Adhesive Capsulitis, or Frozen Shoulder, results in shoulder stiffness, restricted movement, and intense pain, particularly at night(7). Its exact cause remains uncertain, though inflammation leading to scar tissue formation in the joint capsule is suspected(18).
While typically self-resolving over years, appropriate treatment can expedite relief. A meta-analysis revealed that manual therapy combined with exercise effectively addresses Frozen Shoulder(19).
Article Index:
Introduction
Diagnosis
Treatment
Exercises
Exercises for Frozen Shoulder
Conclusion & References
Causes
The causes of Frozen Shoulder remain a mystery, leaving patients frustrated and confused. Researchers have categorized Frozen Shoulder into primary and secondary types based on the condition's origin (7).
Primary & Secondary Frozen Shoulder:
This type of Frozen Shoulder has an unknown cause and is often called idiopathic.
Secondary Frozen Shoulder: This type of Frozen Shoulder results from a suspected cause or surgical incident.
Risk Factors
Several risk factors have been associated with Secondary Frozen Shoulder, including:
Smoking
Extended periods of immobilization
Trauma, injury, or previous surgery to the shoulder
Diabetes, lung disease, heart disease, hyperthyroidism, and Parkinson's disease
It is important to note that smoking increases the risk of rotator cuff pathologies and shoulder dysfunctions in general (8).
Shoulder Joint Anatomy
The shoulder joint, or glenohumeral joint, is intricate, with the ball of the upper arm bone (humerus) fitting into the socket (glenoid fossa) of the shoulder blade (scapula)(3). This joint is encased in a ligamentous capsule filled with synovial fluid, ensuring fluid motion(20). The fluid, secreted by joint linings, aids in lubrication.
While the glenohumeral capsule is relatively delicate, the surrounding rotator cuff muscles enhance stability(10). The fascia within these muscles further stabilizes the shoulder. Collectively, the shoulder's components, including its ligamentous and articular capsules, synovial fluid, rotator cuff muscles, and fascia, ensure both stability and efficient movement.
In the glenohumeral joint movement, the subscapularis muscle, part of the rotator cuff, wraps around the coracoid process of the scapula, mitigating friction on the humeral head and ensuring shoulder stability(27). Alongside the subscapularis, the subscapular fascia and subcoracoid bursae also diminish friction during shoulder motion, further enhancing stability and reducing injury risk(27).
Physiological Changes
Physiological changes that occur during the development of a Frozen Shoulder have been well-documented in current literature (2). The following changes take place during this process:
Inflammation and thickening of the capsule surrounding the shoulder joint
Extreme rigidity of the capsule
Decreased synovial fluid levels within the capsule
Contraction of the joint capsule
The inflammation and contraction of the capsule lead to less space for the humerus (upper arm bone) to move around, resulting in pain, stiffness, and loss of motion in the shoulder (7).
Patients with Frozen Shoulder typically experience difficulty with two ranges of motion, primarily shoulder abduction and external rotation (7).
In summary, the development of a Frozen Shoulder involves a combination of inflammation, thickening, and contraction of the capsule surrounding the shoulder joint. These changes result in decreased synovial fluid levels and less space for the humerus to move around, leading to pain, stiffness, and loss of motion in the shoulder.
Three Phases of Frozen Shoulder
The development of Frozen Shoulder is typically divided into three phases that last several months, as supported by current literature (19). These phases include:
Painful or Freezing Phase (2-9 months): This phase is characterized by pain with any movement and a decrease in the patient's range of motion.
Adhesion Phase (4-12 months): During this phase, the level of pain decreases, but the shoulder's range of motion substantially decreases. This reduction is due to the thickening of the joint capsule with excessive collagen, making daily activities challenging to perform.
Thawing or Resolution Phase (5-26 months): During this phase, the patient's pain decreases, and their range of motion begins to increase.
It is worth noting that while these are the classical phases of Frozen Shoulder, with the right program of therapy, exercise, and possible medication/injections, the duration and intensity of these phases can be greatly reduced (7).
Frozen Shoulder Examination
Several factors should be considered to examine a patient presenting with Frozen Shoulder effectively. The following steps are typically taken to evaluate such patients:
Check active and passive ranges of motion in the shoulder, cervical spine, and thoracic region. This step helps identify any limitations in the patient's range of motion, a common symptom of a Frozen Shoulder.
Check rib mobility, especially the first rib. Limited rib mobility can cause shoulder and neck pain and may contribute to Frozen Shoulder symptoms.
Check External Rotation of the shoulder: Testing the external rotation bilaterally can reveal a positive test when the affected side has a 50% or greater loss of rotation compared to the good side or less than 30 degrees of external rotation. This finding is common in patients with Frozen Shoulder.
