Frozen Shoulder or Adhesive Capsulitis

This article was contributed by Brig Gen (R) Datuk Dr Muhammad Fuad B. Daud, Consultant Orthopaedic Surgeon (Arthroscopy & Sports Surgery), at Pantai Hospital Melaka. To know more about where and when to see Dr Muhammad Fuad B. Daud at his clinic, click here.

Frozen shoulder, also known as Adhesive Capsulitis is a condition which affects the shoulder joint causing pain, stiffness and also limits range of motion. This disorder may often develop rather slowly and can affect daily activities such as reaching for some objects or dressing or even combing one’s hair. Researchers have not yet completely understood frozen shoulder's exact cause. However, several factors may contribute toward its development. To help one understand all of the impacts and the full management of frozen shoulder, this article details an overview of the condition, causes, symptoms, diagnosis as well as treatment options.

What Is Frozen Shoulder?

Frozen shoulder is a condition in which inflammation, thickening, and stiffening affect the capsule around the shoulder joint. Being a structure of a connective tissue, the capsule allows movement that is free and it holds in place the shoulder joint. Frozen shoulder involves an inflammation of the shoulder joint capsule that leads to the formation of scar tissue. In affected people, this scar tissue restricts the shoulder's movement. 

The shoulder joint itself is a ball-and-socket joint, meaning that the ball of the upper arm bone (humerus) fits into a cup-shaped socket in the shoulder blade (scapula). The joint is surrounded by a capsule made of soft tissue that allows the shoulder to rotate and move in multiple directions. When the capsule becomes inflamed and thickened, the range of motion becomes limited, and pain is often experienced when attempting certain movements.

Causes of Frozen Shoulder

The exact cause of frozen shoulder is not fully known, but several factors are believed to play a role in its development. The condition is more common in people aged 40 to 60, with women being more affected than men. In some cases, frozen shoulder develops without any clear cause (idiopathic), while in other instances, it may arise as a result of a known injury or underlying health condition.

Primary (Idiopathic) Frozen Shoulder

In many cases, frozen shoulder occurs without any clear cause. This is known as primary or idiopathic adhesive capsulitis. It tends to develop gradually, with no prior trauma or injury to the shoulder. The exact mechanism behind this type of frozen shoulder is unclear, but it is thought that inflammation of the capsule leads to thickening and contraction of the soft tissue.

Secondary Frozen Shoulder

This form of frozen shoulder occurs due to another medical condition or injury. Some common causes include:

• Shoulder Injuries: People who have had a shoulder injury or surgery may develop frozen shoulder as a result of prolonged immobility. For example, a rotator cuff injury or fracture may cause a person to limit the movement of his shoulder, which could lead to the development of adhesive capsulitis.
• Diabetes: Individuals with diabetes are at a higher risk of developing frozen shoulder. The relationship between diabetes and frozen shoulder has not been fully understood, but it is believed that the condition may result from changes in the connective tissue and blood vessels due to poor blood sugar control.
• Thyroid Disorders: Both hypothyroidism (underactive thyroid) and hyperthyroidism (overactive thyroid) have been associated with an increased risk of frozen shoulder. It is thought that these thyroid imbalances can affect the body’s connective tissue and lead to inflammation of the shoulder capsule.
• Cardiovascular Disease: People with heart disease, particularly those who have had heart surgery, may be at greater risk for frozen shoulder. Poor circulation and prolonged immobility after surgery can contribute to the development of this condition.
• Parkinson’s Disease: Patients with Parkinson’s disease often experience muscle stiffness and rigidity, and this may increase the likelihood of developing frozen shoulder.

Symptoms Through Stages of Frozen Shoulder

Frozen shoulder progresses through three distinct stages: freezing, frozen, and thawing. Each stage is characterised by different symptoms, and the condition may last anywhere from several months to a couple of years. Understanding the symptoms at each stage could help individuals seek appropriate treatment and manage their condition effectively.

Freezing Stage (Painful Stage)

This is the first stage of frozen shoulder and is marked by gradual pain and discomfort in the shoulder. The pain typically starts as a dull ache and worsens over time, especially with movement. It is common for people in this stage to experience difficulty in sleeping, as the pain often intensifies at night. The freezing stage could last for a few weeks to several months, with pain becoming more pronounced.

Frozen Stage (Stiff Stage)

During the frozen stage, the pain may subside somewhat, but stiffness increases. The shoulder joint becomes significantly tighter and the range of shoulder motion is severely limited. Simple tasks such as lifting the arm, reaching overhead, or even brushing one’s hair can become incredibly difficult. This stage can last anywhere from 4 to 6 months or even longer.

