Frozen Shoulder (Adhesive Capsulitis)
Adhesive capsulitis, also called frozen shoulder is a common inflammatory condition where the body forms excessive scar tissue or adhesions in the capsule around the shoulder joint leading to pain, stiffness and dysfunction. Frozen shoulder can often be very painful but is characterized by a severe restriction of movement of the shoulder in all directions which often makes the activities of normal daily life difficult.
Causes & Risk Factors
There are 2 main types of adhesive capsulitis. These are Primary (or idiopathic) adhesive capsulitis which can occur spontaneously without any specific trauma or trigger event with the causes of this not fully understood.
Secondary adhesive capsulitis is often seen after trauma to the shoulder joint which can be in the form of a fracture, dislocation or subluxation of the joint. Frozen shoulder is also a common complication following any surgery of the shoulder (open or
arthroscopic) , including rotator cuff repairs and sub acromial decompressions or arthroplasties.
Frozen shoulder has been found to affect around 4% of the normal population. This number jumps to as high as 20% in patients with diabetes making this one of the major risk factors with both type 1 & type 2 diabetics affected.
It is commonly seen more in females who make up 70% of cases. The most common age group affected is 40-60, while it normally presents in the non-dominant hand.
Other populations suffering from high rates of adhesive capsulitis are anybody who has spent a period of time with the shoulder immobilised (eg in a cast or sling), sufferers of Parkinson’s disease, thyroid disorders or any other autoimmune diseases.
Adhesive capsulitis is often referred to as a self-limiting disease which means that it will usually resolve itself within a certain timeframe. This is widely accepted as being somewhere between 1 and 3 years from onset. However, various studies have shown that between 20% and 50% of patients may go on to develop long-lasting symptoms that can only be resolved through further treatment interventions.
Frozen shoulders progress through 3 distinct clinical phases. These are:
Phase 1: The freezing or painful phase: Typically see development of diffuse, disabling shoulder pain. Is often worse at night initially but then progresses to pain at rest. Associated with increasing stiffness of the shoulder. Lasts on average from two to nine months.
Phase 2: The frozen or adhesive phase: Characterized by progressive stiffness and limitation of all shoulder movements. The pain often settles in this phase. Can last from four to 12 months.
Phase 3: The thawing or regression phase: The recovery phase where there is a gradual return of the range of motion. Can take 12 to 24 months for the complete return of full movement.
Progressively worsening shoulder pain over weeks to months
Gradual loss of movement of the shoulder (In a capsular pattern)
Inability to lift arm above 90deg
Inability to brush hair
Inability to get hand behind back or to do up bra strap
These main symptoms can obviously then lead to problems with most normal activities due to pain and physical restrictions of movement.
Physiotherapy treatment for frozen shoulder will depend on the stage you are in.
The aim of physio treatment during stage 1 is to maintain as much range of movement as possible and limit the degree of joint stiffness. You will be given education about the condition and advice on how to modify your activities to avoid aggravating the problem. Your physiotherapist will also help you to develop a pain-free exercise program aimed at maintaining range of movement, stretching and strengthening the shoulder during this phase.
During stage 2 physiotherapy techniques aim to manage any presenting symptoms. This includes to loosen the shoulder joint, AC joint, SC joints, cervical spine (neck) joints as well as the muscles around the neck and shoulder which often get tight. It is again important not to push the shoulder too far into pain at this stage as it will not improve ROM in an established capsulitis and will often aggravate the shoulder without achieving anything. If there is not a lot of pain, yet the shoulder remains stiff after treatments during this stage, it is often just a case of monitoring and completing a home exercise program until the shoulder enters stage 3.
Stage 3 is the time in which manual physiotherapy interventions are most effective. Manual joint mobilistions and soft tissue release techniques may be uncomfortable but can considerably improve symptoms and movement during this phase. Any weak muscles and altered patterns of movement will also be identified and addressed during this phase with the goal being a full recovery including normal range of movement and strength.
The symptoms and severity of frozen shoulder can vary greatly from one patient to another. Some people have very little pain and manage well with minimal treatment. Others may require corticosteroid injections to help reduce pain and inflammation (It is important to remember that the injection will not usually shorten the recovery timeframe). In some cases, specialists may also recommend manipulation of the shoulder joint under general anaesthetic or a surgical release of the capsule. These procedures have reasonably high success rates and carry risks as with all surgeries and are not commonly required.
If you would like any more information about adhesive capsulitis or would like to speak to one of our expert therapists about this or any other problem, please get in touch today.