A frozen shoulder is a shoulder joint that has lost a substantial amount of its range of motion in all directions due to scarring around the joint. The range of motion is limited not only when the patient attempts motion, but also when the doctor attempts to move the joint fully while the patient relaxes. Symptoms usually include stiffness and pain in your shoulder joint, and typically begin gradually, worsen over time and then resolve, usually within one or two years.
Adhesive capsulitis or frozen shoulder is a condition affecting range of motion in the shoulder, and for which doctors fail to have an exact explanation of why it occurs. The condition has three stages: an early pain stage, where the shoulder feels painful and pain may inhibit range of motion of the shoulder; the frozen stage where shoulder movement may be very limited; and thawing stage when some range of motion is restored to the affected shoulder. Frozen shoulder tends to most commonly occur in people over 40, and may be more common among people with autoimmune diseases, thyroid problems, heart disease, and diabetes.
Frozen shoulder is the result of inflammation, scarring, thickening or swelling, and shrinkage of the capsule that surrounds the normal shoulder joint. Any injury to the shoulder can lead to a frozen shoulder, including tendinitis, bursitis, and rotator cuff injury (rotator cuff syndrome). Frozen shoulders occur more frequently in patients with risk factors of diabetes, chronic inflammatory arthritis of the shoulder, or after chest or breast surgery. Long-term immobility of the shoulder joint can put people at risk to develop a frozen shoulder.
Swelling
A frozen shoulder occurs when there is thickening and swelling of the flexible tissue that surrounds your shoulder joint. This tissue is known as a capsule. Your shoulder is a ball and socket joint, in which the end of your upper arm bone (humerus) sits in the socket of your shoulder blade (scapula). The shoulder capsule is fully stretched when your arm is raised above your head, and hangs down as a small pouch when your arm is lowered. In cases of frozen shoulder, it is thought that bands of scar tissue form inside the shoulder capsule, causing it to thicken, swell and tighten. This leaves less space for your upper arm bone in the joint and makes any movement stiff and painful.
Inflammation
What's really occurring when you have frozen shoulder may be an inflammation of the shoulder capsule, which is the connective tissue between the humerus (arm bone) and the shoulder bone (scapula). The swelling can reduce the normal amounts of fluid present to lubricate joints, which results in reduced ability to move the joint. Frozen shoulder usually affects only one shoulder but it can significantly and sometimes permanently impair movement to the point where it is almost impossible to do simple routine tasks, like moving a fork to your mouth or brushing your hair.
The reason why a frozen shoulder occurs is not fully understood. In some cases, it may not be possible to identify a cause. However, there are several risk factors that make developing a frozen shoulder more likely.
Shoulder injury or surgery
It is possible to develop a frozen shoulder following a shoulder or arm injury, such as a broken bone (fracture) or after having surgery to your shoulder area.
This may be because keeping your arm and shoulder immobile (still) for long periods of time during your recovery may cause your shoulder capsule to tighten up from lack of use. For this reason, it is important not to ignore a painful injury to your shoulder area and to always visit your doctor.
Diabetes
If you have diabetes (a long-term condition caused by too much glucose in the blood), you are more likely to develop a frozen shoulder. The exact reason for this is unknown. If you have diabetes, you are also more likely to:
develop the condition in both your shoulders
have more severe symptoms
It is estimated that around a third of people with diabetes have a frozen shoulder.
Other health conditions
Your risk of developing a frozen shoulder may also be increased by having other health conditions including:
heart disease, where the heart's blood supply is blocked or interrupted
lung disease, which affects your airways
an overactive thyroid gland (hyperthyroidism), where the thyroid gland, which is found in your neck, produces too many hormones (powerful chemicals)
Parkinson's disease, a chronic (long-term) condition that affects the way the brain co-ordinates body movements, including walking, talking and writing
a stroke, when the blood supply to the brain is disturbed or interrupted
Dupuytren's contracture, a condition that causes your fingers to bend into the palm of your hand due to the thickening and shortening of the tissue in your palm
Immobility
Being immobile (not moving) for a long period of time is also a risk factor for frozen shoulder. This can occur if you are in hospital, for example after having a stroke or car accident.
