Frozen shoulder is one of the musculoskeletal conditions that affect people that are beyond 40 years of age. It is estimated that 2 to 5% of adults will develop a frozen shoulder in their lifetime. (1)
A frozen shoulder limits movements both in passive and active range of motions. Mostly, it affects only one shoulder and may get better on its own, but can last for years. In this article, we will be discussing this fairly common condition in details.
What is a frozen shoulder?
Frozen shoulder is also known as adhesive capsulitis. It is a condition in which the shoulder joint loses a significant amount of its range of motion because of scarring. The range of motion is not only limited to when an individual tries to move the joint, but also when an expert attempts moving the joint when the individual is at rest. Other than limited mobility, a frozen shoulder is also characterized by stiffness and pain.
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What causes a frozen shoulder?
To best understand how a frozen shoulder occurs, let us first look at the normal anatomy of the shoulder joint.
The shoulder is the most mobile joint of the human body. (2) It is composed of bones that connect the humerus to the axial skeleton (trunk). These bones are two, the scapula and clavicle. Both of them make up the shoulder girdle.
Four rotator cuff muscles attach to the scapula and are responsible for the mobility and stability of the upper arm. The upper end of the humerus fits into the socket of the scapula to form a ball and socket joint. The joint is then surrounded by a fibrous membrane known as the joint capsule.
The bones, ligaments, muscles, and tendons allow the upper arm to rotate 180 degrees in three different directions, thus enabling the arm to perform a versatile range of activities. The unfortunate bit is that this impressive mobility comes at a cost: it makes the shoulder prone to injury.
Any injury to the shoulder can cause inflammation, scarring, thickening and shrinkage of the normal tissue surrounding the shoulder, leading to frozen shoulder. (3) The tissue then becomes thick and tight, and eventually, the shoulder joint does not have enough space to rotate properly.
Some of the injuries that can lead to a frozen shoulder include
- Rotator cuff trauma– the rotator cuff is a group of muscles, tendons, and ligaments that surround the shoulder joint, to keep it firm within the socket of the scapula bone. A rotator cuff injury can be as a result of irritation or overuse of the muscles or tendons(such as in sports and occupations like painting), aging and deterioration of the cuff. (4)
- Tendinitis– is due to inflammation of a tendon, overuse, infections or rheumatoid disease. (5)
- Bursitis affects the small, fluid-filled sacs that cushion the shoulder joint. Bursitis can occur as a result of injury or strain of the shoulder, trauma from a fall or an underlying rheumatoid condition. (6)
Who is at a higher risk of developing frozen shoulder?
Frozen shoulders occur more frequently in: (7)
- Ages between 40 and 60
- Female gender
- Some conditions such as diabetes, hormonal imbalance or a weakened immune system, make the joints prone to inflammation.
- Injury or surgery (especially breast and chest) make the shoulder more vulnerable to inflammation, or the tissue may heal with adhesions.
- Long periods of inactivity
- Systemic diseases such as hypo or hyperthyroidism, cardiovascular diseases, stroke and neurodegenerative conditions.
What are the signs and symptoms of a frozen shoulder?
Most people become aware that there is a problem with the shoulder when it starts to hurt and movement is limited. After some time, the tenderness may resolve, but a limited range of motion persists. Before long, reaching out for an item or simple activities like dressing become difficult. Other signs include swelling and stiffness.
Generally, there are three stages of frozen shoulder, each with its duration and presenting symptoms. (8)
The freezing stage is the first stage, and it lasts two to nine months. In this stage, the shoulder starts to ache and feels stiff. The pain worsens at night especially when one lies on the affected side.
The component of pain substantially reduces but stiffness increases. It lasts for 4 to 14 months.
Continues for about 5 to 24 months and constitutes of gradual relief and recovery of motions. That means that movement becomes easier and may eventually return to normal. However, pain may occasionally recur.
How is a frozen shoulder diagnosed?
Clinicians rely on history taking, physical examination, and a few tests to make a diagnosis of a frozen shoulder. In history taking, the doctor is usually interested in knowing how the pain started, when it started, whether there was any trauma or if there are other underlying medical conditions that may cause the pain.
A physical examination allows the doctor to assess for movements and to determine whether the pain could be referred from the neck. For the shoulder specifically, the healthcare provider inspects to look out for external scars, deltoid wasting, bony landmarks, and alignment. (9) Next, they palpate to assess the range of motion using four key movements: (10)
- Flexion– the patient moves the arm anywhere from the resting position to straight above the head
- Extension– the patient moves the arm and sticks it right behind
- Internal rotation– the examiner lifts the arm passively away from the back and asks the patient to maintain the position.
- External rotation– the elbow is bent at 90 degrees then forearm is swung away from the body, such as when opening a cabinet door.
Other practitioners also assess for adduction and abduction movements.
Tests that may be necessary include (11)
X-rays are one of the simplest tests to confirm a diagnosis of a frozen shoulder, to rule out the possibility of arthritis, fractures, and dislocations of the shoulder joint.
An arthrography may be done if a standard X-ray does not show the required details of the joint structure and function. A long, thin needle is inserted into the joint to deliver a contrast dye. A series of X-rays are then taken with the shoulder joints in various positions. An arthrography will demonstrate the characteristic shrunken and tight capsule of a frozen shoulder.
