Frozen shoulder can seem like a bit of an enigma and I regularly receive questions from my patients wanting to understand more about this rather unique condition. Here I have tried to answer the most common FAQs associated with this condition, what to expect and how best to manage it.
What is Frozen Shoulder?
Frozen shoulder is a limiting and disabling condition that is caused by inflammation and stiffening of the shoulder joint capsule (combination of several ligaments that support your ball and socket joint). People will experience worsening pain over a period of weeks to months as well as a gradual loss in the ability to move their arm. Typical motions which become severely limited include: the ability to turn your arm out to the side, reaching behind your back and raising your arm above your head. Sleep is often severely disturbed as a result of pain and inflammation; and daily tasks, such as getting dressed or driving can become a real challenge!
Frozen shoulder can be categorised into three distinctive stages:
‘Freezing’ stage (early)
This describes gradual stiffening and deterioration of movement often over a period of weeks to months. You may initially experience mild pain which increases during this time as the inflammation becomes more apparent.
‘Frozen’ stage (middle)
At this stage, the shoulder has become extremely stiff and rigid as suggested by the term ‘frozen’. Adhesions (sticking) and thickening of the joint capsule make rotating your arm almost impossible. Towards the latter part of this stage the pain tends to gradually reduce and you are left with a stiff but less painful shoulder.
‘Thawing’ stage (late)
The final stage, as the name suggests, involves a gradual improvement in movement over several months. As the movement improves the pain should also continue to abate. The majority of patients will regain 90-100% normal movement in their shoulder.
What causes Frozen Shoulder?
The term ‘frozen shoulder’ was first coined way back in 1934, however we still don’t fully understand the underlying causes. Here is what we do know:
There are two types:
Primary Frozen Shoulder
This group describes people who develop frozen shoulder with no underlying cause.
Secondary Frozen Shoulder
In this group of individuals, people can develop the condition as a result of:
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Previous injury to the shoulder such as a fall (usually in the last 3-6 months)
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Previous shoulder surgery
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Other conditions of the shoulder, including rotator cuff disease.
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Treatment for breast cancer, including radiotherapy or axillary lymph node dissection.
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Other medical conditions such as diabetes mellitus and thyroid disease greatly increase the likelihood of you developing a frozen shoulder.
How common is Frozen Shoulder?
As much as 3-5% of the general population will experience frozen shoulder in their lifetime, whereas up to 20% of people with diabetes will experience frozen shoulder in their lifetime. The condition is slightly more common in females than males and often affects people aged between 40-60 years old.
How long does it take to get better?
Most cases (>90%) will fully resolve with time; however it can take between 18-30 months for a full resolution in some individuals.
How is it diagnosed?
In the majority of cases, frozen shoulder is easy to diagnosis. Your physiotherapist will first take a detailed history of your symptoms and activities leading up to the onset of your conditions. They will then undertake a physical examination, where even just a couple of simple movement tests should either confirm or rule out the presence of frozen shoulder.
Do I require a scan?
In short – NO. You do not require a scan if frozen shoulder is suspected as it is often very simple and quick to diagnose with a physical examination.
How is it treated?
Physiotherapy
Thankfully, most cases of frozen shoulder respond well to conservative management, in other words gentle exercises and physiotherapy. Here at Thorpes, our physiotherapists will be able to diagnose the problem and provide you with a treatment and management plan to improve your condition. A combined approach involving hands-on treatment such as: shoulder joint capsule stretches, soft tissue massage of the surrounding muscles and mobilisation techniques can be useful in alleviating stiff and sore areas surrounding the shoulder. Acupuncture can also be effective in reducing pain where pain is limiting the ability to perform exercises.
Many people who have had shoulder stiffness for more than a few weeks can experience neck tension due to compensatory movement patterns. One commonly seen pattern is for a patient with frozen shoulder to ‘hitch’ or shrug their shoulder in attempt to get more movement. This leads to secondary tightness which your physiotherapist can also address. Your physiotherapist can liaise with your general practitioner should you require pain-relieving medications to assist you in the early to middle stages of the condition. Lastly, useful advice such as optimal sleeping positions to offload the shoulder in order to aid a restful night’s sleep will be provided in your physiotherapy plan.
Pain Management
In the early to middle stages of the condition pain is often one of the main symptoms that cause people to seek help. Your General Practitioner will be able to prescribe you medications to help alleviate the pain and reduce inflammation. These will often include non-steroidal anti-inflammatory drugs (NSAIDs) and analgesic medication (painkillers). Many people are understandably keen to avoid medication, but in cases where pain is severe, painkillers can be used in conjunction with physiotherapy to help restore normal movement patterns and assist you in the ability to be able to perform gentle exercises for your shoulder.
Injections
Corticosteroid Injections
Corticosteroid injections can be useful in highly irritable cases where you are unable to function and undertake daily tasks even with regular oral medication. Steroids are potent anti-inflammatories but also dampen your immune system for a short period making you more susceptible to illness. You will require 14 days of ‘relative rest’ post injection before you recommence your exercise programme and physiotherapy. As with all invasive procedures, there is a small infection risk.
Hydrodilatation Procedure
This procedure involves cleaning the shoulder and a small amount of anaesthesia applied. Next, an injection of contrast dye is injected to help visualise the joint. Under image guidance, a needle is inserted into the stiff joint capsule which contains a mixture of saline, steroid and anaesthetic. The doctor performing the procedure will often use a large volume of this therapeutic substance, with the intention of stretching and breaking down scar tissue in the capsule to help improve movement and reduce pain. Relief can be immediate or take up to 6 weeks and for best results, physiotherapy in recommended to commence 1-2 weeks after the procedure.
Surgery
Surgery is reserved for a small minority of people suffering with frozen shoulder who continue to suffer high levels of pain for more than 6-12 months despite conservative management and injection therapy and should therefore be considered as a last resort. There are two surgical procedures available for frozen shoulder:
Manipulation under anaesthetic (MUA)
This involves being put under general anaesthetic and a surgeon performing a sequence of manipulations of the shoulder in different directions in order to tear any adhesions which have formed in the shoulder capsule to improve movement.
This procedure is not appropriate for anyone with diabetes as the stiffness often returns 2-3 weeks post procedure. Also, patients with osteoporosis are at high risk of fracture and anyone with radiation fibrosis (scarring as a result of radiotherapy for breast cancer) is at high risk of nerve injury.
Arthroscopic capsular release
This involves being put under general anaesthetic and a surgeon will use an arthroscope to inspect and release any adhesions in the shoulder capsule. This is a form of keyhole surgery (small incisions made), to minimise trauma and speed up recovery.
This procedure is often safer, effective more quickly and has better outcomes for people with resistant frozen shoulder (diabetics or those who have developed frozen shoulder as a result of injury or after surgery).
Bottom line
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Frozen shoulder is a painful, self-limiting condition which often resolves within 18-30 months.
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Physiotherapy can be useful in helping you to regain movement and reduce pain and is most useful in the middle-late stages of the condition where more vigorous hands-on treatment can commence.
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In the early stages physiotherapy can help you to manage your pain and help you to adapt your daily activities so you can continue what you enjoy doing most.
If you wish to book a physiotherapy appointment or are unsure if physiotherapy can help you, why not contact our team on: 01276 37670 or email us at: admin@thorpesphysiotherapy.com
We are offering FREE 15 minute discovery calls where one of our physiotherapists can call you to discuss your problem and ascertain whether you would benefit from physiotherapy. You can book online here or give us a call.
As ever, keep well and stay safe,
Thanks for reading
Ashley Fowler – Clinical Lead Physiotherapist
Thorpes Physiotherapy