Verify if at least two other ROM planes are reduced by at least 25% compared to the other side. For example, testing the shoulder in abduction and flexion can help identify other planes of reduced range of motion.
Check for active muscle guarding using the Coracoid Pain Test. This test involves applying digital pressure on the area of the coracoid process to determine if there is localized pain, a common symptom of a Frozen Shoulder (12).
The following videos demonstrate the orthopedic, neurological, and vascular testing that should be performed during an examination of a Frozen Shoulder:
Frozen Shoulder Testing
This video demonstrates some of the typical orthopedic examination procedures used to evaluate a patient with Frozen Shoulder.
Shoulder Examination - Orthopaedic Testing
This video utilizes orthopedic examination procedures to diagnose common causes of shoulder pain, including Frozen Shoulder, and explains the evaluation process.
Upper Limb Neuro Exam
The upper limb neurological examination is a critical component of the overall neurological evaluation that assesses the motor and sensory neurons that supply the upper limbs. This examination is crucial in detecting any nervous system impairment.
Peripheral Vascular Examination - Key Points
Performing a peripheral vascular examination is crucial to rule out signs of vascular-related pathology. It can help to mitigate potential cardiovascular and cerebrovascular complications through early detection and treatment. This video highlights some commonly performed procedures in daily clinical practice for assessing peripheral vascular health.
Checking all the Shoulder Joints
In addition to standard orthopedic and neurological testing, evaluating the mobility of all four shoulder joints is important. The following are the recommended procedures for checking the mobility of each joint: (7)
Sternoclavicular (SC) Joint - Check for elevation of 45°, depression of 5°, protraction of 15°, retraction of 15°, and axial rotation. A fused SC joint limits all shoulder motions.
Scapulothoracic Joint (ST) - Check for motion between the scapulae and the rib cage. The scapulae should be able to elevate, depress, protract, and retract over the rib cage, and there must also be upward and downward rotation in the glenoid fossa.
Acromioclavicular (AC) Joint - The acromioclavicular joint allows for a degree of axial rotation and anteroposterior movement. There should be a total glide and rotation of 20-30° with accompanying shoulder joint motions.
Glenohumeral (GH) Joint - In cases of Frozen Shoulder, the Glenohumeral joint is typically most limited in the anterior and inferior capsular region. The Glenohumeral joint should not be limited in all three planes of motion.
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Diagnostic Imaging
Your healthcare provider may order X-rays to rule out any associated or pathological conditions. In cases of Frozen Shoulder, it is recommended that patients undergo plain radiography imaging. This imaging can help rule out infections, metastatic processes, large areas of calcification, avascular necrosis of the humeral head, or charcot joints.
It is also important to note that patients who smoke or have a smoking history should undergo a chest X-ray with apical views to rule out a Pancoast Tumor. This type of tumor can irritate the brachial plexus, potentially causing Frozen Shoulder-like symptoms.
In summary, X-ray imaging can be an essential tool for identifying underlying conditions related to Frozen Shoulder, particularly in patients with a smoking history or other risk factors.
Differential Diagnosis
When diagnosing a Frozen Shoulder, practitioners must consider several other conditions that can present with similar symptoms. These other conditions should be considered in the differential diagnosis (15), and may include:
Bursitis: Patients with bursitis will exhibit an increased passive range of motion (PROM) compared to Frozen Shoulder. Both syndromes will be very painful during the initial stages.
Osteoarthritis: As with Frozen Shoulder, abduction and external rotation will be limited in active range of motion (AROM). However, PROM will not be limited to cases of osteoarthritis.
Rotator Cuff Syndrome: Symptoms of Rotator Cuff Syndrome can be very similar to Frozen Shoulder. In some cases, MRI or ultrasound may be necessary to differentiate between the two syndromes.
It is important for healthcare providers to differentiate between these conditions to ensure proper treatment is provided. While the symptoms may appear similar, proper diagnosis can lead to more effective management of the patient's condition.
Frozen Shoulder Treatment
Manual therapy and exercise are primary treatments for all Frozen Shoulder phases, backed by significant research(19). The goal is to alleviate pain, enhance mobility, and improve daily life activities. Treatment and exercise specifics might differ based on the Frozen Shoulder's stage.
Different manual therapy techniques suit individual patient needs. Only trained practitioners should administer these. For instance, joint mobilization involves passive motion within the joint's natural range, aiding in pain reduction and mobility for Frozen Shoulder patients(25).
Shoulder Joint mobilization: Shoulder joint mobilization is a manual therapy technique commonly used to treat frozen shoulder. This technique involves the mobilization of the shoulder joint to improve joint motion and stretch contracted peri-articular structures such as muscles, ligaments, and tendons. Studies have shown that joint mobilization can be an effective treatment approach for frozen shoulder, helping to improve the range of motion and decrease pain. In a randomized controlled trial, patients who received joint mobilization in addition to exercises showed significant improvements in shoulder pain and function compared to those who received exercises alone. (30)
Soft tissue mobilization: Soft tissue mobilization involves the application of manual pressure to the soft tissues surrounding the affected joint. It can help to reduce pain and improve mobility by releasing adhesions and trigger points (5).
