Defrosting Frozen Shoulder
Updated: May 11
Frozen Shoulder, also known as Adhesive Capsulitis (AC), is a condition that is characterized by severe pain (especially at night), progressive shoulder stiffness, and loss of shoulder motion.
The signs and symptoms of Frozen Shoulder usually begin gradually, and worsen over time. The mystery of Frozen Shoulder lies in the fact that researchers don’t know (and often don’t agree) on what causes this condition.
What we do know is that Frozen Shoulder occurs in two to five percent of the general population, and that it is more commonly seen in the diabetic population (occurrence rate of 10-20%). We also know that Frozen Shoulder is more prevalent in women than men, and that individuals who are 40 to 65 years of age are more likely to develop the condition. (10)
Frozen Shoulder is often considered to be a self-limiting condition, typically lasting from six months up to several years. Fortunately, it is also common for patients suffering from Frozen Shoulder to find relief in a much shorter period of time with the right strategy. (6)
WHY ME? CAUSES OF FROZEN SHOULDER
One of the most frustrating aspects of Frozen Shoulder is that patients never really know why they get this condition. Although researchers often disagree about the root cause of Frozen Shoulder, they have reached consensus that it should be divided it into two categories “Primary” and “Secondary” Frozen Shoulder.
Frozen shoulder is to be considered Primary if it is of unknown origin (idiopathic),
And it is considered to be Secondary if it results from a suspected cause or surgical incident. (11)
Possible secondary risk factors that could be related to Frozen shoulder are:
Extended periods of immobilization.
Trauma, injury, or a previous surgery to the shoulder.
Diabetes, lung disease, heart disease, hyperthyroidism, and Parkinson’s disease.
Note: Smoking increases rotator cuff pathologies, and in general, increases the risk of shoulder dysfunctions. (12)
SHOULDER JOINT ANATOMY AND FROZEN SHOULDER
Your shoulder joint (glenohumeral joint) is a ball and socket joint in which the end of your upper arm (humerus) forms the ball and unites with the socket (glenoid fossa) of the shoulder blade (scapula). In addition to the basic ball-and-socket joint, there are numerous other structures that make up, and support this complex structure.
The shoulder joint is surrounded by a ligamentous capsule that is full of synovial fluid which lubricates the joint and allows for easy motion. Synovial fluid is a viscous, lubricating fluid that is secreted by the membrane lining the joints and tendon sheaths. The Articular capsule, with numerous folds is designed to allow for optimal movement.
The glenohumeral capsule, by itself, is not very strong. However, it is surrounded by the rotator cuff muscles, which act as active ligaments and provide stability for the various structures of the shoulder. The fascia that runs through these muscles also plays a critical role in stabilizing the shoulder joint.
For example, during glenohumeral joint motion, the subscapularis muscle (one of the rotator cuff muscles) coils around the coracoid process of the shoulder blade (scapula) . By performing this action the subscapular fascia, and subscapularis muscles (and subcoracoid bursae) reduce friction on the humeral head which helps provide shoulder stability. (13)
PHYSIOLOGICAL CHANGES WITH FROZEN SHOULDER
Current literature supports the following physiological changes taking places during the process of developing Frozen Shoulder (2). During this process:
The capsule surrounding the shoulder joint becomes inflamed, thickened, and extremely rigid.
This inflammation is often accompanied by a decrease in the levels of synovial fluid within the capsule, followed by contraction of the joint capsule.
This combination of inflammation and contraction leaves less space for the humerus (upper arm bone) to move around.
Patients suffering from Frozen Shoulder usually have trouble with two ranges-of-motion - most commonly with shoulder abduction and external rotation.
The Three Phases of Frozen Shoulder
Current literature shows that development of Frozen Shoulder is typically divided into three phases(2), with each phase lasting for several months before change is noticed:
Painful or Freezing Phase (2-9 months): This phase is characterized by pain with any movement and is accompanied by a decrease in the patient’s range-of-motion.
Adhesion Phase (4-12 months): The level of pain decreases, and is accompanied by a substantial decrease in the shoulder’s range-of-motion. All the activities of daily living become extremely difficult to perform. Range-of-motion decreases during this stage due to the joint capsule thickening with excessive collagen.
Thawing or Resolution Phase (5-26 months): The range of motion will begin to increase and the patient’s pain diminishes.
Note: Though these are the classical phases of Frozen Shoulder, it is my clinical experience that these phases can be greatly reduced in duration and intensity with the right program of therapy, exercise, and possible medication/injections (depending on the case).
DIFFERENTIAL DIAGNOSIS FOR FROZEN SHOULDER
Practitioners should be aware that there are several conditions that could present with similar symptoms to Frozen Shoulder. It is important to consider these conditions in your differential diagnosis. (5) These other conditions include:
Bursitis: Patients with bursitis will show an increased passive range of motion (PROM) as compared with 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). The difference is that PROM will not be limited with osteoarthritis.
