rotator Cuff Tears, Tendinitis, or Bursitis
  • Immobilization of the Arm

Inflammation of the joint capsule holds the shoulder “frozen” in place. Using an arm sling (after rotator cuff surgery, for example) can increase the chances of developing frozen shoulder.

Symptoms of Chronic Lower Back Pain

This condition often starts with little or no trauma. Shoulder pain develops gradually with movement in all directions. Then stiffness sets in. Over time, the pain may decrease, but the stiffness can worsen and limit movement. It is more prevalent in women than men and most common in the 35-55 age group.

Typically, the symptoms associated with Frozen Shoulder occur in 4 distinct phases.

Stage 1: "Prefreezing" — This stage typically lasts 1-3 months with pain as the most significant hallmark of the first stage. Patients describe their pain as a dull ache when not moving that progressively gets worse, described as ‘sharp’ with movement of the shoulder. Patients typically will begin to limit use of the shoulder due to pain and in an effort to protect the shoulder. The most noticeable losses of motion occur in external rotation ‘high five’ position and with internal rotation ‘reaching behind the back.’

Stage 2: "Freezing" Inflammatory Stage — By this stage, patients have experienced symptoms for 3 to 9 months with an increase in pain and stiffness. A high pain rating is experienced of >7/10. Typically, there has been a progressive loss of shoulder movement in all ranges of motion, with active motion < passive motion. Guarding, spasm and pain prevents passive range of motion. There is an increase in pain at night and rest. There is a high level of functional disability that is experienced.

Stage 3: "Frozen" — This stage lasts from 9 to 14 months since the initial onset of symptoms. Generally, there is a significant loss of motion during this stage with the majority of pain at end range. Pain continues to be a major factor in the beginning of this stage, but tends to decrease to moderate levels (4-6/10) during the latter stages. There is occasional night pain and pain at rest. There is a moderate level of functional disability experienced.

Stage 4: "Thawing" — This last stage occurs during months 15-18 since the onset of symptoms. Pain, especially at night will begin to improve, and the ability to complete overhead motion is improving at a rapid rate. Pain is typically lower during this stage < 3/10. Functional disability that patients experience is low.

Diagnosis of Frozen Shoulder

Due to diffuse nature of symptoms during the first stage of frozen shoulder, this condition is often not diagnosed until the latter stages of progression. Oftentimes, patients are being treated for other shoulder injuries when their physical therapists begin to notice additional signs and symptoms that are consistent with Frozen Shoulder.

During a physical therapy evaluation, a thorough medical history review will be completed in order to rule out the presence of other diagnoses. Identification of pre-existing conditions such as diabetes, thyroid and autoimmune disorders that have been associated with contributors to frozen shoulder will be identified. Objective criteria that are used when determining the presence of Frozen Shoulder include:

  • A 50% loss of external rotation when compared to the other side
  • Restriction of active = passive external rotation
  • The presence of a capsular pattern which is characterized as diminishing motions of external rotation, followed closely by flexion and internal rotation
  • Common MRI findings include a thickening of the capsule of the shoulder
  • A normal X-ray series

Treatment of Frozen Shoulder with Physical Therapy

There is no quick fix but physical therapy can definitely help! Your overall goal is to restore movement, so that daily activities can be performed. Once both your objective and functional and limitations have been determined, you physical therapist will develop an individualized program that will help you to achieve your previous level of function. For each stage of Frozen Shoulder, the following interventions will typically be performed.

Stages 1 and 2

The goal is to maintain as much range of motion as possible which will help to reduce the pain that you are experiencing. Your therapist may use a combination of motion techniques and manual therapy techniques to help with your range of motion.

The difficulty and intensity of your intervention will be dependent on the severity of your pain and symptoms. Modifications and recommendations on the appropriate use of your affected arm will be made accordingly. Additionally, a gentle home-exercise program which will include pictures and videos will be issued to you which will help to further expedite your progress.

Sometimes, conservative care does not reduce the pain of frozen shoulder. If not coping, consider injection therapy as an adjunct to your physical therapy with < 6 months being the most effective time frame. This may assist to offer short-term pain reduction that will allow you to fully participate in PT treatment. Though research suggests that these injections won't shorten the duration or length of the condition, they do typically provide some short-term pain relief during the high pain phases of the condition.

Stage 3

The focus of a patient's treatment during this phase is to help them with the return of motion through a series of stretching techniques and manual therapy activities. These techniques will typically be more intense than in states 1 and 2 which will encourage more flexibility and movement. Various hands on techniques performed by the physical therapist will assist with loosing up the surrounding muscles and tissues.

Depending on your tolerance to motion focused intervention, you may begin strengthening exercises that will target both your shoulder and postural muscles. Modifications will be made to your home exercise program according to any progressive changes that have been made during your in-person therapy visits.

Stage 4

Your physical therapist will then focus on return to your normal functional activities and mechanics. Your stretching activities will continue to focus on those motions that you continue to be the most limited. Strengthening will focus primarily on your daily, work and recreational tasks which continue to be difficult for you to perform.

During all stages of rehabilitation, various modalities such as ice, heat and electrical stimulation will be used ‘as needed’ in order to better control pain either before or after your physical therapy.

Physical Therapy can significantly reduce shoulder pain, improve mobility and prevent stiffness from worsening. Sometimes a steroid injection into the shoulder joint may relieve inflammation, and if this is indicated, your physical therapist will discuss this with you and coordinate with your physician.

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Prevention Tips for Frozen Shoulder

While there is no definitive cause for frozen shoulder, identifying the symptoms and working to address them before they become a much bigger issue is essential. At Results Physiotherapy, we help individuals with Frozen Shoulder and can help you alleviate your pain and get back to doing the things you love!

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References and Additional Research Reading

  1. Wong, C.K., Levine, W.N., Deo, K., Kesting, R.S., Mercer, E.A., Schram, G.A. and Strang, B.L., 2017. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy, 103(1), pp.40-47.
  2. Jones, S., Hanchard, N., Hamilton, S. and Rangan, A., 2013. A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder. BMJ open, 3(9).
  3. Celik et al (2016) Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A RCT. Clinical Rehabilitation. 30(8): 786-94.
  4. Gutierrez Espinoza et al (2015) Glenohumeral posterior mobilization versus conventional physiotherapy for primary adhesive capsulitis: a RCT. Medwave. 15(8).
  5. Rawat et al (2017) Frozen Shoulder: Is there a role for strengthening exercises? Journal of Hand Therapy 30: 235-241.
  6. Levine WN, Kashyap CP, Bak SF, Ahmad CS, Blaine TA, Bigliani LU. Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):569-73.
  7. Ranalletta M, Rossi LA, Bongiovanni SL, Tanoira I, Elizondo CM, Maignon GD. Corticosteroid Injections Accelerate Pain Relief and Recovery of Function Compared With Oral NSAIDs in Patients With Adhesive Capsulitis: A Randomized Controlled Trial. Am J Sports Med. 2016 Feb;44(2):474-81.
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