Frozen Shoulder, also known as adhesive capsulitis, is a condition where the joint capsule becomes inflamed and is associated with loss of motion. Here’s how you’ll know if you have this shoulder condition, what you can do about it, and some insight into how physiotherapy can help.
What are the symptoms of Frozen Shoulder?
The two main symptoms of frozen shoulder are pain and stiffness. Pain will develop first and is the most prominent symptom in the early stage. Over time, pain may worsen whilst stiffness in the shoulder joint and a reduction active and passive range of motion develops.
How is Frozen Shoulder Diagnosed?
Despite significant research attempts into the diagnostic criteria for frozen shoulder, the best way to diagnose this painful condition remains a combination of thorough history taking performed by your local physiotherapist, in conjunction with a physical examination.
As physiotherapists, understanding the onset and behaviour of your pain and any risk factors you may possess that are more commonly associated with frozen shoulder presentations (age, diabetes, sex, family history etc.) are pivotal in allowing us to make an accurate diagnosis. Frozen shoulder develops and behaves in a certain way, so seeing whether your symptoms fit the typical behaviour of frozen shoulder is a key part of the diagnostic process.
There are five big behaviour patterns we’ll be on the lookout for:
- A strong component of night pain
- Marked increase in pain with rapid or unguarded movements
- Uncomfortable to lie on the affected side
- Pain easily aggravated by movement
- Onset of pain >35 years of age
Undertaking a thorough history is also important in allowing us to rule out more sinister causes that might need further intervention or follow up, such as a fracture after trauma, or cancer.
On a physical examination, people with frozen shoulders often display significant loss of shoulder movement in external rotation compared to the other side, as well as an inability to fully lift their arm out to the side, overhead, and behind their back. This restricted shoulder movement is also no better when done passively, that is when we take you through the range of motion with you completely relaxed. At the end of range in any direction, pain is usually present and generally, there’ll be no signs of weakness on physical testing.
When we’ve completed the integration of these two diagnostic areas and suspicion of a frozen shoulder is high, we may look to seek an X-Ray to rule out any other causes of shoulder stiffness (fracture, dislocation or sinister pathology amongst others) so we can continue with treatment as appropriate.
Who does Frozen Shoulder affect?
Primary frozen shoulder, that is frozen shoulder that affects people for no apparent reason at all, occurs in approximately 5% of people in the general population. Secondary frozen shoulder, frozen shoulder that occurs due to a known predisposing factor such as post surgically, following a stroke, after an injury or with comorbidities such as Parkinsons, diabetes or other metabolic conditions, occurs in approximately 38% of the population.
It affects women more than men, is four times more likely if you have a family history of frozen shoulder, is extremely frequent in the overweight or obese population (up to 82%) and usually occurs during the ages of 45-60.
How is frozen shoulder managed by a Physiotherapist?
Statistics show that 90% of people with frozen shoulders do really well with non-surgical management, including physiotherapy (Cho et al. 2019). The research says that physiotherapy and a steroid injection are equally effective for frozen shoulders in addressing pain and improving function, and both are superior to no treatment at all (Sun et al. 2016).
It makes sense then that best practice according to the research appears to involve physiotherapy in conjunction with – where pain levels are high and quality of life is being heavily affected – a cortisone injection. Cortisone may lessen pain for periods of up to 26 weeks, a good window of relief whilst physiotherapy, involving frozen shoulder exercises, plays the longer game of keeping pain away and ensuring your function returns to normal.
So how will a physiotherapist help to manage your frozen shoulder? As is the way in managing many painful conditions, physiotherapy treatment involves a combination of a number of things.
- Education and advice: the research shows expectations guide your outcomes. The more you understand about your condition and feel optimistic and in control about your recovery, the better the outcome you’ll achieve.
- Manual therapy or other passive techniques: this can include a combination of joint mobilisation, soft tissue massage and or dry needling. By reducing the sensitivity of shoulder tissues through a variety of techniques, we can positively influence pain for a short amount of time. Whilst doing so can be a good adjunct to treatment, particularly in the early stages, they won’t be the thing that gets you better in the long term.
- Physiotherapy exercise for shoulder pain: Considered a first line treatment for frozen shoulders, this is where getting the long-term outcome you’re seeking lies. It helps both in reducing pain in the short term whilst improving function, quality of life and reducing disability in the long term.
One particular study found the addition of physiotherapy strengthening exercises targeting the shoulder muscles to a multi-faceted physiotherapy approach significantly improves pain, function and range of motion (Russell et al. 2014). Another study found that completing such exercises in a supervised environment was significantly better than performing the exercises at home (another reason we run supervised exercise sessions).
Stretching exercises can also be effective in reducing discomfort and increasing shoulder movement. However, they should always be performed in conjunction with strengthening exercises.
What happens if the frozen shoulder is not treated?
In the health field, when a condition doesn’t receive any treatment, this is termed the ‘wait and see’ approach. There’s good news, there’s been research conducted to compare the wait and see approach in frozen shoulder to other treatment modalities.
In summary, they’ve found that the ‘wait and see’ approach isn’t recommended. This is due to its poorer outcomes in pain and function when compared to cortisone injection and physiotherapy in particular (Blanchard et al 2010).
Diving a little deeper, further research shows that 94% of people get significant improvement without any treatment on their frozen shoulder. However, only 26% of people who received no treatment returned to full function. The last little bit of research to talk about here was a systematic review that said the notion that frozen shoulder resolves completely on its own without treatment was not fully supported (Wong et al. 2017).
In summary, if you don’t seek treatment on your frozen shoulder, it’s likely it will improve substantially over a 1-2 year period. Beyond that, it’s probably unlikely that your shoulder will return to full function and not plague you in some capacity for an indefinite period of time.
How painful is frozen shoulder?
Usually, quite painful! Particularly in the early (freezing phase) to mid stage (frozen phase) at least, and tends to ease in the late stages (frozen to thawing phase). It’s important to remember however that pain is an experience influenced by a multitude of things.
The more concerned, worried, anxious, nervous, scared or isolated you feel about your pain, the worse your pain is going to be. It’s really important to try and stay optimistic, despite how hindersome and painful frozen shoulders may be.
How do you sleep comfortably with a frozen shoulder?
Getting good quality sleep is exceptionally important, not only for your general health and ability to function optimally, but also to help positively modulate pain. We know people who sleep less experience more pain. As such, if we can tick the box of a good night’s rest we’ve played a vital role in helping you feel better on your road to recovery. Sleeping comfortably can be difficult. A hormone called melatonin is released by the body at night to help regulate the sleep-wake cycle. This hormone can also negatively modulate pain, hence why people with frozen shoulder often feel worse during the evening and early morning hours.
Ultimately, there’s no right or wrong way to sleep comfortably – find a position you find comfortable and do your best to get some rest. If sleep is regularly disrupted, you could consult your GP for some pain relief medication in the short term but if poor sleep persists, a cortisone injection may be useful in allowing you to sleep without disruption whilst you continue to receive treatment on your frozen shoulder.
When should you see a physiotherapist?
Ideally, the sooner the better! The best time to see a physiotherapist is as soon as something begins to impact you negatively – either pain or through the inability to do things you’d like to do to the level you’d like to do them. Early intervention also allows proper diagnosis, advice and education, and implementation of a treatment plan to combat your symptoms and get you back to normal as soon as possible.
If you’d like to chat to one of our expert shoulder physios, please don’t hesitate call us on 8490 0777 email us at firstname.lastname@example.org
If you’re ready to start your journey to improved shoulder function and reduced pain, you can book online here.