Shoulder stiffness is not uncommon after a shoulder injury. It is normal to experience some discomfort and stiffness after rock climbing, washing the curtains or that long-overdue tennis match. But if your shoulder becomes stiff out of the blue or the expected stiffness isn’t going away, you may have a frozen shoulder, medically termed adhesive capsulitis. “Frozen shoulder” describes the sensation of what is happening on the inside. Pain and limited movement that gets progressively worse as your shoulder “freezes”.
Adhesive refers to the sticky, tight, stiff and restricted movement of the affected shoulder. Capsulitis is the inflammation of the capsule around your shoulder joint.
A frozen shoulder develops in 3 specific stages:
- An acute or freezing shoulder has a gradual onset of pain at rest, sharp pain with movement and pain at night. is in the process of stiffening, a frozen shoulder is stuck and a thawing shoulder is loosening up once again.
- With a frozen shoulder or adhesive phase pain starts to subside, but movement becomes progressively less. Pain is felt at the end of the available movement.
- A thawing shoulder or in the resolution phase the joint progressively regain movement.
Some studies find adhesive capsulitis to be self-limiting, which means that it happens and heals spontaneously. Other studies have shown that 40% of patients may develop chronic symptoms. Effective treatment will shorten the duration of disability and healing of adhesive capsulitis.
Anatomy of the shoulder
The shoulder or glenohumeral joint (GHJ) needs to move in harmony with three other joints to allow full movement. These joints are the:
- Sternoclavicular (SC) joint between the collarbone (clavicle) and breastbone (sternum)
- Acromioclavicular (AC) joint between the collarbone and acromion (part of the shoulder blade)
- The scapula (shoulder blade) also glides on the ribcage to allow free movement of the shoulder joint.
The shoulder is a ball & socket joint. The glenoid, which is part of the shoulder-blade, forms the socket, and the head of the humerus of the upper arm, forms the ball. The socket is very shallow, especially when compared to the hip joint. This allows a lot of movement, but very little stability. Luckily the shoulder joint has help from muscles and ligaments that assist in the stability of the joint.
Muscles that attach to the shoulder
Nine muscles cross over your shoulder joint by moving forces from your shoulder blade to upper arm. These nine muscles are:
- Deltoid
- Biceps brachii
- Triceps brachii
- Coracobrachialis
- Supraspinatus
- Infraspinatus
- Teres minor
- Teres major
- Subscapularis
- Pectoralis major
These six muscles also produce the movements of your shoulder, even though they do not attach directly onto the shoulder joint:
- Trapezius
- Levator Scapulae
- Rhomboids
- Lattisimus dorsi
- Pectoralis minor
- Scaleni
Ligaments of the shoulder
Ligaments connect bone to bone. The coracohumeral ligament and transverse humeral ligament contribute to shoulder stability by combining and limiting the movement of the shoulder blade and collar bone.
The capsule encircles the entire joint, the same way a cuff goes around your arm. And maybe more famous is the muscles of the rotator cuff. The rotator cuff is made of fibrous tissue. Three of the cuff muscles merges to form the capsule:
- Supraspinatus tendon (above)
- Infraspinatus and teres minor tendons (at the back)
- Subscapularis tendon (at the front)
- Teres minor is part of the rotator cuff, but not the shoulder capsule
What does the shoulder capsule do?
The capsule is like the packaging of the shoulder joint. Almost like the plastic around store bought vegetables, the packaging allows movement of the vegetables, but within a protected space. It provides optimal space for force transfer between connecting surfaces. Different positions will cause different areas of the capsule to become taught and therefore prevent further movement. Like when you reach back to throw a ball, the front of the capsule prevents the shoulder from dislocating.
If you wrapped the bag of veggies in a few layers of bubble wrap, you won’t be able to move the bag at all.
How does frozen shoulder happen?
As the name Adhesive Capsulitis suggests, the shoulder capsule becomes sticky and swollen and then limits movement. Like a spider web that has too many layers. The more collagen is laid down, or the more spider web layers, the less elastic the capsule becomes.
Inflammation is our bodies’ way to facilitate healing, like the ambulance that gets help to an accident scene, after the paramedics are dropped off the ambulance can leave again. Inflammation gets everything needed to heal at the site of injury. It is a natural process and very much needed when there is an injury. Inflammation is not required when there is no acute injury.
