Frozen Shoulder (Adhesive Capsulitis)

What is Frozen Shoulder? (Adhesive Capsulitis)

A man is in distress after experiences shoulder stiffness aka “Frozen Shoulder in his right arm.

Is frozen shoulder a result of icing your shoulder too long or spending too much time in a walk-in freezer? Nope!

Woman performing exercises to strengthen her shoulder

Frozen shoulder or adhesive capsulitis is a progressive inflammatory process that occurs at structures of the shoulder joint (glenohumeral joint) including the joint capsule and surrounding ligaments. This inflammatory process leads to characteristic swelling and stiffening of the joint capsule and ligaments which leads to pain and reduced mobility. The most common findings are synovial inflammation, capsular fibrosis (scarring), and thickening of structures (such as extra-capsular ligaments).

The inflammatory process is spontaneous in nature and thus does not involve any sort of trauma to the shoulder joint. This spontaneous nature is what we call primary (1°) or idiopathic frozen shoulder. Individuals who experience a shoulder injury such as a rotator cuff pathology or a tendinopathy can later develop frozen shoulder, and this is called secondary (2°) frozen shoulder. For clarity, these injuries do not cause the inflammatory process associated with frozen shoulder.

How does it happen?

While we understand that it is an inflammatory process, it is not quite understood why it happens, or rather what causes the process to begin.

Who is more at risk?

The current literature is inconsistent in terms of biological sex and the likelihood of frozen shoulder. Most articles suggest that females are at a greater risk than males, while others suggest the opposite. Nonetheless, most articles agree that frozen shoulder is commonly found within the age-range of 40-60. Individuals living with obesity, diabetes mellitus, or thyroid dysfunction are also at a greater risk of frozen shoulder.

Signs and Symptoms

The most common signs and symptoms include

-       Pain (can be dull and diffuse around the shoulder joint)

-       Night pain or pain sleeping on the shoulder

-       Decreased active and passive range of motion (ROM)

-       Stiffness

-       Muscle atrophy (leading to muscle weakness)

-       Loss of shoulder ROM in a capsular pattern (external rotation > abduction > internal rotation)

Timelines

With respect to timelines, a recently published article suggests that most cases (~90%) of frozen shoulder can be treated successfully within 1-1.5 years. While in some cases it can take up to 3.5 years.

With frozen shoulder, since it is a progressive condition that changes over time, 3 stages, sometimes 4, have been used to describe the progression. The timelines of each stage tend to differ, but the clinical presentations remain the same. They are as follows:

1)    Pre-freezing (0-3 months) – Some pain and loss of ROM (this stage is not present in all literature)

2)    Freezing (3-9 months/2-6 months) – Mostly pain and some loss of ROM at end range

3)    Frozen (9-15 months/ 4-12 months) - STIFFNESS, serious loss of ROM and some pain

4)    Thawing (12-42 months/ 6-26 months) ROM improving, minimal pain

PT Approach

Demonstration of mobility following the PT approach for frozen shoulder

Physiotherapy (PT), with its focus on therapeutic exercise, is part of the conservative approach to treatment of frozen shoulder and continues to be widely used. Other forms of treatment such as cortisone injections are common but are recommended in conjunction with a home-exercise program.

PT can be involved at all stages of the frozen shoulder progression with the following goals:

Stage 1 (Pre-freezing) – Pain management

Stage 2 (Freezing) – Pain management and prevent loss of ROM (prevent thickening)

Stage 3 (Frozen) – Improve ROM, manage pain

Stage 4 (Thawing) – Restore ROM and function

With the earlier stages, it recommended to manage pain and focus on end-range ROM. Less aggressive manual therapy techniques are typically indicated, especially when pain is predominant. The natural progression for restoring range of motion is active-assisted ROM, active ROM (AROM), and lastly AROM with resistance. For improving acute ROM, emphasis on scapular mobilization and gentle posterior mobilizations are encouraged.

Exercises

Try these exercises/modalities to try and help with each stage:

-       Heat (stage 1 and 2)

-       Pendulum swinging (stage 1 and 2)

-       Ball wall walks (stage 1 and 2)

-       Pulley-assisted shoulder flexion (stage 3)

-       Dowel-assisted external rotation (ER), abduction, & internal rotation (IR) (stage 3)

-       Banded ER, Abduction, and IR (stage 4)

-       Banded Y’s, T’s, W’s (stage 4)

A physiotherapist demonstrating shoulder exercises

Author: Matthew Vandervoort