Frozen shoulder is one of the conditions that is a bit misunderstood about why it happens and what you can do about it. It is not uncommon to see people at the clinic who have been diagnosed with frozen shoulder who have a very diverse history behind why it happened.
Some people have predisposing health conditions that make them more susceptible to developing it, some people have had a traumatic injury such as a fracture or, a complication of shoulder surgery; then there are those that get frozen shoulder for what appears to be no reason.
Often patients are told that there is very little that can be done for it and that it will take 2-3 years to resolve. However there is a lot more to the recovery this than and there are treatment options.
We explain about what happens in frozen shoulder in this video here:
The features of frozen shoulder appear to follow a pattern :
Phase 1: This is where we have the start of a painful irritable which is more inflammatory in its nature. Restriction to movement seems to be related to the pain and muscle guarding at this stage rather than structural change.
This may be the dominant phase for 4-6 weeks
Phase 2 : The shoulder is still painful but restriction of movement is becoming more noticeable as the capsule a ligaments become more fibrotic. This fibrosis leads to a thickening and stiffening of these capsules that limits the movement.
This can last from about weeks 4 – 12.
Phase 3 : The “frozen phase”. The pain starts to subside but we are left with restriction of movement at the shoulder joint that affects our day to day function.
This is usually the dominant phase for up to 3 years
Phase 4: The thawing phase. This is where the shoulder starts to move again and slowly regains its movement.
What are the features that diagnose a frozen shoulder ?
The classic movement pattern of a frozen shoulder is restriction of external rotation more than abduction more than flexion. One of the major complaints people have is that they struggle to get their arm behind their back to reach a wallet or do up a bra strap. Its often the last one to come back as it is a combination of movements rather than a single movement.
Here is an example of the frozen shoulder pattern in one of our clients:
External rotation ‘rotating the arm away from the side of the body’: is classically the most limited. Probably due to the fibrosis of the coracoacromial ligament and anterior capsule complex.
Abduction ‘lifting the arm away from the body’: is the second most restricted movement as the inferior capsule or pouch starts to get fibrotic and shrink.
Flexion ‘lifting the arm out in front of the body’: can often have a large range of motion compared to the other movements but in the initial stages can be quite painful.
Why does frozen shoulder happen?
Know one has a definitive answer to why it happens though it does appear to occur in about 2-5% of the population and affects women more than men and is more prevalent in the over 40 age category.
Adhesive capsulitis or frozen shoulder can occur due to trauma such as a fall, be a progression from other inflammatory related shoulder conditions that have caused the shoulder to become immobile or be related to other underlying issues.
These include :
- thyroid disease,
- cerebrovascular disease.
- coronary artery disease.
- autoimmune disease.
- Dupuytren’s disease. Soft tissue contracture found predominantly in Northern Europeans and their descendants…tough luck Vikings.
Are all frozen shoulders actually frozen ?
Adam Meakins describes the pseudo frozen shoulder more as the frozen brain syndrome. Meaning that it’s an over protective nervous system that won’t switch off. In the video below is a demonstration of this phenomenon:
We can clearly see in this video an example of a frozen shoulder actually being more of a protective guarding. When they are awake they show all the classic restrictions of frozen shoulder but under anaesthesia they have full range of movement.
In the video below we look at why this occurs:
Physiotherapy treatment for frozen shoulder
Physiotherapy is probably most successful in cases whereby the shoulder has a greater degree of guarding than actual fibrosis of the capsule. It has been proposed that functional freezing may become more dominant over time as the capsular fibrosis possibly resolves.
Alternatively most frozen shoulders will have a proportion of actual : functional freezing.
The trick with exercises and treatment is finding a level of exercise that you can do that doesn’t aggravate the condition. This is usually a bigger factor in early inflammatory stages rather than the “frozen” stage.
Below are examples of exercises we use that are a mix of stretching , mobility and loading.
Other treatment options for frozen shoulder.
For some individuals further options are required to get the shoulder moving better before physio becomes effective.
Corticosteroid intra-articular injection for frozen shoulder.
This is more than likely beneficial in the initial 2 phases where there is an inflammatory process present.
Intra-articular corticosteroid injection has been observed to offer faster and superior improvement in symptoms compared to oral steroid treatment.56,57 Intra-articular steroid injection decreases fibromatosis and myofibroblasts in adhesive shoulders.
Hydrodilation and frozen shoulder
Hydrodilation, otherwise known as distention arthrography or brisement, describes a process in which capsular distention is achieved by injection of air or fluid under fluoroscopy and local anesthetic to stretch the contracted capsule and thereby increasing the intracapsular volume.
Suprascapular nerve block
Suprascapular nerve block (SSNB) can be performed in the hospital or office setting to provide temporary pain relief to facilitate mobilization. The suprascapular nerve provides sensory fibres to approximately 70% of the glenohumeral joint.
Manipulation under anesthesia, MUA, and frozen shoulder.
MUA relies on aggressive mobilization of the shoulder joint in a controlled setting beyond the normal pain thresholds to tear apart the adhesions and stretch the contracted capsule.
Arthroscopic capsular release is an effective and safe method for treatment of adhesive shoulder capsulitis.83–85 Arthroscopic capsulotomy has two key advantages. First, diagnostic arthroscopy confirms the diagnosis and rules out other potential causes of a painful stiff shoulder. Second, compared to MUA and hydrodilation, it allows for direct visualization of the tightened CHL, thickened rotator interval and contracted capsule to ensure adequate release. The standard arthroscopic capsulotomy is anteroinferior capsular release.
So there you have a rough guide to frozen shoulders and how to thaw them out. If you have any questions please give us a call or book in to see us here:
Frozen shoulder ..let it go. Adam Meakins , sports physio blog :https://www.thesports.physio/frozen-shoulder-let-it-go-let-it-go/