Anatomy of your Shoulder

Your shoulder joint is where the upper arm (humerus) and the shoulder blade (scapula) connect.  It is a mobile joint covered in an loose tissue known as capsule.  Capsule is a common feature in most of our joints.  The capsule of the shoulder is a dense, fibrous connective tissue that attaches to the bones close to the joint surface.  The capsule seals the joint space and helps in stabilizing the joint from excessive amounts of movement.  The laxity in the capsule also allow for the movement of the humeral head within the joint as we move our arm.

Frozen shoulder

In cases of frozen shoulder, medically known as adhesive capsulitis, a thickening occurs of the usually loose joint capsule.  Over time this leads to a stiffening of the capsule and loss of range of motion of your shoulder.  Frozen shoulders are often categorized as primary or secondary frozen shoulders.

Primary frozen shoulders occur when no cause can be linked to the development of a frozen shoulder.

Secondary frozen shoulders develop when other factors play a role in the development of frozen shoulder. These can include intrinsic factors such as if you’ve had a shoulder fracture, rotator cuff pathology or labral injury and extrinsic causes such as if you’ve had a stroke.  Systemic causes include if you have other conditions such as diabetes and thyroid conditions.

Despite this categorization of frozen shoulder, the cause of frozen shoulder is not known.

Stages of a Frozen

If you have a frozen shoulder, your symptoms will tend to follow a pattern as your symptoms progress and resolve.

Frozen Shoulder Stage 1

This is the pre-adhesive stage and this stage typically occurs for the first 3 months.   Your symptoms are characterized by pain at the end range of shoulder movements and high levels of discomfort. In this stage the minimal loss of range of motion may seem consistent with a tendinopathy presentation, however elevated pain levels are noted. You may have tried stretching your shoulder to reduce symptoms but noticed that stretching felt worse.

Frozen Shoulder Stage 2

This stage is commonly known as the freezing stage.  In this stage you are noticing increased pain levels and gradual loss of range of motion of the shoulder in all directions.  Scar tissue is beginning to appear in your shoulder capsule.  This stage can last up to 6 months.

Frozen Shoulder Stage 3

This stage is the frozen stage and is usually characterized by a reduction in your pain but the inability to fully move your arm.  At this point your primary complaint is the inability to move your shoulder.  Scar tissue is more mature at this stage and is limiting most movements of your shoulder. This stage can last up to 6 months.

Frozen Shoulder Stage 4

This is the thawing stage.  At this stage your range of motion is continuing to slowly improve. This stage can last up to 9 months.

Risk factors for Developing a Frozen Shoulder

The cause of frozen shoulder is not yet known. Research does show that frozen shoulder is more common in women than in men. Frozen shoulder is thought to affect 2-5% of the general population and is more common between the ages of 40-65 and in 14% of cases can occur on both sides at the same time.

Several factors have been shown that can increase your risk of developing a frozen shoulder.  If you have the following conditions you are more likely to develop a frozen shoulder

• • • Diabetes
    • Thyroid disease
    • Auto immune disorders
    • Shoulder trauma
    • Heart attack
    • Immobilization of the shoulder

Having had a frozen shoulder of one arm increases your chance of developing frozen shoulder on the opposite side by between 5-34%.

Treatment of Frozen Shoulder

The treatment for frozen shoulder depends on the stage that you are in, so it is important for other shoulder pain conditions including impingement, arthritis and tendinopathy to be ruled out by your physiotherapist. Imaging studies such as X-Rays, ultrasound and MRI are not required to diagnose your frozen shoulder.

In early stages treatment will often include education on frozen shoulder and pain management strategies.  These may include techniques performed in the clinic such as acupuncture or the use of therapeutic modalaties.  Your physiotherapist may prescribe range of motion exercises to encourage movement without aggravating symptoms.  Aggressive stretching and strengthening exercises at this stage will only increase the pain and will not necessarily resolve your symptoms faster.

In later stages of frozen shoulder your physiotherapist may use manual therapy techniques to loosen your shoulder capsule.  If your pain is persisting in these later stages, your physiotherapist will communicate with your doctor, as the use of a cortisone injection may be indicated.  Clinical techniques are complemented by target exercises to improve your movement.  Shoulder strengthening exercises to reduce pain with activities are prescribed. Unresolved capsule restrictions can lead to impingement pain of the shoulder and neck pain.

Unsure where to start?  Or are you looking for a second opinion for persistent shoulder pain? Contact us for a consultation to help you get back on track with your health and fitness goals.

References

1. 1. • Kelley M, Shaffer M, Kuhn J, Michener L, Seitz A, UHL T, Godges J, McClure P “Shoulder Pain and Mobility Deficits: Adhesive Capsulitis” Journal of Orthopaedic Sports Physiotherapy 2013