What is Frozen Shoulder and Can You Prevent It?

Woman With Frozen Shoulder

This morning was the first time you couldn’t reach the cereal bowl in the upper kitchen cabinet – you’ve been struggling for a couple of weeks, but today you had to use your left arm. You’ve been having trouble putting on your shirts – coats require help from a friend. You’ve been waking up more and more each night from the pain. You might have Frozen Shoulder.

What is Frozen Shoulder?

Frozen Shoulder is also known as Adhesive Capsulitis, a shoulder condition that presents with pain and stiffness in the Glenohumeral (Ball-in-Socket) Joint.

A major difference between Frozen Shoulder and other pathologies of the shoulder is marked by limited Active and Passive Range of Motion.

Most other common conditions of the shoulder – tendinitis, impingement, bursitis – include pain and limited Active Range of Motion (AROM), while Passive Range of Motion (PROM) is normal.

The difference?

AROM is accomplished by your own effort. AROM requires contraction of the muscles and tendons which, if injured, will be painful and limit the motion. If the shoulder is being moved passively, though, the range should be normal because the painful tissues are relaxed.

With Frozen Shoulder, when the Joint itself is stiff, both active and passive range of motion will be limited.

A hallmark sign of Frozen Shoulder is near complete loss of both active and passive external rotation – with the elbow at your side, palm up, rotating your arm away from your body.

Who Does Frozen Shoulder Affect?

Frozen Shoulder affects 2.35% to 5% of the general population. In people with Diabetes and Thyroid Disease, that percentage increases to 10.8% to 38%1,2,3,4,5,6.

Frozen Shoulder typically affects people between the ages of 45 and 657,8,9.

Females are more affected than males10,11,12.

When one arm is affected, it is 5% to 34% more likely that the other arm will be affected at some point. 14% of the time, both shoulders are frozen at the same time 13,14,15.

How Does Frozen Shoulder Happen?

The actual cause of Frozen Shoulder is not fully understood. However, there may be a link to elevated cytokine levels in the blood.

Warning: we’re about to geek out.

Cytokines help repair tissues during the inflammatory process. If, for instance, you had a minor injury leading to inflammation, the increased cytokine levels could exaggerate the inflammation, causing increases in pain. This might then lead to an exaggerated fibrosis response, resulting in severely restricted motion of the shoulder16,17,18,19,20.

A much more practical reason you might get a Frozen Shoulder is due to prolonged immobilization after an injury or surgery to the shoulder.

It’s common after a fracture or Rotator Cuff Repair Surgery to have to immobilize the shoulder in a sling for roughly six weeks. During this period, the joint capsule can become quite stiff. I see it happen all the time.

How Long Does Frozen Shoulder Last?

Frozen Shoulder typically lasts about 30 months and happens in 3 phases21:

  1. Freezing: During the freezing phase, you gradually have more and more pain and stiffness.
  2. Frozen: During the frozen phase, the pain might be less, but the stiffness remains.
  3. Thawing: During the thawing phase, the shoulder slowly regains its range of motion. This phase typically lasts the longest.

How Is Frozen Shoulder Treated?

If you’re looking for a quick-fix for Frozen Shoulder, I’m sorry to say you’re probably not going to find one.

Research doesn’t support the benefits of most modalities such as heat, ice, ultrasound, electrical stimulation22.

Stretching exercises have been shown to improve pain and motion over time. However, depending on your level of irritability, aggressive stretching might actually make things worse23.

Therefore, it’s important to stretch in a gradual manner. For instance, if your pain level is high, you might want to start with low intensity stretches for a short duration of time. As you begin to be able to tolerate stretches over time, you can increase the intensity and duration.

How often should you stretch? I recommend most people stretch as often as possible – at least three times per day. That said, I also tell patients to listen to their bodies – if the pain is too much, only do what you can tolerate.