Rotator Cuff Syndrome: Symptoms can be very similar to Frozen Shoulder. MRI or ultrasound may be required to differentiate between these two syndromes.
EXAMINATION OF FROZEN SHOULDER
To effectively evaluate a patient who seems to be presenting with Frozen Shoulder you should:
Check active and passive ranges of motion in the shoulder, cervical spine, and thoracic region.
Check rib mobility, especially the first rib.
Check External Rotation of the shoulder: Test bilaterally, a positive test is when the affected side has 50% or greater loss of rotation when compared to the good side, or where there is less than 30 degrees of external rotation.
Verify if at least two other ROM planes are reduced by at least 25% when compared to the other side. For example test the shoulder in abduction and then in flexion.
Check for active muscle guarding. Use the Coracoid Pain Test to evaluate. (The Coracoid Pain test uses digital pressure on the area of the coracoid process to determine if there is localized pain.
Check mobility of all four shoulder joints:
Sternoclavicular (SC) Joint - Check elevation 45°, depression 5°, protraction 15°, retraction 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 must be able to elevate, depress, protract,and retract over the rib cage. There must also be upward and downward rotation in the glenoid fossa.
Acromioclavicular (AC) Joint - The acromioclavicular joint allows a degree of axial rotation and anteroposterior movement. There is normally a 20-30° of total glide and rotation with other accompanying shoulder joint motions.
Glenohumeral (GH) Joint - In cases of Frozen Shoulder the Glenohumeral joint will be most limited in the Anterior and inferior capsular region. (8) The Glenohumeral joint should not be limited in all three planes of motion.
Clinical Tip: No muscles attach directly to the SC joint. The SC joint motion somewhat mimics the reciprocal motions of the Scapulae. The muscles that attach to the clavicle, which may affect clavicular motion, are the SCM, deltoid, pectoralis major (clavicular head), subclavius and trapezius.
DIAGNOSTIC IMAGING FOR FROZEN SHOULDER
Your practitioner may order X-rays, primarily to rule associated or pathological conditions.
It is my recommendation that all patients presenting with Frozen Shoulder should undergo plain radiography imaging. This could help rule out infections, metastatic process, large areas of calcification, avascular necrosis of the humeral head, or charcot joints.
Note: Patients who smoke (or have a history of smoking) should also have a chest X-Ray with apical views. This is to rule out a Pancoast Tumor which can irritate the brachial plexus, making this a possible cause of Frozen Shoulder type symptoms (14).
Manual therapy and exercise should be the first-line of treatment for all stages of Frozen shoulder (19). (There is considerable research to support the use of manual therapy in the treatment of Frozen Shoulder (2).)
The objective of manual therapy is to reduce pain, increase mobility, and provide functional improvements with activities of daily living (ADL). The exact combination of treatment and exercise recommendations that we typically provide does vary based on the current phase of the Frozen Shoulder.
Below are examples of manual therapy approaches that we could use depending on the specific needs of each patient. Note: These videos are for demonstration purposes only, MSR procedures should only be performed by a qualified practitioner.
5 Point Shoulder Joint Mobilization - Part 1: In this video Dr. Abelson demonstrates the Motion Specific Release "5 Point Shoulder Joint Mobilization" protocol. When we think of the shoulder, we often think of it as being just one joint. In reality, we must consider five different joints. Understanding the inter‐relationships between the structures in these five joints will play a critical role in successfully resolving shoulder injuries. (This video will be public on August 11/2020)
5 Point Shoulder Joint Mobilization - Part 2: (This video will be public on August 20/2020).
6 ‐ Point MSR Rotator Cuff Protocol: 6 ‐ Point MSR Rotator Cuff Protocol: The rotator cuff is made up of four major muscles and their associated tendons: supraspinatus, infraspinatus, teres minor, and the subscapularis. This group of muscles is also referred to as 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 in order to maintain optimal shoulder function. (Video to be released to the general public August 5/2
Frozen Shoulder is a condition that I often treat concurrently with the a medical practitioner. Manual Therapy, with exercise, and in combination with anti-inflammatory medications and glenohumeral joint injections can often help break the pain-cycle much faster.
You may be wondering, "Why don't I just get the injections - without the therapy or exercise?" Unfortunately, injections by themselves are not as effective as when they are combined with manual therapy and exercise. Research has shown that when manual therapy and intra-articular injections are combined, patients improve their function and achieve increased ranges-of- motion much more rapidly than with injections alone (15,16).