Magnetic Resonance Imaging (MRI) provides a detailed image of the shoulder. It can detect minute changes like microscopic tears of the rotator cuff. An MRI is also very reliable when there is a need to evaluate the bulk and quality of rotator cuff muscles and to detect tumors.
Laboratory tests are not mandatory, but they are necessary for excluding other conditions. The doctor may order immunological studies to rule out autoimmune disorders, erythrocyte sedimentation rate (ESR) and rheumatoid factor (RF), to exclude rheumatoid arthritis. (12)
How is it treated?
If not treated, the pain of a frozen shoulder can remain for years and at times remain permanent. It is therefore best to find out the best management approach to speed up the healing process and treat the underlying causes. A combination of physical therapy, medications, possible surgery and home remedies has the highest successful treatment chances. These treatment approaches aim at controlling shoulder pain and preserving as much motion ability of the shoulder as possible.
Physical therapy is the cornerstone of recovering from a frozen shoulder. It aims at performing stretching exercises that make the shoulder regain its lost motion. It also includes electric simulation, strength exercises, heat and cold compressions. Physical therapy sessions may take a few weeks to months before seeing progress, depending on the severity of scarring of the tissues. (13)
A physical therapist first assesses the level of activity that one can withstand then comes up with a regimen to be followed. Once some range of motion is achieved, the therapist can then prescribe home exercises. A critical thing to note about exercise is that it should be done correctly, in the right form and done to the point of tension but not pain. Also, always warm up the shoulder before exercise by taking a warm shower for ten to fifteen minutes, use a moist heating pad or a warm dampened towel.
Anti-inflammatory medications such as ibuprofen, aspirin, diclofenac, and naproxen are prescribed to combat inflammation as well as pain. The drawback of some of these anti-inflammatory drugs is that they predispose one to damage of the gastrointestinal tract. An alternative for long-term use is acetaminophen. It is safe even when used for a prolonged period, so long as the recommended dose is adhered to.
Cortisone medications can be given either orally or as injections into the joint. (14) They provide pain relief for several weeks or up to a few months. These medications work by suppressing immune responses, thereby reducing inflammation. (15) Oral pills such as prednisolone may cause widespread side effects, and therefore, injections are preferred.
A surgical intervention is usually the last resort if conservative treatment is not effective or is not an option. It is typically done in the second (frozen) stage to stretch and release the constricted joint capsule. The most common surgical interventions include arthroscopy and manipulation under anesthesia.
Arthroscopic surgery uses an instrument known as an arthroscope to remove or release scar tissue. The surgeon makes two to three small incisions on the shoulder then using a special radiofrequency thermal probe, cuts the abnormal capsule tissue. (16)
Manipulation under anesthesia is indicated for simple frozen shoulders as it does not involve any incisions. The procedure is performed when the patient is sedated. The surgeon then moves the shoulder through motions that force the capsule and scar tissue to stretch. (17)
After surgery, physical therapy follows to ensure that the shoulder regains its normal function. Most of the patients regain full range of motion in 3 to 6 months.
Heat compressions or cold packs on the shoulder for 10 to 15 minutes three to four times a day are some of the most natural home treatments for joint problems. Heat causes vasodilation, thus bringing more blood supply to the affected area. It also reduces joint stiffness, swelling and relaxes muscle spasms. A warm towel, heating pad, or warm water bottle can be used.
Cold packs ease pain and swelling by numbing the affected area and reducing inflammation. (18) One can use ice put in a sealable bag then covered with a cloth, or the pack can be improvised by dampening a towel with cold water, place it in a sealable bag then put in the freezer for 15 minutes.
To avoid burns and other soft tissue injuries, do not place the heating pads and ice packs directly over the skin. Precaution should be taken especially if there is nerve damage in conditions like diabetes.
Gentle stretch exercises may be done at home to get the shoulder progressively moving. They go a long way in preserving shoulder comfort and range of movement. Be sure to always warm up before doing any exercise.
Some of the stretches for a frozen shoulder include
- Pendulum stretch– begin by relaxing the shoulders then lean over slightly. Allow the affected arm to hang down freely then swing it in a small circle. Repeat ten times on each side, once a day.
- Towel stretch– get a small towel about 3ft long. Hold the towel on the back in a horizontal position then use the unaffected arm to stretch it upwards. Repeat 15 to 20 times a day.
- Armpit stretch– place the affected arm on a shelf that is breast-high then slightly bend the knees to open up the armpit, and to come to a slight squat position then straighten. Repeat up to 20 times once a day.
- Cross-body reach– when seated or standing, use the unaffected arm to lift the other one at the elbow then bring it across the body and hold for 15 to 20 seconds. Do it 15 to 20 times a day.
Can it be prevented?
Having a frozen shoulder is comparable to having an engine that won’t start or one that does not start up quickly. Although there is nothing can be done about some of the causes and risk factors of a frozen shoulder, there are some measures that one can put in place to prevent long-term complications and injuries. Here are some simple tips to dramatically reduce the chances of developing a frozen shoulder.
- Always seek early treatment after an injury
- Avoiding repeat injuries by using the right lifting techniques and protective gear during sports
- Regular, guided exercise regimen that involves stretch and strength workouts targeted at the shoulder and spine.
- If diabetic, keep blood sugars in control
- Include vitamin D, calcium and friendly bacteria in the diet. It will strengthen the bones and decrease the risk of autoimmunity problems.