One thing Physical Therapists can do that you’ll have a harder time doing yourself is joint mobilization. It’s been shown that low and/or high grade joint mobilizations can improve motion and function in individuals with Frozen Shoulder24. However, it’s been shown that when people treated with joint mobilization and exercise (stretching) are compared to people treated with just exercise (stretching), both significantly improve25.

So… do you need to come to physical therapy every day to be stretched? No. I see patients with Frozen Shoulder infrequently – we’re talking once per week to start, then every other week, then once every month or two as pain begins to subside. Once pain levels are manageable and once you’re educated on what stretches to do, how to do them, and what to expect, you’re capable of essentially treating yourself.

Of course, everyone is different and has different needs. If someone is in a great deal of pain and finds joint mobilizations therapeutic, I might see that person more frequently – everyone responds differently, it just depends.

Even though as a PT, I don’t deal with the medication side of things directly, I’d be remiss to tell you about one other treatment alternative: corticosteroids (cortisone injections). It’s been shown that, in the first 3-6 weeks after an injection, symptoms can be significantly reduced26,27,28. However, no long term differences have been shown. I’m not a physician and I’m not personally recommending this as a treatment option. From what I’ve seen and read, corticosteroids are most favorable in patients with high irritability who don’t respond well to conservative treatment29. Please speak with your doctor about the potential benefits and side-effects of corticosteroids.

Can Frozen Shoulder Be Prevented?

Ahhh, the million dollar question.

My answer: It depends.

Sometimes Frozen Shoulder just happens and we don’t really know why.  In these instances, I don’t see how it can be prevented.

Other times, though, I believe Frozen Shoulder absolutely can be prevented.

How?

Remember: Frozen Shoulder often occurs after a period of prolonged immobilization, right?

Therefore, it’s imperative to keep the shoulder moving.

How do you move the shoulder when it’s immobilized?

Passively. After most surgical procedures involving the shoulder, passive range of motion is encouraged. The problem, though, is that most people don’t know what PROM is. Much of the time, they aren’t sent to PT until a few weeks later – sometimes I might not see them until after the full 6 weeks they’re immobilized!

So if you’re scheduled for surgery, or if you fracture your arm, ask your doctor about PROM and ask to be sent to PT – ASAP!

By the way, my advice to keep the shoulder moving goes for minor pains in the neck or shoulder region, as well. I can’t tell you how many times I’ve seen a patient who was initially diagnosed with tendinitis or bursitis that eventually became a frozen shoulder because, what to we do when we hurt? We stop moving.

My advice for minor aches and injuries like this: get going with PROM immediately. At the very least, buy a pulley on Amazon for super cheap, throw it over your closet door, and spend a few minutes stretching up and down a few times per day.

Be proactive instead of reactive.