Note: anti-inflammatory medications have been found to be most helpful to patients during Phase 1 of Frozen Shoulder. The medication allows the patient to better tolerate therapy and exercise. Unfortunately, in cases with prolonged symptoms, anti-inflammatory medications have NOT been shown to decrease pain or improve function (19).
TREATMENT DURING PAINFUL OR FREEZING PHASE
Once a practitioner has completed his/her analysis, and determined which phase of frozen shoulder that the patient is suffering, then an appropriate treatment and exercises plan can be implemented.
During Phase 1 – Painful or Freezing Phase, we recommend using the following treatment strategy.
Avoid all painful activities.
Use Heat. Heating the involved shoulder to treatment to increase blood circulation, increase range-of-motion, and reduce muscle viscosity. Heat causes a neuromuscular mediated relaxation response. (6)
Perform all exercises in a pain free AROM (Active Range of Motion).
Perform stretching exercises for just a short duration (2 to 5 seconds), but they should be performed 4 to 6 times per day.
Perform pulley or pole exercises, depending on patient tolerance.
Pendulum exercises can be performed several times per day.
Apply gentle manual therapy procedures to patient tolerance.These procedures include both osseous and soft tissue techniques. The objective of these procedures is to increase range-of-motion, reduce muscle viscosity, increase blood flow, displace waste produces, speed healing.
Mobilize/manipulate restrictions in the thoracic cervical region if indicated.
Note: It is extremely important that you DO NOT not try to force an increase in range of motion. Also as mentioned we recommend concurrent treatment combining therapy, exercise and injections or medication.
TREATMENT DURING THE ADHESION PHASE
As we discussed earlier, the Adhesion Phase typically occurs after four months. During this phase, we recommend that you:
Use heat to increase range-of-motion, and reduce muscle viscosity.
Stretching exercises can become more aggressive to increase AROM (perform within patient tolerance which should be increasing).
Apply prolonged stretches, with a minimal load, to increase plastic elongation. (3) We suggest using light hand-weights to increase stretching effectiveness.
Mobilize the shoulder joint to end-range to improve joint motion and stretch contracted peri-articular structures (muscles, ligaments and tendons). These techniques include shoulder joint distraction procedures.
Perform phase one manual therapy procedures within patient tolerance. Slightly increase intensity and begin to consider a larger kinetic chain.
TREATMENT DURING THAWING OR RESOLUTION PHASE
As the patient's condition improves, we encourage them to:
Use heat to increase range-of-motion, and reduce muscle viscosity.
Increase the frequency and duration of the stretching routine, to patient tolerance.
Apply pulley or pole exercises to patient tolerance, several times per day. (See Video)
Use manual therapy procedures to patient tolerance. Consider both local and global tensegrity. Procedures must include both osseous and soft tissue protocols.
THE EARLIER THE BETTER
Manual Therapy is Supported by Research
Research supports the use of manual therapy to improve patient function during any stage of Frozen Shoulder. The research also shows that the greatest improvements are seen when the treatment is administered at an early stage (17,18).
FROZEN SHOULDER EXERCISES
Frozen Shoulder Routine - Motion Specific Release: We have found the following exercises to be an important component of the over all strategy in treating Frozen Shoulder. This is a sample of some of the exercises that we prescribe to our patients.
5 Daily Shoulder Mobilization Exercises: As patients progress, we will start to introduce other exercises into the program such as these shoulder mobilization exercise.
Strengthening Internal & External Shoulder Rotation: Once your range of motion improves, you can add in rotator cuff–strengthening exercises to your routine. Before performing strengthening exercises warm up your shoulder, and do your some stretching exercises before you perform strengthening exercises.
WHEN CONSERVATIVE CARE IS NOT ENOUGH
If conservative care does not achieve the desired results, then surgery may be an option you may want to consider.
Today there are several surgical options that your doctor may want you to consider.
A selective arthroscopic capsular release is sometime recommended for patients with frozen shoulder (20).
Also research has shown that a procedure called an inferior capsulotomy has yielded good results in certain cases (21).
Whether or not one of these procedures is right for you is something you need to discuss with your medical doctor.
Most practitioners will not recommend these procedure unless symptoms persists after sufficient conservative treatment has been implemented for at least six months.
Benefits and possible complications of surgery is something that needs to be carefully discussed with your medical practitioner.
Every case of Frozen Shoulder is different and must be treated on an individual basis.
The good news is that most cases of Frozen Shoulder respond well to manual therapy in combination with an appropriate exercise program. In some cases the appropriate use of medications and injections could speed the process when combined with conservative care.
In our experience, using a combination of therapies can effectively reduce pain, increase range-of-motion, and get patients back to their active lifestyle in a much shorter period of time.
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DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publications which will be available later this year.
Dr. Abelson is the owner of Kinetic Health, a partner in BKAT Motion Specific Release, and a partner in Rowan Tree Books.