Trigger point release: Trigger point release involves the application of manual pressure to localized areas of muscle spasm or tension. It can help to reduce pain and increase joint mobility in patients with Frozen Shoulder (4).
Myofascial release: Myofascial release is a technique that involves the application of sustained pressure to the myofascial tissues. It can help to reduce pain, improve joint mobility, and increase flexibility (24).
5 Point Shoulder Joint Mobilization - Part 1: The Motion Specific Release "5 Point Shoulder Joint Mobilization" protocol is demonstrated in this video. The shoulder is often considered a single joint; however, in reality, it comprises five different joints. Understanding the interrelationships between the structures within these joints is crucial to address shoulder injuries successfully. The protocol aims to mobilize each of the five joints, reduce pain, and improve shoulder mobility. It is important to note that a qualified practitioner should only perform this procedure. (31)
5 Point Shoulder Joint Mobilization - Part 2:
Dr. Abelson demonstrates effective Motion Specific Release (MSR) procedures for shoulder joint mobilization in this video. These techniques aim to increase mobility and reduce pain in the shoulder joint by mobilizing specific structures within the joint. It is important to note that a qualified practitioner should only perform these procedures. (31)
6 ‐ Point MSR Rotator Cuff Protocol: In this video, Dr. Abelson demonstrates the 6 ‐ Point MSR Rotator Cuff Protocol: The rotator cuff comprises four major muscles and their associated tendons: supraspinatus, infraspinatus, teres minor, and the subscapularis. This group of muscles is also called the SITS muscles (the first letter of their names). The SITS muscles are involved in almost every type of shoulder movement. It is extremely important to have strong, flexible, and balanced SITS muscles to maintain optimal shoulder function. (31)
Concurrent Treatments
Frozen Shoulder often involves a collaborative treatment approach. Combining manual therapy and exercise with anti-inflammatory drugs and joint injections can expedite pain relief. While injections alone may seem appealing, research indicates greater functional improvement and increased mobility when combined with therapy and exercise(13,22).
Anti-inflammatory drugs are especially beneficial during Frozen Shoulder's Phase 1, enhancing therapy and exercise tolerance. However, for extended symptoms, these drugs don't consistently reduce pain or enhance function(6). Thus, an integrated approach, combining manual therapy, exercise, and medications/injections when suitable, is advised for best results in treating Frozen Shoulder.
Treatment During Painful or Freezing Phase
During the Painful or Freezing Phase of a Frozen Shoulder, treatment strategies should focus on reducing pain and inflammation, improving blood circulation, and gradually increasing the range of motion. Some of the recommended treatment strategies, based on current literature, include: (9,17,28,31)
Avoiding all painful activities.
Applying heat therapy to the affected shoulder increases blood circulation and reduces muscle viscosity. This can be done using a heating pad or a warm towel.
Performing exercises within a pain-free Active Range of Motion (AROM).
Doing stretching exercises for a short duration (2 to 5 seconds), 4 to 6 times daily.
Doing pulley or pole exercises, depending on the patient's tolerance.
Performing pendulum exercises several times per day.
Applying gentle manual therapy procedures, such as osseous and soft tissue techniques, increases the range of motion, reduces muscle viscosity, increases blood flow, displaces waste products, and speeds up healing.
Mobilizing/manipulating restrictions in the thoracic and cervical region if indicated.
It is essential to avoid forcing an increase in the range of motion during this phase.
Treatment During The Adhesion Phase
During the Adhesion Phase of a Frozen Shoulder, the following treatment strategies are recommended:
Heat therapy: Use heat to increase blood flow, improve range of motion, and reduce muscle stiffness. (1)
Stretching exercises: Perform stretching exercises within patient tolerance to increase active range of motion. The stretching exercises should become more aggressive and prolonged to increase plastic elongation. (17,26)
Joint mobilization: Mobilize the shoulder joint to end-range to improve joint motion and stretch contracted peri-articular structures such as muscles, ligaments, and tendons. Shoulder joint distraction procedures can also be used for this purpose. (29)
Manual therapy: Continue to perform Phase 1 manual therapy procedures within patient tolerance. Consider a larger kinetic chain and slightly increase the intensity. (9,11)
Treatment During The Thawing or Resolution Phase
Recommended treatment during this phase includes the following:
Use of heat to increase range of motion and reduce muscle viscosity
Increasing the frequency and duration of stretching routine to patient tolerance
Application of pulley or pole exercises to patient tolerance several times per day
Use of manual therapy procedures to patient tolerance, considering both local and global tensegrity
Importance of early intervention
Research supports using manual therapy to improve patient function during any stage of a Frozen Shoulder. However, the greatest improvements are seen when the treatment is administered early. Therefore, seeking treatment as soon as possible is important to achieve optimal results. (14)
Recommended Treatment Frequency
Manual therapy for Frozen Shoulder is paramount for several compelling reasons. Firstly, it directly addresses the pain, one of the most debilitating symptoms of the condition. By manipulating and mobilizing the affected tissues, manual therapy can alleviate pain and offer immediate relief. This not only improves a patient's quality of life but also facilitates better sleep, which is often disrupted due to nocturnal pain.
