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Recovery Tip

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Frozen Shoulder

It’s something that everyone has heard of but not too many people know what it is. Frozen shoulder is a common term for a condition called adhesive capsulitis.


There are three stages to Frozen Shoulder (FS):

Freezing Stage (1)

This is the first and most painful stage of the FS cycle. In this stage, there is rampant inflammation in the capsule or ligaments of the shoulder. This causes adhesions – for the ligaments that make up the capsule to stick to themselves.

Usually this is at the bottom of the capsule, as you can see here. The most common directions of shoulder movement that are restricted because of this are flexion (raising your hand in front of you), abduction (raising your hand to the side) and external rotation (moving your forearm away from your body, with your elbow by your side).


A common sign of this stage is that when the movement is restricted, it gets gradually more painful until the end of the movement, which is most painful. This makes it tricky for your physiotherapist, because this also mimics other conditions and injuries of the shoulder. That is why a proper comprehensive analysis of the shoulder is required.


In this stage, the main forms of treatment involve preserving the range of motion of the shoulder and strength of the shoulder muscles, and decreasing pain. Anti-inflammatories are particularly effective in this stage of FS. Hands-on treatment and electrotherapy for pain, and an at-home exercise program for movement and strength are the main forms of treatment in the Freezing stage.


Frozen Stage (2)

This is where the shoulder is truly ‘frozen’. The inflammation gradually recedes, and the pain lessens. However, the range of motion restriction remains. People in this stage of FS have limited movements, but no pain at the end of the movement – the arm just doesn’t move any more.

Treatment in the Frozen stage usually consists of improving range of motion while respecting pain levels. However, a lot of people find they get pretty frustrated with physiotherapy in this stage of the disease because it can be very difficult to make even small improvements. According to research on FS, regular hands-on treatment is not any better than a self-management program in this stage of the disease.  It’s important to maintain communication with your physio so they can monitor your progress and adjust your program accordingly.

Thawing Stage (3)

This is the final and most productive stage of a FS. In this stage, there is no inflammation so pain is usually at a reasonable level – until your physio gets their hands on you!

Hands on treatment for this stage of FS consists of breaking down those pesky adhesions in the shoulder capsule. This involves pushing the shoulder into the end of range, and then pushing a little further to break down the scar tissue and collagen cross-bridges that are restricting the shoulder. It sounds pretty painful (because it can be) but it is incredibly effective in regaining range of motion for the final stage. Some patients find that over-the-counter pain medication about 30 minutes before their appointment helps to tolerate the treatment and it’s after effects.

Your physio will also upgrade your exercise program, relatively quickly, during this stage of the healing process. By regaining range, we are able to challenge the shoulder muscles in more ways and regain other important things like strength, joint-position sense and improved timing of muscle activation (neuromuscular control). This helps get you back to your old self, with a fully functional and pain free shoulder, as fasts as possible.


How Long Does a Frozen Shoulder Last?

Most of the research agrees that the full three stages of a FS is finished within 18 months to 2 years after the patient first presents to a health professional. The length of time of the individual stages varies from person to person.


Who gets a Frozen Shoulder?

There are a few risk factors for developing FS, but there are no hard and fast answers about who gets it. FS can develop in one or both shoulders, at the same time or one after the other. The good news is, it doesn’t seem to affect the same shoulder twice.

Risk factors include:

-       Female gender: for every 42 males affected, there are 58 females

-       Age: 40-65 years

-       Recent surgery or trauma

-       Hormonal/Metabolic disease: e.g. diabetes, thyroid disease

-       Cardiac diseases

-       Neurological disorders: e.g. stroke, Parkinson’s

-       Malignancies i.e. cancers

-       High cholesterol

-       Some medications

-       Dupuytern’s contracture (a musculoskeletal condition of the hand/last two fingers)


What causes Frozen Shoulder?

Well, we’re not really sure. There are a few theories as to why FS happens. Some theories focus on an inflammatory driver of the contracture whereas others focus on a fibrosing driver. 


How do we fix Frozen Shoulder? 

The unknown aetiology is partly why scientists find it so hard to decide which treatments are best for a FS.


Physiotherapy treatment is usually referred to in the literature as ‘conservative management’, because it doesn’t involve an “intervention”.

Some of these are called

-       Rest

-       Educating the patient about the condition

-       Pain relief (e.g. medications)

-       Joint mobilisation

-       Thermotherapy (e.g. heat packs)

-       Massage

-       Exercises

-       Acupuncture/Dry Needling

-       Laser therapy


Other treatments of a more surgical nature include

-       Oral or injected corticosteroids

-       Capsular distension (where a surgeon uses saline solution to blow up the capsule like a balloon, which breaks the adhesions)

-       Manipulation Under Anaesthetic (where a surgeon knocks you out and pushes your arm way up above your head, to break the adhesions)

-       Nerve blocks (a surgeon injects an anaesthetic into the nerve, to make it and everything is supplies go numb)

-       Arthroscopic capsular release (where a surgeon cuts into the capsule to release it)