Signs, Symptoms, and Treatment of Frozen Shoulder

by Johnathan Bernard, MD

Signs, Symptoms, and Treatment of Frozen Shoulder

A lot of people are familiar with or have been diagnosed with adhesive capsulitis, commonly known as frozen shoulder. At this point in our medical research of the condition, we are not exactly sure how it is caused or why it occurs. What we do know is that it is basically the inside lining of the shoulder starting to “freeze.” It gets extremely inflamed, and it creates a contracture, which stiffens inside the shoulder.

Certain risk factors can increase the likelihood of frozen shoulder developing. For instance, after having surgery, your arm may be immobilized for an extended period of time. Medical conditions such as diabetes or thyroid conditions can also heighten the chances of developing frozen shoulder. We also know that this condition occurs more frequently in women that it does in men.

A frozen shoulder goes through three different phases. First, it begins with the freezing process. You won’t have pain at rest, but pain will begin to occur when you move your shoulder, and the amount that you can move your shoulder will be gradually reduced. Then, your shoulder will progress to being “frozen,” where it is very difficult to move and you may be in pain even when at rest. Eventually, the shoulder will “thaw out” as it slowly starts to loosen up. These three distinct phases can take days, weeks, or months to go through.

Dr. Jo Hannafin, a physician working bath the Hospital for Special Surgery where I trained, is responsible for a lot of the groundbreaking work regarding frozen shoulder. She discovered exactly how it works, how it occurs, how to treat it, and what to do early on in the freezing process. If you use a cortisone injection early, you can actually stop the shoulder from freezing.

Physical therapy plays a huge role in helping patients get back to their full range of motion. When the shoulder starts to thaw out and is less painful to move, you can work with a physical therapist to stretch that shoulder capsule out. There are several at home exercises you can do to help improve your mobility that your physical therapist can show you.

For diagnosis of a frozen shoulder, we will often start with x-rays. There are plenty of other things that can cause stiffness in the shoulder. I like to think of what’s called a differential or everything that could possibly cause shoulder pain. I will categorize your specific condition with either pain, weakness, stiffness, or instability and group all of these differentials together. An x-ray won’t tell us

as physicians if you have frozen shoulder, but it will show us if you have impingement, rotator cuff problems, arthritis, calcific tendonitis, and so on.

The physical exam is what will help determine if you have frozen shoulder. One of the classic things I see on a physical exam for a frozen shoulder is that you lose external rotation, which is when you move your arm out to the side. If you’ve really plateaued and are not improving after six to eight weeks of physical therapy, an MRI may be ordered by your physician to look at the details of the ligaments, tendons, cartilage, and bone. Surgery is the last resort. If needed, we can do an arthroscopic approach to remove any scar tissue or address any other issues that could be causing your shoulder pain.

Frequently asked questions

Does strengthening the deltoid muscle and surround muscles help with frozen shoulder?

Absolutely.

The deltoid muscles act as a lever and helps bring the arm up. Strengthening that deltoid muscle allows for that arm to have better range of motion. If the deltoid muscle is weak or inflamed, the way in which the shoulder moves can be altered, and it’s very difficult to restore normal function if the deltoid is weak or impaired. One of the first things we try to do when dealing with frozen shoulder is to activate the deltoid to get the shoulder motion going.

Does chiropractic or manual therapy help loosen the shoulder and diminish pain?

When we treat adhesive capsulitis, we look at the different phases of frozen shoulder and try to anticipate what intervention will work best at what phase. I actually discourage any sort of manipulation during the freezing phase. The cortisone injection is more suited for that specific phase or waiting until you’re not actively freezing to perform manipulations.

There are a lot of great chiropractic manipulations once you’re starting to thaw and get the rest of range of motion back. Manipulating the shoulder by putting pressure in certain areas is very helpful. We’ll sometimes do what’s called a manipulation under anesthesia for patients who haven’t reached their desired results in therapy. We’ll perform a regional block by numbing up the nerves and then gently pressing on the shoulder. Then, we’ll have patients immediately go to therapy. There’s a huge role for chiropractic manipulation at that time because the muscles can contract.

How do I know if I have frozen shoulder or if my shoulder cartilage is worn out?

One of the telltale signs of adhesive capsulitis is when you lose your external rotation. Arthritis can also cause that loss of range of motion with external rotation, but unlike adhesive capsulitis, arthritis does appear when we perform an x-ray. That’s another reason why we get x-rays of the shoulder to rule in or out arthritis.

Is there a risk of long-term complications with frozen shoulder?

There’s no specific risk of long-term complications from adhesive capsulitis. I often will try to decipher what the source of a patient’s pain is. X-rays give us a good sense of your ligaments, tendons, cartilage, and bones. You can sometimes have bone spurs that rub against the rotator cuff tendon, and if you lose range of motion from frozen shoulder, you can make things like a rotator cuff tear worse.

Could a sudden movement such as reaching back to push a seat belt release button lead to frozen shoulder?

Yes, I’ve seen some patients do that exact motion and trigger frozen shoulder. It can happen from something as innocent as a life event such as reaching behind you for a seat belt. Frozen shoulder just needs a spark, and once the kindling is lit, the inflammation can lead to both your active and passive range of motion being affected.

A common complaint I hear from patients, especially women who have never injured their shoulder, is that they will be doing a daily life activity such as reaching for a seatbelt or reaching behind their back for a bra strap and will trigger frozen shoulder. Unfortunately, there’s no real prevention method that you can do in these situations