Frozen Shoulder

Do I have frozen shoulder?

What is Frozen Shoulder?

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‘Frozen shoulder’ is the commonly used term to describe ‘adhesive capsulitis’, a disabling and sometimes severely painful condition of the shoulder. It is a disorder where the shoulder capsule and connective tissue surrounding the shoulder joint becomes stiff and thickened greatly restricting motion and causing chronic pain(1). True frozen shoulder has a prolonged natural history that usually ends in resolution of its own accord. It is important to have a proper diagnosis to guide optimal management of the condition (2).

What causes a Frozen Shoulder?

It is not known what causes a frozen shoulder. Occasionally it can start after a
local shoulder injury but it frequently starts with no specific preceding incident. It has not been found to be inflammatory or autoimmune in nature as previously thought. It can last from 5 months to up to 3 years (3).

Who is at risk of developing a Frozen Shoulder?

Frozen shoulder is thought to affect 3% of people over their lifetime (4). People in their 50s and 60s are most likely to develop the problem(5). It is very rare in those under 40 years of age. It tends to be more common in females than males (incidence females: males 6:4) (5).

The likelihood of developing frozen shoulder is also increased in those who also suffer from other health problems such as diabetes, stroke, lung disease, connective tissue disorders and heart disease (6).

How can I know I have ‘frozen shoulder’ and not something else?

The three main hallmarks of frozen shoulder are shoulder stiffness that comes on for no specific reason; severe pain that becomes worse at night and in cold weather; and near complete loss of passive AND active external rotation of the shoulder (3).

Shoulder pain is associated with conditions such as - shoulder impingement, bursitis, rotator cuff tear, calcific tendonitis, referred pain from the neck and nerve pain. These problems may also cause reduced movement but they will not cause the movement loss in all directions or the pattern of pain typical of frozen shoulder.

A frozen shoulder can usually be diagnosed on examination by your doctor or physiotherapist, with no special tests needed. An xray may be obtained to ensure the shoulder joint looks normal and there is no evidence of arthritic changes or injury to the joint. An MRI may be performed if the diagnosis is unsure, but it is used to rule out other problems rather than investigate frozen shoulder (5,6).

3 stages of Frozen Shoulder

Stage 1: Freezing stage
The shoulder gradually becomes painful and loses movement over six weeks to nine months. Shoulder outward motion is usually lost first, followed by other directions of movement. This is the most painful stage. Overzealous stretching and activity is NOT recommended in this stage as it is likely to worsen the symptoms.

Stage 2: Frozen stage
In this stage, restriction of range and stiffness is the main concern. Usually pain has settled. This stage may last from 4 to 9 months. Therapy during this stage has not shown to provide much benefit.

Stage 3: Thawing stage 
Treatment is most beneficial at the thawing stage and should aim at maximising range of movement and slowly building strength. Shoulder motion should slowly return to normal but for some people movement may remain mildly restricted. This stage can last five months to 26 months. (3)

Treatment for Frozen Shoulder

Treatment for frozen shoulder usually consists of pain relief and physical therapies to improve movement and muscle function.

Stretching exercises are a mainstay of treatment for ‘frozen shoulder’ and need to be performed up to three times a day. The kind of stretches will differ depending on the stage of your problem and your needs, so it is important that your program is developed under the guidance of your physiotherapist.

Strengthening exercises help reduce loss of muscle strength and muscle mass due to disuse of the shoulder and scapula muscles. For normal shoulder activity is also important to maintain proper postural muscle control and endurance.

Heat and TENS can be used frequently for pain relief. Heat helps to loosen the shoulder joint and capsule. TENS (transcutaneous electrical nerve stimulation) is a form of electrotherapy that is designed to provide pain relief. Once prescribed by your physiotherapist TENS can be applied as a home treatment. Ultrasound has been found to provide some benefit in the ‘freezing stage’ for pain relief and mobility (6)

Mobilisations are physical techniques performed by your physiotherapist, to locally stretch and lengthen the shoulder capsule and provide pain relief.

Acupuncture can be beneficial when used in conjunction with other treatments for frozen shoulder. It can reduce pain in the ‘freezing stage’ and improve mobility during the ‘thawing stage’.

Medication is important for managing the pain associated with frozen shoulder, but does not have an impact on the syndrome of ‘frozen shoulder’ itself. As the condition is not inflammatory, anti-inflammatory drugs have not been found to be of benefit.

What else can be done?

Cases that are not responding well to conservative management may be referred to an orthopaedic specialist for manipulation under anaesthesia and, rarely, arthroscopic release. Corticosteriods (steroid injections) have been found to provide limited benefit (6).

When is the best time to see my therapist?

It is important to see your doctor or physiotherapist if you have signs of a painful or restricted shoulder. Proper diagnosis is important for appropriate shoulder treatment. Once identified as a frozen shoulder, an individualised exercise program and pain relieving modalities are important for management. Treatment during the ‘thawing stage’ will deliver best results (5,6).

APMA would like to thank the Fortus Health for permission to reprint this information.

References

1. C. M. Robinson, K. T. M Seah, Y. H. Chee, P. Hindle, I. R. Murray. Frozen shoulder. J Bone Joint Surg Br January 2012 94-B:1-9.


2. Dias, R, Cutts, S, Massoud, S. Frozen Shoulder. BMJ: British Medical Journal, 12/2005, Volume 331, Issue 7530, pp. 1453 - 1456

3. S. Brue, A. Valentin ,M. Forssblad, S. Werner, C. Mikkelsen, G. Cerulli. Idiopathic adhesive capsulitis of the shoulder: a review. Knee Surgery, Sports Traumatology, Arthroscopy Volume 15, Issue 8 , pp 1048-1054


4. Harrison's Principles of Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005 Dahan TH, Fortin L, Pelletier M, Petit M, Vadeboncoeur R, Suissa S. Double blind randomized clinical trial examining the efficacy of bupivacaine suprascapular nerve blocks in frozen shoulder. J, Rheumatol 2000;27: 1329-31

5. http://en.wikipedia.org/wiki/Adhesive_capsulitis_of_shoulder

6. http://www.qcos.net.au/pdfs/frozen_shoulder.pdf

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