What is a Frozen Shoulder?
Frozen Shoulder or Adhesive Capsulitis is a painful shoulder condition that is characterised by a lack of range of motion of the shoulder joint.
The lack of motion occurs due to thickening and the development of adhesions of the capsule that surround the shoulder joint. These adhesions block the shoulder as it moves towards the end of its range & induces significant pain. This pain eases somewhat when the arm is resting by your side.
Classic limitations with frozen shoulder include:
- Difficulty getting dressed
- Difficulty putting on a seatbelt
- Difficulty bringing the arm up behind your back
If you have a frozen shoulder it normally affects one side at a time & is most common in middle-aged individuals between the ages of 45 & 60. It tends to occur more in people who are sedentary.
If you are suffering with a frozen shoulder you are likely to report the following history:
- A gradual onset over several weeks
- Difficulty performing basic shoulder movements
- Trouble sleeping on the painful side
There are three stages to the condition that are commonly referred to as:
Stage I (the freezing stage)
Stage II (the frozen stage)
Stage III (the thawing phase)
Causes of Frozen Shoulder
Frozen Shoulder is idiopathic in nature. This is the medical term used when the cause of a condition is unknown. It occurs more frequently in those who suffer with diabetes and metabolic syndrome.
Some have suggested an autoimmune component may be associated. An autoimmune condition is where the body erroneously attacks its own tissues as it mistakes it for a foreign body i.e. the immune system is overactive. Other potential factors include:
- Shoulder disuse or immobilisation
- Poor postural alignment
- Arthritis
- Rotator cuff (shoulder muscles) injury
- Lung & heart disease
Ross discussing Frozen Shoulder on KFM radio:
Stages of Frozen Shoulder
Stage I:
Stage I is known as the freezing stage. In stage I the patient often reports several months of sleepless nights due to pain from lying on the affected shoulder.
Symptoms involve an increase in shoulder pain & decreased range of motion. On examination, pain is present at the end of range of shoulder movements. External shoulder rotation is generally the most painful movement.
Stage II
In stage II (the frozen phase) a severe limitation of movement allied with severe stiffness & pain is normally evident. This phase of the condition will generally last from between 4-12 months.
The theory is that thickening of the synovium of the shoulder joint capsule takes place secondary to inflammation & that this causes the severe symptoms evident at this stage.
Stage III
In stage III (the thawing phase) a gradual decrease in pain & inflammation. This is accompanied by a gradual increase in range of motion.
Treatment of Frozen Shoulder
Phase I:
To manage night pain it is best to lie on the unaffected side & place the affected arm on a pillow while minimising internal shoulder rotation.
The patient may perform gentle range of motion exercises & mild isometric exercises at 25% of maximal contraction for 5-8 seconds at a time.
Manual decompression treatment may be utilised to decrease the pressure on the shoulder capsule. Stretching to improve shoulder abduction & external rotation should be the primary focus. Shoulder mobilisation techniques may also be applied to minimise capsular adhesions & increase range of motion.
Stage II:
Treatment of pain will continue as with previous stages. Increased in range of motion & gradual strengthening of the shoulder is critical at this phase. Moist heat may be applid to the shoulder prior to stretching the shoulder to relieve pain & stiffness.
Stage III:
At phase III, the goal of treatment is to gradually increase the laxity of the capsule & to continue building muscle strength of the shoulder. Exercises incorporating pulleys, wands & gym balls may be incorporated at this stage.
What is the Best Treatment for a Frozen Shoulder?
A recent review of all the published literature analysed the impact of various interventions to determine which are the most effective in treating frozen shoulder.
They reported that joint mobilisation, when combined with intermittent stretching, proved more effective than either technique applied individually (Celik ad Kaya Mutlu).
The research also found that passive progressive stretching helped to increase the range of motion at the shoulder. Use of this technique led to an improvement that was sustained at 12 month follow-up.
In terms of pain, several techniques were found to be effective. These included Mulligan joint mobilisation techniques, continuous passive motion, lidocaine injections and rotator cuff strengthening.
Can an MRI Scan or x-ray diagnose a frozen shoulder?
Traditionally, a frozen shoulder is diagnosed based on clinical testing as opposed to MRI scans or x-rays. As changes within the shoulder capsule are not adequately visualised on MRI strengthening then this would not generally be used as a diagnostic tool.
X-ray scans are not used for frozen shoulder diagnosis as these are utilised more for visualisation of bone & therefore x-rays would be used primarily for diagnosing a suspected shoulder (humerus bone) fracture.
Having said that, x-rays are useful in ruling out other conditions that can mimic a frozen shoulder as opposed to diagnosing frozen shoulder itself. Expert guidelines recommend that if you have been diagnosed with a frozen shoulder that you should have an x-ray to rule out more sinister (but rare) conditions that can mimic the condition.
Evidence for MRI scans: Recent studies have demonstrated that a ligament in the shoulder called the coracohumeral ligament (see image below) is shortened and thickened when someone is suffering from a frozen shoulder. In one study by Li et al. 2011 they analysed 72 patients with frozen shoulder & compared this with a group of 120 normal volunteers.
The (coracohumeral) ligament was found to be significantly thicker in those with frozen shoulder versus the control group.
Ref: Henry Vandyke Carter, Public domain, via Wikimedia Commons
How long does a Frozen Shoulder last?
Now here’s the bad news: the average duration of each of these 3 stages is 30 months. The range of time for each stage varies from between 12 to 24 months.
Schaffer et al. (1992) found that 50% of patients with frozen shoulder reported some pain & stiffness seven years after suffering from the condition.
Don’t panic just yet though: with appropriate treatment you can make significant inroads into this timescale. Recent research has demonstrated that new blood vessel growth is evident at the involved shoulder in the early stages of the condition. This may explain the link between certain metabolic and circulatory conditions, such as diabetes, hypothyroidism, metabolic syndrome, and the presence of a frozen shoulder.
A low-grade inflammatory process is evident in those with those suffering with this condition. Low-grade inflammation is known to be present in most chronic health conditions.
One paper suggested that frozen shoulder may be an age related symptoms of metabolic syndrome and chronic low-grade inflammation (Pietrzak 2016). Indeed, the research is delving further into the link between systemic (body-wide) health state and the presence of such conditions.
References:
Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long term follow up. J Bone Joint Surg Am 1992;74: 738-46.
http://www.ncbi.nlm.nih.gov/pubmed/1624489
Li JQ, Tang KL, Wang J, Li QY, Xu HT, Yang HF, Tan LW, Liu KJ, Zhang SX. MRI findings for frozen shoulder evaluation: is the thickness of the coracohumeral ligament a valuable diagnostic tool? PLoS One. 2011;6(12):e28704. doi: 10.1371/journal.pone.0028704. Epub 2011 Dec 7. PMID: 22163326; PMCID: PMC3233594.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3233594/
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