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Frozen shoulder

What is frozen shoulder?

Frozen shoulder typically presents as an extremely painful and irritable shoulder. It usually arises quickly and for no apparent reason. The “causal” movement may have been minimal or nothing at all. This condition changes over time from a painful predominant stage to a stiff predominant stage.

The physiological changes:

In the stiff predominant stage, a significant reduction in range of movement is observed. At a cellular level, frozen shoulder is now understood to be an immune response. Such a response involves increased inflammation, denser collagen (scaffolding of human tissue) and the formation of more contractile proteins. These changes lead to the contracture of certain ligaments in our shoulder and the shoulder capsule.

This disease process starts in the top/front aspect of the shoulder. Anatomically, this involves the coracohumeral and superior glenohumeral ligament, the biceps tendon, and anterior joint capsule. 

Types of frozen shoulder: 

  1. Primary: no apparent cause, see the risk factors below.
  2. Secondary: after trauma/shoulder injury, brain and heart surgery or immobilisation of the shoulder for prolonged periods. 

How common is frozen shoulder? 

  • 2-5% of the general population.
  • Peak age for onset is mid 50’s. 

Early symptoms of frozen shoulder may include the following:

  • Background dull pain in the deltoid region.
  • Eye-watering pain on sudden movements. 
  • Severe night pain with frequent waking.
  • Difficult finding position of comfort for the shoulder. 

What are the risk factors?

People with certain other co-morbidities are more likely to develop frozen shoulder. In particular, 10-20% of people with diabetes develop frozen shoulder and those with thyroid dysfunction or cardiovascular disease are also at an increased likelihood. Additional possible contributing factors include:

  • Depression & psychosocial stress.
  • Fear avoidance and negative pain beliefs. 
  • Obesity. 
  • Medication for epilepsy or gastric cancer.  
  • Genetic predisposition. 
  • High cholesterol. 
  • Lack of exercise with arm movements in all directions.  
  • Perimenopause.

Previously, researchers thought frozen shoulder consisted of 3 phases:

  1. Freezing: 4-9 months (a painful and gradual loss of movement). 
  2. Frozen/stiff: 4 months -no longer than 1 year (extremely limited shoulder range of movement). 
  3. Thawed: 4 months 2yrs+ (slow increase in range of movement). 

It is currently thought that these painful/stiff phases overlap each other.

Diagnosis of frozen shoulder: 

  • The most common signs are a loss of active and passive external rotation. (Active movement is when you move your arm and passive movement is when someone else moves your arm for you). This loss will be > 50% of your usual range.
  • Other shoulder movements can also be affected. These include abduction (side raise), internal rotation (inward rotation) and flexion (forward raise).

Prognosis/management of frozen shoulder:

The good news is that frozen shoulder is self limiting. This means that a large number of patients can get better with intervention within 1-2 years. A good time to seek Physiotherapy intervention is when your pain is more manageable. Book in to see your GP to discuss when it’s most appropriate for you to commence treatment. 

Recent evidence suggests an early  injection of corticosteroid or hydrodilation is favourable for effective short term pain relief. In addition, these interventions are thought to down regulate the disease process and may reduce the length of the disease. 

What does Physiotherapy management involve?

  • Education to improve the patient’s understanding of the condition and any functional impacts.
  • Implementing strategies to reduce the impact of the condition and optimise function.
  • Encouragement of earlier movement.
  • Pain free strengthening (especially the Rotator Cuff) to enhance recovery when tolerable.

What about surgical intervention?

Patients who do not get better with conservative treatment can undergo surgery to “release” the shoulder joint. Surgery is not recommended until >1 year after symptoms and does come with its own set of risks. 

This blog is not a substitute for professional medical advice. It should be used in conjunction with verbal information and treatment given by your health/medical professional.

Lucy Bowden
Physiotherapist

References:

  • Cavalleri, E., Servadio, A., Berardi, A., Tofani, M., & Galeoto, G. (2020). The Effectiveness of Physiotherapy in Idiopathic or Primary Frozen Shoulder: a Systematic Review and Meta-Analysis. Muscle Ligaments And Tendons Journal, 10(01), 24. doi: 10.32098/mltj.01.2020.04
  • Cucchi, D., Marmotti, A., De Giorgi, S., Costa, A., D’Apolito, R., & Conca, M. et al. (2017). Risk Factors for Shoulder Stiffness: Current Concepts. Joints, 05(04), 217-223. doi: 10.1055/s-0037-1608951
  • Kwaees, A., & Charalambous, P. (2014). Surgical and non-surgical treatment of frozen shoulder. Survey on surgeons treatment preferences. Muscles, Ligaments And Tendons Journal. doi: 10.11138/mltj/2014.4.4.42
  • Maund, E., Craig, D., Suekarran, S., Neilson, A., Wright, K., & Brealey, S. et al. (2021). Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Retrieved 13 December 2021
  • Rangan, A., Hanchard, N., & McDaid, C. (2016). What is the most effective treatment for frozen shoulder?. BMJ, i4162. doi: 10.1136/bmj.i4162
  • Ryan, V., Brown, H., Minns Lowe, C., & Lewis, J. (2016). The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review. BMC Musculoskeletal Disorders, 17(1). doi: 10.1186/s12891-016-1190-9

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