What is a Frozen Shoulder?

Mike Darnell, PT

October 2009

The term “frozen shoulder” is one that is familiar to many people.  Just as the name suggests, the shoulder becomes stiff and very difficult to move.  The correct medical name is adhesive capsulitis.  However, not all shoulders that are stiff and difficult to move are “frozen” or more correctly identified, adhesive capsulitis.  The process whereby a shoulder becomes frozen is partly inflammatory in addition to scar tissue (fibrosis) build-up.  The cause of this process remains unknown.  People who are more likely to develop a frozen shoulder are individuals over age 40 and usually women who have had a known traumatic event such as a fall that injures the arm or shoulder complex.  Many times the injury goes through the usual time cycle of pain and stiffness and then seemingly recovers only to become frozen at a later time.  Also, people with diabetes, hypothyroidism, or a history of stroke or myocardial infarction are more likely to develop a frozen shoulder.  Recent DNA research suggests that genetics is likely responsible for the development of a frozen shoulder with certain individuals.  It is believed that degenerative joint processes, especially where the collar bone forms a joint with the upper portion of the shoulder blade, produce a local irritation of the underlying supraspinatus tendon.  In response to the irritation, the body produces antibodies that begin to affect adjacent tendons causing them to “stick” to the outer covering of the joint.  This outer layer, much like a loose golf ball covering, is called the capsule.  This autoimmune reaction produces an irritation to the capsule thus causing the shoulder to be painful and stiff.    

 There are two types of frozen shoulder.  Primary adhesive capsulitis is considered that type which does not have a clear cause and is most likely due to a metabolic disorder previously mentioned such as diabetes, hypothyroidism, or autoimmune disorders.  Secondary adhesive capsulitis has a more obvious cause such as previous trauma or underlying pathology of the joints, muscles, and tendons of the shoulder.  These pathologies, especially if painful, will cause the person to avoid moving their shoulder thus causing the freezing process to begin.  Both types of frozen shoulder result in essentially the same tissue changes.  Either type progresses through a well known course of 4 distinct though overlapping stages.

 Stage 1 consists of the first 3 months of the disease.  Pain is predominant and the individual begins to limit the use of their shoulder and extremity.  Stage 2 is called the freezing phase and occurs from 3 to 9 months of the disease.  Pain is persistent as is progressive loss of shoulder motion.  Tissue biopsy at this time is distinct and different from Stages 1, 3, or 4.  Stage 3, which is also called the frozen phase, occurs from 9 to 14 months and is marked by a reduction in pain but significant loss of motion.  Stage 4 is called the thawing phase and is characterized by a slow, steady recovery of motion.  So in essence, a frozen shoulder is a self-limiting disease which means that it will typically get better on its own despite what you do.   However, studies have shown that individuals who seek treatment within 1 month of symptom onset recover in an average of 1.5 months, whereas individuals who seek treatment from 2-5 months following the onset of symptoms take an average of 8.1 months to recover.  Those individuals delaying treatment for 6 to 12 months after the onset of symptoms require an average of 14 months to recover.  This clearly makes the case for early detection and treatment.  Early interventions that expedite recovery include a steroid injection, physical therapy, and a home exercise program. 

Treatment by a physical therapist who is well trained in manual techniques is very important.  The therapist needs to understand the 4 stages of frozen shoulder and be able to identify which stage the individual may be in at any given moment in time.  Occasionally, more aggressive measures may be required such as a manipulation under anesthesia or release of scar tissue through arthroscopic surgery.  Following these less conservative measures, physical therapy is vital to the patient’s recovery of motion.

Self-care activities during Stage 1 and 2 include routine movement of the shoulder in a pain free manner such as with the use of a pulley system; achieving and maintaining good posture; and positioning of the arm for comfort.  Self-care activities during Stage 3 and 4 include low-load long duration stretching.  Depending on the stage of the frozen shoulder, stretching that is too forceful may actually worsen the condition.  Stretching and strengthening must be performed properly.  “No Pain…No Gain” is a refrain that has its place in physical therapy but at times too much pain may be a warning signal that too much force is being applied.

People with rotator cuff tears or other conditions that require surgical intervention should discuss any stiffness of their shoulder with their physician prior to surgery.  Surgical repair to a shoulder that is frozen, especially in Stage 2, may cause the post-surgical rehab process to be more painful and lengthy when compared to just a tear without a frozen shoulder component.

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