What is Frozen Shoulder and How Does it Cause Pain?
Do I have Frozen Shoulder (adhesive capsulitis)?
Shoulder pain is one of the most common reasons for people to visit a physical therapist second only low back pain and neck pain. There are many different reasons why people can have shoulder pain, including rotator cuff pathology, impingement, arthritis and frozen shoulder. The focus of this article will be on frozen shoulder, which is also known as adhesive capsulitis (use that to sound smart at your next get together). Contrary to what you might think, it has nothing to do with being outside in cold weather too long. Frozen refers to the stiffness that accompanies this condition.
Frozen shoulder is a common disorder that is seen at Excel Physical Therapy, whether after a surgery, or without any specific cause. Frozen shoulder is a condition that is characterized by marked stiffness and pain. Over time this leads to significant disability due to the severe pain and limited flexibility of the shoulder.
There are four stages of Frozen Shoulder that vary in length and symptoms.
- Stage I lasts approximately three months, and is characterized by pain with shoulder movement in most directions. Pain is often sharp with movement at the end of range, and there is an ache at rest. Pain is also commonly felt at night, particularly when lying on the affected shoulder. This stage has inflammation of the joint lining which is likely what causes the pain. The joint lining has not yet begun to stiffen, so range of motion is likely the same as the opposite shoulder
- Stage II, which is known as the freezing stage, typically lasts 3-9 months. This is when flexibility of the shoulder begins to reduce due to pain. New nerves and blood vessels make their way into the joint, which can increase pain and sensitivity. At this time, people often begin to notice difficulty reaching over head, or reaching behind their back with the painful arm. A patient assessed by a health care provider in the first two stages of frozen shoulder may be misdiagnosed with impingement or a rotator cuff tear. Stage III, known as the frozen stage, is when the stiffness is most notable. The growth of blood vessels and nerves decreases in this stage, but the joint capsule (connective tissue) begins to tighten leading to decreased range of motion over time.
- Stage III lasts from 9-15 months from the onset of symptoms. Frozen shoulder is more easily diagnosed in this stage due to the extensive range of motion loss.
- Stage IV is known as the thawing stage. During stage IV pain reduces significantly, but stiffness remains for a certain period of time, and eventually reduces. This stage can last from 15-24 months, and minor limitations in range of motion and function can persist indefinitely.
Frozen shoulder is typically a condition that is diagnosed in the clinic with physical examination.
It may be helpful to obtain an x-ray to make sure it isn’t osteoarthritis or other bony conditions. After those are ruled out, a detailed patient history is obtained, followed by a physical examination that consists of movement and flexibility testing, strength testing and any specific joint tests. Loss of motion is the most common findings with frozen shoulder. Strength will typically be normal in patients with frozen shoulder. If active (patient moving) and passive (therapist moving) range of motion are limited by greater than 25% in most directions with a negative x-ray, frozen shoulder is likely.
Treatment options for frozen shoulder.
As much as you might want to, amputation of the shoulder isn’t recommended. Many people report relief of pain and some return of range of motion after receiving a cortisone injection into the joint. Anti-inflammatory medications may also help reduce pain.
Physical therapy has also been shown to be effective for frozen shoulder. This can include joint mobilizations, soft-tissue mobilization (similar to massage), ultrasound, and stretching. Research (and our experience) shows that the most effective combination seems to be cortisone injection and physical therapy. Doing strengthening exercise in the early phases can be counterproductive, increasing pain and slowing recovery. Treatment may take a while to return range of motion and pain to an acceptable level, but it is still faster than waiting for it to improve on its own.