Everything You Want to Know About "Frozen Shoulder"

Frozen shoulder is a common cause of shoulder pain, but is widely misunderstood. There can also be overlap of symptoms with  other conditions, occasionally leading to initial difficulty with diagnosis. Frozen shoulder is a very specific process, so knowing more about frozen shoulder can help you feel more confident about your prognosis, decrease pain, and get you moving without pain sooner!

Anatomy: 

Your shoulder is a ball and socket joint made up of the humerus (ball) and the glenoid of the scapula (socket). The anatomical name is the “glenohumeral joint.” The socket isn’t very deep, allowing for a very large range of motion at the joint, and there is a lot of soft tissue supporting the joint. The tissue connecting the humerus to the glenoid is called the joint “capsule,” which is connective tissue that wraps around the joint. The capsule is lined on the inside with synovial tissue, which produces synovial fluid to lubricate the joint. 

Frozen shoulder is essentially a disease process where the joint capsule becomes inflamed and stiff. The progression often follows this general timeline: 

Stages:

  • Stage 1: Synovial cells on the inside of the joint capsule over-produce inflammatory chemicals, causing synovitis (literally the medical term for “inflammation of the synovium). 

    • Symptoms include pain both at rest and with activity

    • Pain tends to be worse at night

    • There is a significant functional impact on daily activities including getting dressed, driving, reaching, etc. 

  • Stage 2: Increase in cell activity over-produces collagen in an unorganized pattern, causing stiff and thickened capsular tissue. 

    • Symptoms include progressive stiffness, especially with loss of external rotation and abduction ranges of motion. 

    • Pain tends to subside over time, especially at rest and at night. Pain is still present with end-range movements. 

  • Stage 3: Inflammatory process subsides, allowing the shoulder joint to tolerate end range of motion and overall recovery of shoulder function. 

Frozen shoulder can be primary, meaning it happens without a preceding incident, or secondary, meaning it happens after a shoulder injury or surgery. It almost always happens between the ages of 40-65, and is more common in those with diabetes or thyroid problems. 

If you think you have frozen shoulder, it’s very important to be evaluated by a medical professional (a physical therapist or primary care doctor) to rule out other causes of shoulder pain, including shoulder arthritis, tendonitis, or other pathology. It can be reliably diagnosed with a clinical history and physical examination, but imaging can be helpful to rule out other conditions if symptoms do not progress as expected. 

Prognosis:

The good news is, everyone who gets frozen shoulder will improve over time. The inflammation will stop, and it is possible to recover your range of motion and functional use of your arm. However, recovery is often slow - total recovery often takes 1-2 years. Early treatment has been shown to improve pain and function in the short term, leading to less interruption of daily activities for a shorter period of time, and might also improve long-term outcomes. 

Treatment: 

Medical treatment: Includes anti-inflammatory injections into the joint, or joint manipulations under anesthesia (MUA) to improve range of motion. 

  • Cortisone injections have been shown to improve pain and function for several months. Research has shown that injections along with physical therapy are more effective than either intervention in isolation. 

  • MUA is an option for later-stage disease where there are still significant range of motion limitations. However there is not enough high quality evidence to make a recommendation on whether this should be done routinely. 

Physical therapy treatment for Frozen Shoulder: This will vary depending on the stage of the disease. 

  • Stage 1: The goal is to decrease pain, but also maintain as much function as possible. Research has consistently shown that continuing to use the affected arm for regular daily activities, within tolerance, will improve long-term outcomes. It’s also very important to understand that with frozen shoulder, using the arm does not cause damage! Treatment at this stage can look like: 

    • Passive or assisted range of motion exercises to decrease muscle guarding 

    • Low-load strengthening exercises to keep the muscles healthy. (Many of my patients actually tolerate mid-range strengthening quite well, even very early on!)

    • Manual therapy as needed with the goal of reducing pain

  • Stage 2 and 3: The goal is to restore shoulder function. Because this stage can last for some time, there will be times that you are learning to compensate for changes in your shoulder's motion and times that you will work to regain normal function. That way you have confidence using your arm, even if there are changes in how it normally works. Treatment at this stage can look like: 

    • Progressive stretching of the shoulder to regain range of motion (as tolerated)

    • Progressive strengthening including rotator cuff training, multi-segment movements such as pushing, pulling, and pressing

Do you suspect you might have frozen shoulder? Contact us if you have questions or want to learn more.