If your doctor suspects frozen shoulder, he or she will probably gain the most information by a simple physical exam to check your range of motion. Medical history, especially to check for any of the above mentioned conditions, will be considered and your doctor may also order x-rays or a magnetic resonance imaging (MRI) test to specifically evaluate inflammation of the shoulder capsule. When diagnosis is confirmed, doctors usually refer patients to physical therapists to start immediately on range of motion exercises that can help restore greater function to the shoulder joint.
A frozen shoulder is a painful, persistent stiffness of the shoulder joint, which makes it very difficult to carry out the full range of normal shoulder movements.
You may find it difficult to carry out everyday tasks, such as:
dressing
driving
sleeping comfortably
Some people find they are unable to move their shoulder at all, which is why the condition is known as a frozen shoulder.
The symptoms of a frozen shoulder advance slowly and are usually experienced in three separate stages that are spread over a number of months or years. However, the symptoms of frozen shoulder can vary greatly from person to person.
The three stages of frozen shoulder are described below.
Stage one: During stage one, your shoulder will start to ache and will feel stiff before becoming very painful. The pain is often worse at night and when you lie on the affected side. This stage lasts two to nine months.
Stage two: Stage two is known as the adhesive stage. Your shoulder may become increasingly stiff, but the pain will not usually get worse. Your shoulder muscles may start to waste slightly because they are not being used. This stage lasts four to twelve months.
Stage three: Stage three is the recovery stage. During this stage, you will gradually regain movement in your shoulder. The pain will begin to fade, although it may recur from time to time as the stiffness eases.
Although you may not regain full movement of your shoulder, you will be able to do many more tasks. Stage three can last five months to three or four years.
Initial symptoms of the condition, during the painful stage, definitely suggest a visit to your physician. Some physicians believe that earlier diagnosis of frozen shoulder is advantageous because a physical therapy regimen can immediately begin. This may help restore greater range of motion to the shoulder. Even when patients reach the thawing stage, not all range of motion will be restored to the affected joint, arm and shoulder. Early intervention bodes well for better recovery from this condition.
Treatment for a frozen shoulder varies depending on the stage of the condition and the severity of your pain and stiffness. The aim of treatment is to keep your joint as mobile and pain free as possible while your shoulder heals.
A frozen shoulder usually resolves itself over a period of 18 to 24 months. While treatment will not necessarily speed up your recovery, it can make it more bearable.
The early stage of a frozen shoulder is the most painful stage.
If you are in the early stage of frozen shoulder, your doctor may recommend that you avoid movements that make the pain worse, such as stretching overhead. However, do not stop moving altogether.
Treatment during this stage is mainly focused on relieving the pain.
Painkillers
If you are in pain, you may be prescribed painkillers, such as paracetamol, or a combination of paracetamol and codeine. Some painkillers, such as paracetamol, are also available over-the-counter (OTC) in pharmacies. Always follow the manufacturer's instructions to ensure that the medication is suitable for you, and that you are taking the correct dose.
If your pain is more severe, your doctor may recommend or prescribe a non-steroidal anti-inflammatory drug (NSAID). As well as easing pain, NSAIDs will help reduce the swelling in your shoulder capsule. NSAIDs are most effective when taken regularly, rather than as and when the symptoms are most painful.
There are some side effects associated with NSAIDs. See the patient information leaflet that comes with your medication for more information about the possible side effects.
Do not take NSAIDs if you have:
asthma (a condition that affects the lungs)
high blood pressure (hypertension)
kidney or heart problems
Corticosteroid injections
If you have a severe case of frozen shoulder, treatment using painkillers may not be enough to control the pain. If this is the case, you may be able to have corticosteroids injected into and around your shoulder joint.
Corticosteroids are medicines that contain hormones (groups of powerful chemicals that have a wide range of effects on the body). They help to reduce swelling and pain. Corticosteroids may also be given with local anesthetic (painkilling medication).
Corticosteroid injections can help relieve pain and improve the movement in your shoulder. However, the injections cannot cure your condition and your symptoms will gradually return. Corticosteroid injections will also not be used once the pain has faded from your shoulder and only the stiffness remains.
Too many corticosteroid injections can cause damage to your shoulder, so you may only be able to have this type of treatment up to three times in one year. You will need at least three to four weeks between injections.