In a frozen shoulder inflammation occurs within the joint space within the capsule. The cytokines, you can think of them as the guys who phoned the ambulance, sustain the unnecessary inflammatory response. He kind of has memory loss and keeps calling the ambulance even though there is no accident, too many vehicles in too little a space. This inflammation leads to fibrosis of the capsule where collagen (type I & III) is laid down. Collagen is present in all our connective tissues, but too much of it leads to tissue contraction or shortening.
As the capsule becomes stiffer the shoulder loses mobility.
After trauma, like shoulder dislocation, or surgery the risk for developing adhesive capsulitis is higher. Because of the trauma within the capsule, the ambulance is needed to facilitate healing. Any mistaken messages or sustained inflammation can lead to a frozen shoulder.
Causes of Frozen Shoulder
We do not known why some people are unfortunate to have cytokines that cry wolf and cause this unnecessary inflammatory response. Some factors that increase the likelihood of developing a frozen shoulder are:
- Diabetes Mellitus
- Cardiopulmonary disease
- Cervical disc
- Stroke
- Humerus Fracture
- Previous traumatic shoulder injury, like a dislocation
- Parkinson’s disease
- Rotator cuff pathologies
- Biceps tendinopathy
- Calcific tendinopathy
- Arthritis
- Previous trauma to the joint (dislocation)
- Prolonged immobilisation (after surgery/previous injury)
- Thyroid disease
- Autoimmune disease
Adhesive capsulitis is more prevalent in:
- Women
- People between 40-65 years of age
- People who have had it before (5-34% chance of developing frozen shoulder of the opposite side)
Symptoms of Frozen Shoulder during the different phases
How bad is it?
Adhesive Capsulitis is a self-limiting condition, which means that it has no long term risks for your general health. It usually resolves just as spontaneously as it developed. In other words, we don’t know why you get it, how bad you will get it or how long you will take to recover. It can resolve as early as six months, or take as long as 3 years. The functional limitation that a frozen shoulder can place on your day to day functioning is frustrating, to say the least, this is where the team at Cilliers Swart Physiotherapy can help you.
Frozen Shoulder can be either:
Primary idiopathic – completely spontaneous without any previous injury/trauma
Secondary – usually occurs post-trauma (injury/surgery)
What we do know is that you lose what you don’t use. If you stop moving entirely to avoid pain, you won’t be able to move later because of stiffness. By consulting a physiotherapist, you can maintain your current movement and strength.
From the pathology of shoulder capsulitis you will experience:
- Constant pain that is worsened with a sudden movement. Small movements, like changing gears, can be just as painful as big movements, like reaching for a shelf.
- Pain is decreased with rest and heat application.
- Stiffness prevents you from moving initially and later fear of pain stops you from trying to move, this cycle needs to be broken as soon as possible.
- Muscular compensation patterns may cause neck pain and headaches and even referral down your arm and shoulderblade.
- There will be little visible swelling, because the inflammation is within the capsule, and no bruising.
Diagnosis of Frozen Shoulder
A Frozen shoulder can take up to 2 years to resolve, how well you recover depends entirely up to you. What function you’ll have by the end of the final stage is in your hands. Our treatment is focused at slowing down the destruction while keeping you active and safe without accelerating the damage to the capsule, joint and muscles. It’s hard to hear, but this too shall pass if you do your part – just let us do what we do best. Our physiotherapists understand the intricacies of the movement of your shoulder. There are many structures to test, and we even consider the complex biomechanics of your shoulder, neck and upper back movements. We can accurately diagnose your shoulder problem.
During your physiotherapy evaluation, we’ll be stretching & stressing the soft tissue structures like muscles, ligaments, nerves, tendons and the capsule. We will assess the joint range actively and passively, the joint surfaces and restrictions. This way we can address all the contributing factors.
X-ray
X-rays show bone, it is of little use if you suspect that the capsule causes the symptoms. The soft tissue of the capsule will not be visualized. X rays can give us valuable information regarding the joint space and surface.
MRI
All the tissues, soft and bone, will be visible with a MRI. It is a very costly procedure that needs to be ordered by a specialist.
