Frozen Shoulder

How does it typically present?

Pain and marked restriction of shoulder movement. In the first stage there is mainly pain; later there is marked restriction of movement.

The restricted movement causes:

• marked difficulty with all shoulder movements
• and typical pain at night

What is frozen shoulder?

It is a disease of the joint capsule – the envelope of the shoulder joint (see the article on anatomy). This is the tissue that wraps around the shoulder joint. Normally it is thin, flexible tissue (like Lycra fabric). For an unknown reason, the tissue's structure changes and it turns:

• from thin, flexible tissue → into thickened, stiff tissue

The first part of the process is inflammatory and causes pain, which lasts several weeks. Later the pain eases, and once the capsule becomes stiff the main problem is restricted movement.

Usually the process happens without any connection to an injury or trauma to the shoulder, but the same process sometimes appears:

• after shoulder operations, mainly those involving the joint capsule
• or after shoulder fractures

The stages of the disease

The disease has three stages:

1. The freezing stage: characterized by pain with increasing restriction of movement. This stage lasts several weeks.
2. The frozen stage: characterized mainly by restricted movement, but also by pain, mainly when trying to move. This stage lasts several months, usually 8–9. This is the stage at which people usually come to see a doctor.
3. The thawing stage: movement gradually improves until an almost full range of motion returns. This stage also lasts from several months up to two years.

Usually, at the end of the thawing period the shoulder returns to normal. The process does not recur in the same shoulder, but it can appear in the other shoulder.

How is frozen shoulder diagnosed?

No imaging test can confirm the diagnosis, although an MRI can show findings of a thickened capsule. Several conditions are needed to diagnose frozen shoulder:

There must be restriction of movement in every direction, including:

• raising the arm forward and to the side
• moving the hand behind the back
• external rotation of the arm with the arm held against the body

The restriction is:

• active (movements performed by the patient)
• and also passive (movements performed by the examiner)
• and the restriction is similar in both

There must be no background of a known shoulder problem, such as:

• a chronic illness
• paralysis
• a shoulder fracture
• or an operation in the shoulder region, for example surgery in the armpit or chest

An X-ray must rule out another cause of the restricted movement, such as:

• wear of the cartilage
• deformity of the joint

Usually further tests such as ultrasound or MRI are not needed, except in unusual cases.

How is frozen shoulder treated?

Frozen shoulder is a condition that resolves on its own and does not require treatment. Beyond that, the various treatments given while the shoulder is in the frozen stage simply do not help: not medication, not injections, not physiotherapy and not any alternative treatment!

Treatment in the frozen stage is intended only to relieve pain, and will not make the shoulder release any sooner. Treatment includes:

• local heat
• and pain medication

As far as possible, avoid movements that push into the point where the shoulder blocks, because that is what causes the pain. There is no reason to avoid normal activity within the range you have. Accept the shoulder's limits and keep your activities within that range.

In the frozen stage there is no place for physiotherapy treatment. There is no need to fear that the shoulder will waste away.

When the release (thawing) stage begins, the patient will feel a gradual improvement in daily function:

• it becomes easier to comb your hair or shave
• easier to get dressed and to eat
• and so on.

Only at this stage, when the patient feels an improvement, is there a place for physiotherapy to improve shoulder function. The improvement is very slow, over months up to a year from the start of the release stage.

In most cases – more than 95% – the shoulder recovers and no intervention of any kind is needed!

Unusual cases

In unusual cases the restriction can last for a long time, beyond a year. In such cases arthroscopic surgery to release the capsule should be considered. Most often these are patients with juvenile diabetes, but it can also occur in healthy patients.