After the initial, painful stage, stiffness is the main symptom of a frozen shoulder. At this time, your doctor may suggest that you start doing shoulder exercises, and they may refer you for specialist treatment from a physiotherapist (a healthcare professional who is trained in the use of physical methods, such as massage and manipulation, to promote healing).
Shoulder exercises
If you have a frozen shoulder, it is important to keep your shoulder joint mobile with regular, gentle exercise. Not using your shoulder can cause your muscles to waste and may make stiffness worse. Therefore, if you can, continue to use your shoulder as normal.
However, if your shoulder is very stiff, exercise may be painful. Your doctor or physiotherapist can give you exercises that you can do without further damaging your shoulder.
Physiotherapy
If you are referred to a physiotherapist, they will help you maintain movement and flexibility in your shoulder using a number of techniques. You may have treatments such as:
massage
thermotherapy with warm or cold temperature packs
transcutaneous electrical nerve stimulation (TENS, see below)
Shiatsu massage is also becoming increasingly popular as a complementary physiotherapy for frozen shoulder pain relief.
Transcutaneous electrical nerve stimulation (TENS)
Transcutaneous electrical nerve stimulation (TENS) is a type of physiotherapy that may help ease the pain of frozen shoulder. It numbs the nerve endings in your spinal cord that control pain, so that you can no longer feel it.
Treatment with TENS is usually given by a physiotherapist. Small electrical pads (electrodes) will be applied to the skin over your shoulder. These will deliver small pulses of electricity from the TENS machine. Your physiotherapist can control the strength of the pulses and how long they last.
The current, delivered through electrodes taped to your skin, isn't painful or harmful. It's not known exactly how TENS works, but it's thought that it might stimulate the release of pain-inhibiting molecules (endorphins) or block pain fibers that carry pain impulses.
Some alternative therapies, such as acupuncture (a treatment that involves inserting fine needles into your skin at certain points on the body) claim to relieve or prevent the symptoms of a frozen shoulder.
Acupuncture is a procedure that has been used in China for thousands of years. It involves inserting extremely fine needles in your skin at specific points on your body. Typically, the needles remain in place for 15 to 40 minutes. During that time they may be moved or manipulated. Because the needles are hair thin and flexible and are generally inserted superficially, most acupuncture treatments are relatively painless.
If you decide to use herbal remedies, check with your doctor first because some remedies, such as St John's Wort, can react unpredictably with other medication or make it less effective.
Surgery for frozen shoulder is rarely necessary, but you may be referred for surgery if other treatments have not worked after six months. You could be referred to:
an orthopedic surgeon, who specializes in conditions that affect the bones and muscles
a rheumatologist, who specializes in conditions that affect the muscles and joints
There are two possible surgical procedures, which are explained in more detail below.
Manipulation
You can have your shoulder manipulated (moved) while you are under general anesthetic (a painkilling medication that makes you unconscious). During this procedure, your shoulder is gently moved and stretched while you are asleep.
Afterwards, you will usually require physiotherapy to help maintain mobility in your shoulder. Manipulation may be used if you are finding the pain and disability from your shoulder difficult to cope with.
Arthroscopic capsular release
An alternative procedure to manipulation is arthroscopic capsular release. This is a type of keyhole or non-invasive surgery. The surgeon will carry out the procedure after making an incision (cut) that is less than 1cm (0.4in) long.
During arthroscopic capsular release surgery, your surgeon will use a special probe to open up your contracted shoulder capsule. They will then remove any bands of scar tissue that have formed in your shoulder capsule, which should greatly improve your symptoms.
As with manipulation, you will need to have physiotherapy after arthroscopic capsular release surgery. This is to help you regain a full range of movement in your shoulder joint.
The key to recovery from frozen shoulder is to keep maintaining as much movement in the affected shoulder as possible. Patients are advised to adhere to all recommendations by a physical therapist and to do any proposed exercises and stretches on schedule. Usually it is patients who don't seek treatment that end up with significant impairment of the shoulder joint. To prevent this, zealously follow the exercise schedule your doctor or physical therapist suggests and keep, as pain or lack thereof permits, attempting to move the shoulder as much as possible. Even with rehabilitative therapy, some impairment of the joint may remain, but with carefully guided exercise, you have greatest likelihood of restoring greater range of motion and getting back the use of your arm and shoulder.