Thawing Stage (Recovery Stage)

In the thawing stage, the stiffness begins to loosen up and the range of motion starts to improve. However, recovery is gradual and it may take several months for full mobility to return. This stage might last anywhere from 6 months to 2 years, depending on the severity of the condition and the treatment plan used.

In addition to pain and stiffness, individuals with frozen shoulder may also experience a noticeable decrease in the ability to move the shoulder. The loss of range of motion could make it difficult to perform everyday activities, such as reaching behind the back, lifting objects, participating in sports or exercising.

Diagnosis of Frozen Shoulder

Frozen shoulder is usually diagnosed through a combination of medical history, physical examination, and imaging tests. During the physical exam, the doctor will assess the shoulder’s range of motion and apply pressure to specific areas to check for pain and tenderness. The doctor may also ask the patient to perform certain movements to determine the extent of the stiffness and pain.

In some cases, additional tests may be required to rule out other conditions that could cause similar symptoms, such as arthritis or rotator cuff injuries. Common diagnostic tests include:

• X-rays: While X-rays do not show the soft tissue damage associated with frozen shoulder, they can help rule out other issues, such as arthritis or bone fractures.
• MRI (Magnetic Resonance Imaging): An MRI provides detailed images of the soft tissues around the shoulder joint, helping to confirm the diagnosis of frozen shoulder and identify any other issues affecting the shoulder.

Healthcare providers use a variety of methods to diagnose frozen shoulder effectively.

Treatment Options for Frozen Shoulder

Treatment for frozen shoulder depends on the severity of the symptoms and the stage of the condition. In most cases, non-surgical treatments are effective in relieving pain and restoring movement. However, in more severe cases, surgical intervention may be necessary. Below are the most common treatment options for frozen shoulder:

• Physical Therapy: Physical therapy is one of the most important treatment options for frozen shoulder. A physical therapist could work with the patient to improve shoulder mobility and strength through targeted exercises. These frozen shoulder exercises are designed to stretch the joint capsule and improve range of motion, helping to reduce stiffness and pain.
• Pain Management: Over-the-counter pain relievers, such as ibuprofen or acetaminophen, can help manage pain and reduce inflammation. In more severe cases, corticosteroid injections may be used to reduce inflammation and provide temporary relief from pain. These injections are typically administered directly into the shoulder joint.
• Heat and Ice Therapy: Applying heat or ice to the shoulder can help reduce pain and inflammation. Heat is generally used before physical therapy to relax the muscles and prepare them for movement, while ice is applied afterward to reduce swelling.
• Joint Mobilisation: In some cases, a healthcare provider may perform manual techniques to gently move the shoulder joint and break up adhesions. This helps to restore mobility and alleviate stiffness.
• Surgical Treatment: If conservative treatments are unsuccessful, surgery may be considered. The two most common surgical options for frozen shoulder are:
• Shoulder Arthroscopy: This minimally invasive procedure involves making small incisions and using a camera to guide the surgeon in removing scar tissue and adhesions from the shoulder joint.
• Manipulation Under Anesthesia (MUA): In this procedure, the patient is placed under general anesthesia, and the doctor moves the shoulder joint forcefully to break up scar tissue and improve movement.

Preventing Frozen Shoulder

While it may not always be possible to prevent frozen shoulder, there are steps that can reduce the risk of developing the condition:

• Stay Active: Regular shoulder exercises and physical activity may help keep the joint flexible and prevent stiffness.
• Treat Injuries Promptly: If one experiences a shoulder injury, seek prompt medical treatment and avoid prolonged immobility.
• Manage Underlying Conditions: If one has diabetes, thyroid disorders, or heart disease, it is best to work with one’s doctor to keep these conditions under control, as they can increase one’s risk of developing frozen shoulder.

Conclusion

Frozen shoulder is a painful and frustrating condition that may significantly impact an individual’s quality of life. While the exact cause is not always clear, it is believed that inflammation, injury, and underlying medical conditions can contribute to its development. Early diagnosis and treatment are essential for reducing pain, improving mobility, and speeding up recovery. With a comprehensive treatment plan, including physical therapy, pain management, and, in some cases, surgery, most people with frozen shoulder can make a full recovery. If one experiences shoulder pain or stiffness, it is thus highly advisable to consult an orthopaedic specialist to determine the best course of action.