Secondly, manual therapy can potentially shorten the duration of each phase of Frozen Shoulder. By actively working on the joint and surrounding tissues, the thickening and adhesions that restrict movement can be minimized, accelerating the transition from one phase to the next. Furthermore, improved range of motion achieved through manual therapy ensures that patients maintain a level of functionality, allowing them to perform daily activities with less hindrance. Overall, incorporating manual therapy provides a holistic approach, targeting both the symptoms and the underlying biomechanical factors, fostering faster recovery and a return to normalcy.
Painful or Freezing Phase (2-9 months):
Treatment Frequency: Manual therapy 1-2 times weekly. During this phase, alleviating pain is a primary goal.
Clinical Review: Initially, a review should be conducted every 2 weeks to monitor pain levels and any improvements or changes in the range of motion. As the phase progresses and depending on improvement, the interval can be extended to monthly.
Adhesion Phase (4-12 months):
Treatment Frequency: Manual therapy 1 time weekly. The focus here would be on preventing further loss of range of motion and beginning the process of restoring mobility.
Clinical Review: Monthly reviews would be beneficial during this phase to monitor the stiffness, thickening of the joint capsule, and any changes in daily activity capability.
Thawing or Resolution Phase (5-26 months):
Treatment Frequency: Manual therapy bi-weekly to monthly, given that the patient's condition is starting to improve. The emphasis would be on enhancing the range of motion.
Clinical Review: Bi-monthly to quarterly, depending on the patient's progression and improvement in pain and mobility.
It's essential to note that individual patients may progress differently, and the recommended frequencies and review times can be adjusted based on the patient's specific needs and response to treatment.
Frozen Shoulder Exercises
Frozen Shoulder Routine - Motion Specific Release: To help our patients manage their Frozen Shoulder at home, we prescribe a specific exercise regimen. The program typically includes pendulum exercises, 5-part proprioceptive neuromuscular facilitation (PNF) exercises, and partner stretches. These exercises are designed to improve the range of motion, reduce muscle stiffness, and promote healing. Here is a sample of the exercises we recommend for patients to perform at home.
5 Daily Shoulder Mobilization Exercises: This video is particularly beneficial for individuals who frequently engage in prolonged sitting due to work or leisure activities. These targeted exercises offer significant advantages in improving posture and mobility. By incorporating these exercises into your daily routine, you can anticipate considerable enhancements in shoulder health and range of motion.
Strengthening Internal & External Shoulder Rotation: As your range of motion improves, it is recommended to incorporate rotator cuff strengthening exercises into your routine. However, before starting any strengthening exercises, it is crucial to warm up your shoulder and perform stretching exercises. Specifically, focusing on strengthening internal and external shoulder rotation exercises can benefit Frozen Shoulder patients.
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When Conservative Care Is Not Enough
If conservative treatment for Frozen Shoulder is ineffective, surgery may be an option (2). A selective arthroscopic capsular release may sometimes be recommended (2). Another surgical option is an inferior capsulotomy, which has positive outcomes in certain cases (21).
However, surgical intervention is typically not recommended until conservative treatment has been implemented for at least six months without satisfactory results (Buchbinder, R., Green, S., Forbes). Before deciding, it is important to carefully discuss surgery's benefits and potential risks with your medical practitioner.
Conclusion
In conclusion, Frozen Shoulder is a debilitating condition that can greatly affect a patient's quality of life. Diagnosing and treating it early is essential to prevent prolonged recovery times. Conservative care should always be the first line of treatment, and manual therapy, exercise, and medication should be combined for optimal results. Patients with Frozen Shoulder should consult their medical practitioner to rule out other conditions with similar symptoms and to obtain a proper diagnosis.
Surgery is seldom needed, and most practitioners recommend conservative treatment for at least six months before considering surgical options. However, if conservative care is not enough, surgical options are available. Selective arthroscopic capsular release and inferior capsulotomy have been effective in certain cases. Surgery's benefits and possible complications should be carefully discussed with your medical practitioner. Overall, with proper diagnosis and treatment, most patients with Frozen Shoulder can recover their full range of motion and return to their daily activities.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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