What is Frozen Shoulder?
Despite the chilly name, nothing is cool about frozen shoulder! In today’s blog we are going to be discussing what frozen shoulder is, how it is diagnosed, and different treatment options. Another commonly used name for this condition is adhesive capsulitis, but for today’s blog we will use the term frozen shoulder.
The Shoulder Joint
To help explain what this condition is, let's brush up on some shoulder anatomy!
The shoulder joint is what we refer to as a ball and socket joint; think golf ball on a tee! This allows the joint to be very mobile and gives us the freedom to move our shoulders in many different directions. Here are a couple key structures when talking about frozen shoulder:
This picture depicts the ligaments around the shoulder capsule.
Glenohumeral (shoulder) capsule
This capsule surrounds the entire shoulder joint. It’s filled with fluid that helps lubricate the joint.
Glenohumeral ligaments
These are the ligaments surrounding the shoulder joint and help provide stability, holding the ball in the socket.
Rotator Cuff muscles
The rotator cuff is composed of 4 muscles including the supraspinatus, infraspinatus, teres minor & subscapularis (an easy way to remember them is the acronym SITS). This actively provides shoulder stability.
What is frozen shoulder?
In a frozen shoulder, the structures surrounding the shoulder joints, such as the capsule and ligaments become inflamed and tight, causing pain and significant restrictions in shoulder range of motion.
Frozen shoulder is often accompanied by the following presentation:
Progressive worsening of pain and stiffness in the affected shoulder
Difficulties with daily activities including grooming, dressing, and reaching
Difficulties with sleep; being unable to lie of the painful side
Constant pain at rest
Unable to lift arm to the side without shrugging the entire shoulder
Loss of external rotation range of motion in the shoulder (see image)
Tarra depicting 90° Internal Rotation (left) and 90° External Rotation (right)
Frozen shoulder progresses in 3 stages
Stage 1: Freezing
The first stage of frozen shoulder is characterized by the shoulder progressively becoming stiff and painful to move. Pain will slowly increase and is often worse at night. In this stage pain is greater than stiffness. This stage typically lasts 3-9 months.
Stage 2: Frozen
By the second stage the pain in the shoulder may lessen but the shoulder remains stiff or “frozen”. This stage lasts 6-15 months.
Stage 3: Thawing
Exactly as the name suggests, this stage is accompanied by the gradual ability to move the shoulder. Pain will continue to lessen during this stage. Full or near full recovery of strength and range in the shoulder will occur during this last stage. In this stage stiffness is greater than pain. This stage can last 12 months-2 years.
As you can tell there are large variations in timelines for these stages, and thus your recovery. These stages help guide which treatment and goals we set as part of your rehabilitation.
What causes frozen shoulder?
Despite years of research the exact cause of frozen shoulder is still not known!
However, several associated risk factors have been identified. These include:
Diabetes Mellitus (either type I or II)
Thyroid disease (hypothyroidism > hyperthyroidism)
History of Dupytren’s Contractures
Prior episode of frozen shoulder in your other arm
The most common demographic affected by frozen shoulder are individuals between the ages of 40-70, and occurs more commonly in females than males. It is estimated that frozen shoulder affects 2-5% of the general population. It is important to note that this percentage increases to 10-20% in individuals living with diabetes.
Do I have a frozen shoulder?
Like with all pain in the body it is important to determine the cause of your pain in order to appropriately treat it! Having a stiff and sore shoulder does not mean it is frozen.
Other possible causes of shoulder stiffness/pain can include:
Shoulder Osteoarthritis (OA)
Acromioclavicular joint dysfunction
Rotator cuff injury
OR
Referred pain from the neck or upper back
It is essential to determine the cause of your stiff and sore shoulder to appropriately treat it. This includes a thorough history and clinical examination to exclude other possible causes.
What can physiotherapy do to help?
Physiotherapy can help determine the exact cause of your pain and stiffness. Your physiotherapist will take a detailed history to determine the presence of any risk factors associated with frozen shoulder, previous trauma, and your current experience with your shoulder pain. This will be followed by a thorough examination of your neck, middle back and shoulder. This will help your physiotherapist to best diagnose and treat your shoulder pain.
Generally in frozen shoulder, physiotherapy treatment depends on what stage of frozen shoulder you are in. Oftentimes we break it into two different phases:
Phase I: pain predominant
Phase II: stiffness predominant
Pain Predominant Phase (pain > stiffness):
In this stage, physiotherapy includes lots of education! Your physiotherapist will work with you to help determine activity modifications and discuss strategies to help monitor and manage pain levels. You will also be provided with appropriate exercises to perform at home. In this stage, your physiotherapist may also recommend talking to your family doctor about a corticosteroid injection (CSI) in the shoulder to aid in pain management (see alternative treatment options for more information about CSI).
Stiffness Predominant Phase (stiffness > pain):
The goal in this stage is help restore range of motion in the shoulder. Your physiotherapist will work with you to help create a home exercise program focused on stretching and restoring normal shoulder mechanics. In addition, they may utilize hands-on approaches in clinic, such as joint mobilizations, to aid in the restoration of range. They will continue to review strategies to help manage your condition during your daily activities.
Are there alternative treatment options?
Intra-articular corticosteroid injections
Intra-articular corticosteroid injections (CSI) are another commonly used technique in individuals with frozen shoulder. Studies show better outcomes when CSI are paired with physiotherapy treatment focused on shoulder mobility and stretching exercises. The goal of this injection paired with physiotherapy is to decrease the pain in the shoulder and improve shoulder range of motion.
Hydrodilatation
Hydrodilatation is another intervention that is used in the management of frozen shoulder. This includes an injection of saline containing steroid, local anesthetic and contrast material into the shoulder joint under imaging guidance. The goal of this injection, similar to CSI, is to decrease the pain in the shoulder and hopefully gain more range of motion.
Surgery
Rarely surgery is required for frozen shoulder. When needed, surgical approaches used in the management of frozen shoulder include manipulation under anesthesia and arthroscopic arthrolysis (also known as capsular release of the shoulder).
Will I ever get better?
The positive note, most individuals with frozen shoulder make a full or near-full recovery but this can be a long process! Physiotherapists can help guide you through this process making the road to recovery quicker and easier to navigate.
If you are living with frozen shoulder and looking for some guidance, click here to book with our physiotherapists to get started.
Tarra D’hoine
Physiotherapist
Hi there! My name is Tarra. I completed my undergraduate degree in Hamilton at McMaster University obtaining an Honours Bachelor of Science in Kinesiology and then returned to London to complete my Master of Physical Therapy at Western University. My approach to physiotherapy care is simple, it revolves entirely around you. I want to work with you to identify your goals and determine how physiotherapy can help you achieve them. Using a focus on education, self-management, and exercise-based rehabilitation, I aim to empower clients to reach their goals.
