Tell me about shoulders…
The shoulder is a ball-and-socket joint, with a socket that is very shallow to allow for maximum movement and flexibility. It’s surrounded by a thick, strong capsule made of ligamentous tissue, which contains the synovial fluid which lubricates the bones and cartilage and keeps the joint moving smoothly, and which (along with the muscles) helps to prevent you from dislocating your shoulder joint.
What is a frozen shoulder?
What’s actually going on inside a frozen shoulder is still a bit open to debate, but essentially the capsule seems to get tight and sticky. This causes the shoulder joint to stiffen up and become sore when you try to move it, because joint capsules have a lot of nerve endings and do not like being stretched. The surrounding muscles then tend to go into spasm (because brains respond to all injuries in the same way: it might be broken and unstable, I must immobilise it) and gradually more and more of your upper body can stiffen up, along with the shoulder joint.
Why do we get frozen shoulder?
Adhesive capsulitis, more commonly known as frozen shoulder, is a condition that will affect between 2-5% of the population over the course of a lifetime. It affects more women than men, and is especially common after the menopause. It’s slightly more common to get it in your non-dominant shoulder. If you’re unlucky enough to be affected in both shoulders, you usually won’t have it in both shoulders at once.
There are two main types of frozen shoulder – primary and secondary. We don’t really know why primary frozen shoulder happens! One theory is that it can be a response to a minor shoulder injury (like jarring your shoulder if you trip and catch yourself from falling) but nobody has proved that this is actually true. We do know that you are more likely to get primary frozen shoulder if you have other conditions such as diabetes, heart disease, Parkinsons or depression; but again, we don’t know why.
Secondary frozen shoulder tends to happen after your shoulder has been immobilised for some reason, and then it doesn’t get going again afterwards. This could be after a fracture, after shoulder surgery, or sometimes after undergoing surgery for breast cancer. Again, it doesn’t seem to be especially predictable, as many people recover from these types of issues quite well. Theories as to the cause include factors such as hormonal issues, autoimmune problems, systemic inflammation, genetics, posture and occupation.
How is frozen shoulder diagnosed?
The key features of a frozen shoulder are stiffness and pain. However, it often takes a while before you really notice it, probably because it’s more often the non-dominant shoulder that develops it. So if you don’t tend to spend a lot of time putting your hair up, or doing up your bra behind your back, then it might be quite advanced before it really starts to affect your life… you’ll just gradually adapt to it, and possibly not notice until you try to do something out of the ordinary.
But other conditions can also cause stiffness and pain in the shoulder, so how do we know when it’s frozen? The real differentiator is that in a frozen shoulder, you lose the passive range of movement (ie when a doctor or therapist moves the arm for you while you relax your muscles) as well as the active range (which is when you can’t move it by yourself, which isn’t very uncommon in any condition that hurts!) We will often take an MRI scan of a shoulder that seems to be frozen, but that’s more about ruling out other structural problems that might be mimicking adhesive capsulitis, such as a torn rotator cuff, a torn cartilage, or a bone issue such as an unhealed fracture or a tumour.
What are the stages of frozen shoulder?
We often talk about there being three stages to a frozen shoulder, and rather aptly they are: freezing, frozen, and thawing!
The freezing stage is when most people notice it (which means, as I mentioned earlier, that there’s probably a pre-freezing stage when the movement gradually becomes restricted but you don’t notice it so much) as this is the most painful stage. People in this stage tend to hold the shoulder stiffly, with the shoulderblade hunched, and the arm tucked into the side. They can’t reach high shelves, and struggle (if it’s the dominant arm) to brush their hair or reach things out of their back pocket. They can’t sleep on the affected side, and it wakes them at night. They often also get sudden sharp pains, which can last for a few minutes, if they move the arm awkwardly.
The frozen stage is when the shoulder is at its stiffest. The pain will often decrease during this phase, but so will function, as you stop being able to move your arm very much at all. I’ve seen patients whose arms are almost welded to their sides in this stage, though they can often sleep more easily than when the shoulder was in the freezing stage. Normal daily activities – driving, showering, cooking, washing up, even eating – can get quite difficult during this period.
Finally, the thawing stage is where things start to recover. Gradually, movement starts to return. Left to its own devices, this can take anywhere from a few months to around three years, and full recovery is possible but not inevitable. In some cases, it is possible to recover from a frozen shoulder without treatment. However, high quality physiotherapy will usually help to speed up recovery, and lead to a better long-term outcome.
Can physiotherapy help?