Sonar (Diagnostic Ultrasound)
Sonar will show the soft tissue and capsule. This would be the first choice of image to get if we suspect your symptoms are caused by pathology to the capsule. Both shoulders can be compared, which is always useful.
How we test adhesive capsulitis
As physiotherapists, we can assess the shoulder in its entirety. Muscle power, nerve function, joint mobility and capsular end feel on movement. This is great to have a baseline to work from, and over time with treatment; you will be able to track your progress.
With a frozen shoulder the most critical sign we look for is a loss of both active (you moving your shoulder), and passive (physio moving your shoulder) movement with a tight end feel that causes your pain.
- Your movement will be less in:
- External rotation (upper arm turns out)
- Abduction (shoulder moves out)
- Internal rotation (upper arm turns in)
Why is my shoulder stiffness not going away?
Frozen Shoulder is an inflammatory condition, which means that you can expect flare-ups. You need to be Goldilocks and find the balance between too much and too little because both can prolong your recovery from adhesive capsulitis.
Repetitive, forceful movements to gain range can cause an increase in inflammation and worsening capsule stiffness. The stiffer the capsule the more restricted your shoulder movement.
Waiting it out and keeping your shoulder still is also not the answer, because if you don’t use it, you lose it. If you don’t use the muscles they can atrophy and become weak, the capsule loses its elasticity and the joint loses its lubrication. A planned approach is key to your recovery.
A big problem we see with frozen shoulders these days
Many other pathologies are wrongfully diagnosed as Frozen Shoulder. The loss of movement seems to blind healthcare practitioners, who then make the diagnosis without exploring other avenues. Rotator cuff tears or bursitis can have equally limited active movement due to pain or a muscle tear, but the passive movement won’t be restricted. Rather get the right diagnosis from a thorough assessment, and make treatment decisions based on the facts.
Forceful manipulation of your shoulder to tear adhesions is not the answer because the body will just react by increasing the inflammatory response. Tearing of any sort, even if it is an adhesion that is restricting movement is still a tear or injury and will be dealt with like any other injury.
A shoulder sling is not a long term solution. It may limit movement, even more, the inflammation in the capsule! Slings and braces can cause weakness that is difficult to recover from. Please use a sling or brace responsibly, considering the “side effects”.
Physiotherapy treatment for Frozen Shoulder
Shoulder stiffness, due to adhesive capsulitis, greatly impacts your day to day abilities, we understand this. First, we need to address your pain. And how your pain affects your every day activities. Are you able to get dressed, do your work, cook the dinner, play with the kids or participate in your sport? It is essential to understand what is happening inside of your joint so that you can adjust your habits to hasten the recovery, maintain your available movement and regain lost range of motion. We are experts where it comes to joints and healing. You can trust us to guide you through your recovery with evidence based treatment.
Phases of Rehabilitation for Frozen Shoulder
Freezing phase
Ice helps with pain management and swelling. When you are experiencing pain and swelling it is good to use cold therapy, like ice cubes wrapped in a towel, for about 10 minutes every two hours until the swelling subsides. Heat improves mobility by easing tension in the muscles around the shoulder joint. You can use a hot water bottle or bean bag for 20 minutes 3 times a day. Be sure to put a towel between the heat pack and your skin to avoid burning or blisters.
The aim is to maintain the available movement of your shoulder joint. We use joint and neurodynamic mobilizations to maintain the available range of movement. Strengthening of the stabilizing muscles around your shoulder joint is essential. Therefore, your physiotherapist will give you exercises to do at home to maintain strength.
Frozen phase
We monitor the progress of your pathology and track the fibrous tissue formation. On a cellular level, we’re able to influence collagen formation of the capsule with using Laser, Ultrasound and electrotherapy. If all direction of movements of your shoulder is painful, isometric contractions give you all the benefits of exercise, without any of the pain. An isometric contraction means that the muscles contracts, but the joint does not move. It may not feel like much, but the benefits are great. We use these muscle contractions to help with initial activation of the muscles around your shoulder. These muscle contractions are also great for pain relief.
Thawing phase
Now we need to regain the elasticity of your capsule. We will use joint mobilisation, myofascial release techniques, deep dry needling and stretches to restore the movement of your shoulder.
