Frozen Shoulder (adhesive capsulitis)
A frozen shoulder is a shoulder in which movement is severely restricted. The shoulder joint is surrounded by a capsule – a layer of tissue that encloses the entire joint and seals the shoulder hinge off from the tissue outside it.
Between the top of the shoulder (acromion) and the coracoid process lies a broad, firm and sharp-edged band of connective tissue, the coracoacromial ligament.
Together with the acromion, this ligament forms the roof of the shoulder joint. Soft tissues (capsule, tendons, bursa) can become pinched between this roof and the head of the upper arm. The capsule can sometimes become inflamed (capsulitis) and start to stick together (adhesive) or shrink. Inflammation of the capsule can be triggered by overload of structures within the joint – tendons, bursa and muscles, for example. The capsule loses its elasticity, hardens and thickens. As a result, the arm can perform fewer and fewer movements, and the capsule may go on to stick together or shrink further.
Symptoms
The symptoms are restricted arm movement and pain on moving. The arm is used less and less, and rested more. It can no longer be lifted, moved out to the side, or rotated outward. The extent of the restriction differs from person to person, depending on the severity of the frozen shoulder. You can assess whether a pattern of adhesive capsulitis is developing using 3 movement tests.
The tests are positive if they match one of the descriptions given below.
Test 1
Lie on your back and clasp your hands together. Stretch your arms up so they point towards the ceiling. Then move your arms, kept almost straight, backward and try to lay them down flat.
- Are you unable to lay the arm down flat?
- Is there pain at the end of the movement?
In an early-stage frozen shoulder, the whole movement may cause some pain, with a sharp increase in pain as the arm reaches a position almost or fully stretched out behind the head.
In an advanced frozen shoulder, you will have great difficulty bringing the arm far backward because of severely increasing pain and strong restriction of movement.
Test 2
Lying on your back with your arms at your sides, bend the elbows 90 degrees. From this position, move the forearms outward. In a healthy shoulder, the forearm will form an angle of roughly 45 to 80 degrees with the vertical.
Very flexible people can lay their forearms flat on the table. In general, in a healthy situation, the dominant arm (the one you write and throw with) reaches slightly further than the non-dominant arm.
- Is there a large difference between left and right?
- Does the shoulder or upper arm hurt as soon as you reach the end of the movement?
- In an advanced frozen shoulder, the arm stays pointing upward and barely rotates outward at all.
In an early-stage frozen shoulder, the whole movement can cause pain, which increases as the arm nears a position almost or fully rotated outward.
In an advanced frozen shoulder, you will have great difficulty rotating the arm far outward because of severely increasing pain and restriction of this movement.
Test 3
From standing or sitting, try to bring the affected hand up behind your back while raising the healthy hand.
Normally, you should be able to bring your hand to the middle of your back. Very flexible people can bring the hand up between the shoulder blades. In general, in a healthy situation, the dominant arm (the one you write and throw with) will reach slightly less high.
- Can you not get the affected hand above your pelvis (buttock), or can you barely get it behind your body at all?
- Is there a lot of pain at the end of the movement?
In an early-stage frozen shoulder, the whole movement can be quite painful, with the pain increasing as the arm gets close to, or fully behind, the back.
In an advanced frozen shoulder, you will have great difficulty, with the hand barely rising above the buttock crease or hardly reaching behind the body at all.
If these 3 test movements are positive – that is, restricted and painful – an early pattern of adhesive capsulitis, or frozen shoulder, may be present.
Causes
The causes of progressively restricted shoulder movement are not always clear. There can be several underlying causes:
- Impingement of muscle tissue, tendon tissue or the bursae is often the trigger for an inflammatory reaction, which in turn leads to a capsular response, such as pain on movement.
- Pain from damage to one of the tissues after a fall onto the shoulder or a sprain.
- After surgery or a fracture (broken bone) following an accident, sudden inflammation of the capsule (capsulitis) can painfully restrict freedom of movement within a short time.
- Sometimes no cause can be found at all, and the condition appears to arise spontaneously.
The physiotherapist
The most important treatment is prevention. You can help prevent a frozen shoulder from developing by continuing to move the shoulder in a controlled, graded way after any shoulder injury (bruising, dislocation, fracture) – always following the guidance of the treating doctor or physiotherapist. The physiotherapist teaches the exercises to be performed correctly and provides encouragement where needed. Some exercises a physiotherapist may offer:
- Pendulum movements. Sit on a chair with your legs slightly apart, let the arm hang between them, and make small circles. This can also be done standing, with the healthy arm resting on a table for support: lean forward slightly, place the legs in a split stance (one foot forward, one back), and make small circles with the affected arm.
- Stretching and mobilisation (see the movements in the tests above). The physiotherapist can assist here and apply a bit more pressure, moving the shoulder through as many directions as possible to help release the restrictions.
- Strengthening exercises.
These exercises are adapted to the patient's condition (the extent of the restriction in the shoulder joint). Expected recovery time depends somewhat on the severity of the frozen shoulder.
In the first stage, which can last roughly two to nine months, the pain is at its worst, and movement of the joint is only possible to a limited extent.
In the second stage, stiffness sets in and the loss of movement is at its greatest. Pain remains present but is often less severe. This stage can last roughly two to six months.
The final stage is marked by the stiffening process no longer being active. Movement and function appear to recover, partly because spasm around the joint no longer occurs. The capsule is short and thickened, but the sharp pain has gone. It can now gradually loosen and stretch further as the patient's own movements increase. This stage can last roughly two to nine months.
In other words: if left to run its natural course, the condition lasts around 9 months to 2 years. In practice, however, patients are regularly seen who still have significant residual loss of shoulder mobility years after a frozen shoulder. It often turns out that they were treated incompletely, briefly, or not at all.
Continuing to move the shoulder stops the increasing stiffness from taking hold and prevents, or limits, the formation of adhesions. In the 2nd phase this becomes harder, since adhesions have already formed. Even so, in this phase too, a sound approach focused on self-mobilisation can genuinely speed up recovery of joint play and function. With the help of the physiotherapist, movements can be carried out correctly and as fully as possible.
The pain must remain tolerable and acceptable to the patient. Motivating and coaching the patient pays off when there is good cooperation. Continuing to guide, motivate and adjust the exercises as the situation improves is a crucial task for the supervising physiotherapist.
If the pain becomes unmanageable or uncontrollable, for whatever reason, referral to the GP is advised for medication or other treatment (such as injections). If, even in these patients, residual restrictions in movement are still present after years, mobilisation of the glenohumeral (and scapulothoracic) joint by a manual therapist is indicated.
Possible treatment by specialists
Surgery or manipulation
If conservative treatment ultimately fails to help, manipulation under anaesthesia is an option. Under anaesthesia, the adhesions are carefully released by gently tearing them apart (manipulation). Nowadays, adhesions are also released internally through arthroscopic surgery. After surgery or manipulation under anaesthesia, continuing to exercise is essential to maintain the range of motion gained in the shoulder.