In a word – yes! There are lots of things physios can do to help, from actually treating the shoulder and the surrounding area, to teaching you how to help yourself, to working out ways to manage your life and sleep so that your shoulder doesn’t take up too much of your life.
Frozen shoulder treatment
The first thing to do though, is to work out if it really is a frozen shoulder. As I mentioned, there are several other painful shoulder conditions that can mimic one, from a rotator cuff tear to a cartilage tear to a fracture; but it’s also possible for an apparently stiff shoulder to be compensating for an issue elsewhere in the body – for example, a stiff ribcage or a sore neck. We need to know what we’re dealing with before we can start treating it effectively.
Having said that, it’s important to be clear that treating a true frozen shoulder is not going to be a quick fix. Unsticking a joint that really feels as though it’s been superglued in place is not fun, and can be arduous, repetitive and time consuming. You will have to do a lot of stretching in between physio sessions in order to progress – this is not a condition physios can effectively treat passively, unless you plan to attend sessions pretty much daily!
What techniques do you use to treat frozen shoulder?
If you’re at all familiar with the way I work, you might already have guessed that I have cherry-picked techniques from a lot of brilliant clinicians and tutors! I will probably not use all techniques for every patient, but here are a selection of those that I use quite regularly, where appropriate.
In a frozen shoulder therapy session, I tend to do a fair amount of hands-on therapy, especially in the early stages, as this is the part you will struggle to do yourself at home. I will often be working on other areas of your body as well as the shoulder, as the shoulder has direct relationships with the ribcage, neck and elbow; and indirectly with a lot more of the body than that! Stiff or painful areas will often cause or react to other stiff or painful areas, so I believe it’s important to treat other problematic areas, as well as the shoulder, so that the other areas stop triggering the shoulder pain and stiffness.
I also perform techniques to the shoulder joint and muscles directly, often including
- “release with awareness” techniques to the biceps, rotator cuff, deltoids, trapezius and pectoral muscles to restore normal muscle tone
- fascial rolling techniques to restore glide between the different layers of soft tissue
- accessory mobilisation techniques to restore space and glide to the joints of the neck, shoulder, ribcage, clavicle and elbow
- passive stretches to the neck, ribcage and shoulder complexes to restore length to the muscles and ligaments
- neural gliding techniques to restore range to the brachial plexus
- neuromuscular facilitation techniques to help you activate and lengthen the affected muscles around the shoulder area
I then teach exercises to help you restore your shoulder function, including:
- initially, I tend to opt for closed-chain stretches as the brain tends to trust these more, and to allow the body to relax into the stretch.
- gradually, I add active assisted stretches using straps, poles and weights to encourage the muscles to function eccentrically
- later, sustained multidirectional open-chain stretches can help restore flexibility to the capsule
- at all stages, I think it’s important to include neural flossing and gliding exercises to encourage more flexibility in the nerves that go from your neck down your arms to your fingers
- similarly, weightbearing proprioceptive exercises help to retrain your brain and restore its trust in the affected arm, and over time the range and load can increase while the base of support decreases
- in the later stages, we are likely to add faster, more explosive and higher-load exercises, involving and integrating more areas of the body
- throughout the process, we keep revisiting your goals and your daily activities, so that we maintain the focus on making your life easier.
What other help might I need?
If we suspect that there might be something going on other than a pure frozen shoulder, then in the early stages we might want to get an MRI scan and/or an opinion from an orthopaedic shoulder surgeon, a rheumatologist or a sports doctor. Getting a full picture can be important, especially if the issue doesn’t appear to be straightforward.
Similarly, even if the issue does appear to be a straightforward frozen shoulder, if it doesn’t respond to physiotherapy in the way we expect it to (which happens in around 20% of cases), this is another reason to involve an orthopaedic shoulder surgeon. They may refer you to see a musculoskeletal radiologist for an injection. The two types of injections that are usually recommended for frozen shoulders are either a corticosteroid injection, if the issue seems to be more on the inflammatory side; or a hydrodilation, which is where they try to stretch the capsule from the inside, by filling it with water, a bit like filling up a balloon with water. Both of these approaches need to be done in conjunction with physiotherapy and stretching – they do not solve the problem on their own, but sometimes can be a useful adjunct.
If an injection does not help, then we could collectively decide that a trip to the operating theatre would be useful. An orthopaedic shoulder surgeon can help by surgically dissecting some of the tight bands of capsule that have got stuck together, and/or by performing a “manipulation under anaesthetic” which is essentially a powerful stretch, taking the shoulder through a full range of motion while you’re asleep. This can stretch or tear the adhesions in the capsule, which in turn should make it easier for the physiotherapy treatment and exercises to take effect.