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  1. Lundberg BJ. The frozen shoulder. Clinical and radiographic observation. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand. 1969;119:1-59. ↩︎
  2. Pal B, Anderson J, Dick WC, Griffiths I. Limitation of joint mobility and shoulder capsulitis in insulin and non-insulin dependent diabetes. Br J Rheumatol. 1986;25:147-151. ↩︎
  3. Aydeniz A, Gursoy S, Guney E. Which musculoskeletal complications are most frequently seen in type 2 diabetes mellitus? J Int Med Res. 2008;36(3):505-511. ↩︎
  4. Bridgman J. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis. 1972;31:69-71. ↩︎
  5. Balci N, Balci MK, Tuzuner S. Shoulder adhesive capsulitis and shoulder range of motion in type II diabetes mellitus: association with diabetic complications. J Diabetes Complications. 1999;13(3):135-140. ↩︎
  6. Milgrom C, Novack V, Weil Y, Jaber S, Radeva-Petro- va DR, Finestone A. Risk factors for idiopathic fro- zen shoulder. Isr Med Assoc J. 2008;10(5):361-364. ↩︎
  7. Neviaser RJ. Painful conditions affecting the shoulder. Clin Orthop. 1983;173:63-69. ↩︎
  8. Neviaser RJ, Neviaser TJ. The frozen shoulder. Diagnosis and management. Clin Orthop. 1987;(223):59-64. ↩︎
  9. Neviaser JS. Adhesive capsulitis and the stiff and painful shoulder. Orthop Clin North Am. 1980;11(2):327- 331. ↩︎
  10. Binder A, Bulgen D, Hazleman B, Tudor J, Wraight P. Frozen shoulder: an arthrographic and radionuclear
    scan assessment. Ann Rheum Dis. 1984;43:365-369. ↩︎
  11. Sheridan MA, Hannafin JA. Upper extemity: emphasis on frozen shoulder. Orthop Clin North Am. 2006;37:531-539. ↩︎
  12. Hannafin JA, Chiaia T. Adhesive capsulitis. A treatment approach. Clin Orthop. 2000;372:95-109. ↩︎
  13. Bulgen DY, Binder A, Hazleman BL, Park JR. Immu- nological studies in frozen shoulder. J Rheumatol.
    1982;9(6):893-898. ↩︎
  14. Griggs S, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am. 2000;82(10):1398-1407.
  15. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am.
    1992;74(5):738-746. ↩︎
  16. Bunker TD, Reilly J, Baird KS, Hamblin DL. Expression of growth factors, cytokines and matrix metalloproteinases in frozen shoulder. J Bone Joint Surg Br. 2000;82(5):768-773. ↩︎
  17. Rodeo SA, Hannafin JA, Tom J, Warren RF, Wickiewicz TL. Immunolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder. J Orthop Res. 1997;15(3):427-436. ↩︎
  18. Hutchinson JW, Tierney GM, Parsons SL, Davis TR. Dupuytren’s disease and frozen shoulder induced by treatment with a matrix metalloproteinase inhib- itor. J Bone Joint Surg Br. 1998;80(5):907-908. ↩︎
  19. Mullett H, Byrne D, Colville J. Adhesive capsulitis: human fibroblast response to shoulder joint aspirate from patients with stage II disease. J Shoulder Elbow Surg. 2007;16(3):290-294. ↩︎
  20. Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br. 2007;89(7):928-932. ↩︎
  21. Dias, Richard; Cutts, Steven; Massoud, Samir. Frozen Shoulder. BMJ : British Medical Journal; London331.7530 (Dec 15, 2005): 1453. ↩︎
  22. Ellenbecker TS, et al. The Shoulder: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts of Orthopedic Physical Therapy, 3rd Edition. 2011. ↩︎
  23. Diercks RL, Stevens M. Gentle thawing of the fro- zen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg. 2004;13(5):499-502. ↩︎
  24. Vermeulen HM, Rozing PM, Obermann WR, Saskia C, Vliet Vlieland TP. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther. 2006;86(3):355- 368. ↩︎
  25. Nicholson G. The effects of passive joint mobilization on pain and hypomobility associated with adhesive capsulitis of the shoulder. J Orthop Sports Phy Ther. 1985;6:238-246. ↩︎
  26. Arslan S, Celiker R. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. Rheumatol Int. 2001;21(1):20-23. ↩︎
  27. van der Windt DA, Koes BW, Deville W, Boeke A, de Jong BA, Bouter LM. Effectiveness of corticosteroid injections versus physiotherapy for the treatment of painful stiff shoulder in primary care: randomized trial. BMJ. 1998;317:1292-1296. ↩︎
  28. Carette S, Moffet H, Tardif J, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum. 2003;48(3):829-838. ↩︎
  29. Ellenbecker TS, et al. The Shoulder: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts of Orthopedic Physical Therapy, 3rd Edition. 2011. ↩︎
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  • Chisom

    Thanks for the write up, question is, you said there are 3 stages of the frozen shoulder; freezing, frozen and thawing. Can a freezing should be prevented from getting to the frozen stage, if diagnosed early and AROM exercises was encouraged plus the stretching?

    • Michael Curtis

      From what I’ve researched, if it’s a true Frozen Shoulder, the process will run its course. The role of treatment then becomes managing symptoms and maintaining ROM early on while regaining it later on.