How to treat a frozen shoulder

I’ve never understood why people describe Frozen Shoulder or Adhesive Capsulitis as a self-limiting condition that fully resolves over time. It doesn’t resolve by itself. You have to work VERY hard to get your full shoulder function back to normal and then it still doesn’t always get back to where it was before. And this is not just my opinion - the research also shows that several patients will still have limited range of motion or pain 5 years after developing a frozen shoulder.

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In this article:

• What causes a Frozen Shoulder?

• Treatments for Frozen Shoulder

Here's the video of the live stream I did about Frozen Shoulders. You'll find a detailed demonstration of some of the exercises that I prescribe my patients.

What causes a Frozen Shoulder?

Researchers are not quite clear yet on why some people develop frozen shoulders. What they do know is that it seems to be caused by an over-reaction of the immune system. Your own immune system causes a massive inflammatory reaction (inflammation) in the shoulder which causes adhesions, fibrosis and thickening of the capsule and ligaments that surround the shoulder joint. This in turn causes the space inside the joint to narrow.

Primary frozen shoulders develop without any clear cause while secondary ones can be triggered by a trauma or injury to the shoulder.

Women between the ages of 40 and 60 tend to get this more often than men. I couldn’t find any research that linked this to the menopause but one has to wonder if it plays a role when you look at that age bracket. Other conditions that have been found to be risk factors include having auto-immune conditions e.g. rheumatoid arthritis, diabetes, very high cholesterol, thyroid disease and after having a stroke.

Treatments for Frozen Shoulder

For most patients their frozen shoulders usually start with a niggle which very quickly (over days or weeks) turns into a very painful shoulder that interrupts their sleep. During this phase my patients are often very frightened of moving the arm since even small movements or bumps can cause intense pain. This pain is thought to be mostly due to the active inflammatory reaction that is taking place inside the shoulder’s capsule.

Most of my patients find very little relief from regular pain medication and anti-inflammatory drugs during this stage. I also find hands-on therapies like massage and dry needling often have extremely short lived effects when the shoulder is in this very painful phase and they’re pretty much a waste of time because they don’t alter the inflammatory response, hence the pain just returns.

The most useful intervention for this stage is a corticosteroid injection and I tend to work very closely with our sports doctors when it comes to frozen shoulders. We’ve found that early intervention with corticosteroid injections can shorten the painful phase (and the research agrees) because it shuts the inflammation down and this in turn prevents our patients from losing so much of their movement. The research has also shown that injections into the shoulder joint are more effective than ones into the sub-acromial space.

Once the inflammation has calmed down and patients report that they can sleep better at night, both massage and dry needling can help to reduce muscle spasm and pain that is caused through the irritated muscles in the neck and shoulder girdle.

Exercise is an extremely important part of the treatment for frozen shoulder. BUT please don’t do forceful stretches when your poor shoulder is in the very painful phase. You’ll just make the pain feel worse. Gentle pendulum movements are more appropriate during this phase (see the video for a full demonstration).

Throughout this painful stage the shoulder starts to progressively stiffen up due to the adhesions and thickening of the capsule and ligaments. People with frozen shoulders usually have severely limited range of motion. In practice I find that external rotation and trying to take the arm behind their backs are by far the 2 most limited movements.

As your shoulder pain settles down, doing strong stretches are very important. I don’t believe in doing strong painful stretches or passive mobilisation for my patients in the clinic. I get very good results from just getting them to do their own stretches 3 to 5 times a day. Doing little bits often seem to produce very good results, BUT the stretches has to be held for 30sec or longer in a strongly uncomfortable range and repeated at least 4 times (see the video for a detailed explanation). They should not cause their shoulders to hurt for more than 30minutes after doing the exercises and it should definitely not stir up their night pain.

If we reach a plateau and the shoulder seems unwilling to budge despite them doing their exercises regularly, I will usually refer them back to the sports doc for an Ultrasound–Guided Hydrodistention injection. During this injection the doctor injects a large volume of sterile water into the joint capsule, causing it to stretch. This works really well. In the old days the only option for these patients would have been to have the shoulder manipulated under anaesthetic, but these injections work just as well and they are much less traumatic. Manipulations under anaesthetic can cause labral tear, rotator cuff tears and even fractures.

I usually also introduce strengthening exercises long before my patients have regained full range. I find that this can help them regain their range of motion more quickly than if they were only doing flexibility exercises (see video).

In practice I find that with this combination of treatment (injections + exercise) my patients take between 4 to 6 months to get 90% of their shoulder function back. They then have to work very hard for at least another 6 months to get that last 10%.

In the sports medicine practice that I’ve worked in for the last 9 years we’ve never had to send a patients for surgery. I think this is down to the combination of the injections and exercise and making sure that patients understand that they have to be VERY diligent with their exercises.

Let me know if you have any questions. Need more help with an injury? You can consult me online via video call for an assessment of your injury and a tailored treatment plan.

Best wishes

Maryke

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram.

References:

1. Brukner, P, et. al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education.

2. Akbar M, McLean M, Garcia-Melchor E, et al. Fibroblast activation and inflammation in frozen shoulder. PloS One 2019;14(4):e0215301.

3. Butt MI, Iqbal T, Anjum S. Comparison Between Manipulation Under Anaesthesia and Intra-Articular Steroid Injections for Frozen Shoulder. Journal of Rawalpindi Medical College 2018:342-45.

4. Chen R, Jiang C, Huang G. Comparison of intra-articular and subacromial corticosteroid injection in frozen shoulder: A meta-analysis of randomized controlled trials. International Journal of Surgery 2019

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