An eccentric muscle contraction means that the muscle is lengthening while it contracts. It usually involves a slow, controlled movement, like the tricep that lengthens when you lower your body down with a pushup. You don’t want strong muscles that cannot control a movement. These exercises will be added to your rehabilitation to allow you control over your shoulder movements. These type of exercises is vital at conditioning the muscle fibers to absorb a force. On completion of this phase you should be able to control loaded movement from your shoulder, like dips or wall push ups.
The kinetic chain refers to the muscles up- or downstairs from your shoulder that aid in control and stability when you use the shoulder. An imbalance may hinder your rehabilitation and therefore needs to be addressed. During this phase of rehabilitation, we will add exercises to strengthen your neck too. Poor neck posture can influence your shoulder’s position and therefore the way it moves.
Healing time for Frozen Shoulder
A frozen shoulder can take anything from two to nine months to heal. It can even take as long as three years to fully recover. Patience and perseverance is therefor extremely important to prevail.
Other medical management for Frozen Shoulder
Medication
Your GP may prescribe oral medication. Analgesics will aid in pain relief and anti inflammatories reduces inflammation. Steroids may also be prescribed to reduce inflammation. Because diabetes may predispose you to adhesive capsulitis, it is very important to not take long term steroids that can influence your blood sugar.
Injection
To stop the inflammatory process a corticosteroid injection into the joint may be considered. Steroid injection should be followed with physiotherapy to change the tissues while the pain is under control. Injection directly into the joint space can only be done three times within a 12 month period. Steroids that are delivered in such close proximity to tendons and ligaments, may influence their integrity, leading to greater elasticity and less stability.
Chiropractic treatment
Manipulation by a chiropractor may be considered to gain range of movement. Because manipulation is a forceful movement, injury to delicate structures can not be excluded. Manipulation is not a magic cure, you need to put in the hard work to maintain what was gained after treatment.
Biokinetics
Assessment and treatment form a biokineticist can be done once your pain is controlled. This will ensure compliance and keep you gaining movement and strength while your shoulder heals.
Surgery for Frozen Shoulder
Surgery will only be considered after a minimum of 6 months of conservative treatment. Capsular release of the rotator cuff and coracohumeral ligament can be done arthroscopically. This procedure has less risk of injury to other structures than manipulation under anesthesia. After surgery you will have to wear a sling for 6 weeks and progressively regain your strength and movement. The stronger you are before surgery, the better the outcome will be.
Many patients lose sight of the post op rehabilitation and believe that after the procedure everything will be fine. When instruments are used with a surgical interventionist causes a certain amount of “damage” . Care needs to be taken to allow these areas to heal too. To make surgery worthwhile, the money you spend and long recovery you sign up for, you really need to put the effort in for your rehabilitation. It can take up to three months to recover full range of motion and strength.
Another option is manipulation under anesthesia. While you are under the orthopedic surgeon will take advantage of the loss of reflex protective muscle spasm and tone to take your shoulder through full range of motion. The capsule will inevitably sustain small tears where it is too tight to allow the movement. It is especially important to put the time in with after care once again. You will need to progressively build your strength to maintain the range that the surgeon won for you during the procedure.
What else could the pain be?
OA of the shoulder joint is a degenerative disease that influence the articulating surfaces of the bone. A tell tale sign of OA is morning stiffness that gets better as you move. Diagnosis can be confirmed by X ray.
Inflammation of one or more of the bursa around the shoulder is very painful. Bursae are little fluid filled pockets between ligaments, tendon and bone. They lessen the friction between the structures. Inflammation lessens the available space and therefor causes pain. The passive movement will be less sore and not as limited as with adhesive capsulitis.
Parsonage-Turner Syndrome (PTS)
PTS is caused by inflammation of the brachial plexus, the nerves that supply the arm, after a traumatic injury. Symptoms resolve much quicker than with adhesive capsulitis. Neurological symptoms, that are not present with adhesive capsulitis, includes numbness and pins and needles.
Rotator Cuff Pathologies
Rotator cuff tendinopathy, inflammation and/or injury to the tendon also presents with a loss of external rotation and strength. Repetitive or new activities causes rotator cuff tendinopathy.
When the rotator cuff is pressed against the acromion by the humeral head during movement it is known as shoulder impingement. This is a symptom of shoulder pathology which leads to friction, inflammation and pain. It is common to have impingement symptoms with any shoulder injury.
