Is frozen shoulder a result of icing your shoulder too long or spending too much time in a walk-in freezer? NOPE!
Frozen shoulder or adhesive capsulitis is a progressive inflammatory process that occurs at the 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 and thus does not involve any 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, 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 & Symptoms:
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)
Muscle atrophy (leading to muscle weakness)
Loss of shoulder ROM in a capsular pattern (external rotation > abduction > internal rotation)
Timelines of Progression & Healing
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.
Since frozen shoulder 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:
Pre-freezing (0-3 months) – Some pain and loss of ROM (this stage is not present in all literature)
Freezing (3-9 months/2-6 months) – Mostly pain and some loss of ROM at the end range
Frozen (9-15 months/ 4-12 months) - STIFFNESS, serious loss of ROM and some pain
Thawing (12-42 months/ 6-26 months) ROM improving, minimal pain
The Physiotherapy (PT) Approach
Physiotherapy, with its focus on therapeutic exercise, is part of the conservative approach to the 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 is recommended to manage pain and focus on the 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.
Try these exercises/modalities to help with each stage
Stages 1 and 2 Exercises:
Ball wall walks
Stage 3 Exercises
Pulley-assisted shoulder flexion
Dowel-assisted external rotation (ER), abduction, & internal rotation (IR)
Stage 4 Exercises
Banded ER, Abduction, and IR
Banded Y’s, T’s, W’s