Frozen shoulder is just one of the many shoulder complaints we see in our clinics in Dunstable and Leighton Buzzard. But what exactly is it, and what should you expect? In this article we look at the latest thinking behind this tricky condition.
Who gets frozen shoulder?
Frozen shoulder (more formally called ‘adhesive capsulitis’) occurs most often in adults between 40 and 60 years of age.
About 8-10% of adults will suffer from frozen shoulder at some point. However, it’s more common in people who have diabetes, affecting 1 in 5 patients.
It can develop in a shoulder that’s been injured (even a minor trauma, such as bumping the shoulder on a door). Sometimes it happens when your shoulder movement has been limited for a while, such as when immobilised in a sling.
We know it occurs more frequently in people who have certain other health conditions. These include diabetes, cardiovascular disease, Parkinson’s disease, and Dupuytren’s disease.
In other cases, there’s no apparent cause.
The reasons why people develop frozen shoulder aren’t clear. It’s possible that some people have an underlying susceptibility. This might be to do with a raised level of inflammation throughout the body. There’s some evidence that there may be a genetic link, too.
Once thought to be simply a shoulder problem, experts increasingly view frozen shoulder as a symptom of a systemic (body-wide) state.
Understanding this means we can develop ways to treat overall health as part of the management of frozen shoulder.
What are the symptoms?
Pain builds up in the shoulder gradually, over a period of weeks to months. People often first notice pain with certain movements, such as putting a jacket on, or reaching into the back seat of a car.
For many people, the pain is initially intermittent but becomes constant. The shoulder is often painful at night, disturbing sleep.
This combines with a gradual reduction in shoulder movement. First, you start to lose external rotation (turning the arm backwards, such as when drying your hair). Then, bringing the arm up to the side or the front becomes harder. As the shoulder becomes stiffer, you start to lose internal rotation (turning the arm inwards, such as when doing up a bra).
As the condition progresses over the months, the stiffness continues to get worse, although the pain starts to diminish. At its peak, it can be hard to move your arm at all, which can make everyday life difficult.
Eventually, the shoulder gradually starts to ease and movement returns. For over 90% of people, full function returns, although it can take up to about four years. A minority of people, however, continue to have residual symptoms for many years.
What’s happening in the shoulder?
The problematic part of the shoulder is the capsule (a tough pouch of connective tissue that encloses the joint) and nearby tendons and soft tissues. It’s not a bony problem, like arthritis is.
Investigation into the condition shows that the capsule becomes inflamed, and later it tightens and develops scar tissue.
We can describe the process of frozen shoulder as follows:
- The body thinks there’s a problem in the shoulder. The immune system activates, bringing about an inflammatory reaction. This is like the pain and swelling you get when you twist your ankle, for example.
- One of the functions of the immune response is to activate specialised cells called myofibroblasts. These are normally involved in healing, helping to contract a wound. Researchers think that they may be partly responsible for the contracture that happens in the shoulder capsule during frozen shoulder.
- Although contraction of the joint’s soft tissues can, at least in part, explain why movement becomes so limited, it turns out that there’s also a neurological inhibition. That’s when the brain is extremely reluctant to move the joint. This became clear when frozen shoulder patients who were under general anaesthetic, and thus totally relaxed, could have their shoulders moved. It therefore couldn’t be simply a structural problem. This might be the brain’s way of protecting a joint it thinks is in trouble.
- Further research shows that new blood vessels and nerve tissue grow in the joint, a process that can cause significant pain.
Although we don’t yet fully understand what triggers this immune reaction and inflammation, or why it happens in the shoulder, it seems likely that it’s a consequence of other issues in the body.
Some people already have high levels of inflammation, such as those with diabetes. It also appears possible that some people have a genetic predisposition that heightens their inflammatory response.
What should you expect if you have frozen shoulder?
For the vast majority of people, the good news is that the condition will resolve with no significant long-lasting effects. The real problem is that it can take a long time – often three or four years.
Some people will continue to have symptoms, though mild ones, for a much longer period – up to about 10 years. The duration and severity of symptoms tends to be worse for people who have diabetes.
What are the treatment options?
Decisions about what to do for frozen shoulder are highly individual.
Your decision will depend on whether your frozen shoulder is at the earlier ‘pain-predominant’ stage, or the later ‘stiffness-predominant’ stage. The severity of your symptoms will also affect your choice.
It’s best to talk to your GP, osteopath, physiotherapist or medical professional. They can work with you to decide what course of action, if any, will be best for you.
Here are some options:
- Do nothing. If your symptoms are manageable, you may prefer to wait it out. We know that, for most people, full function will return over a period of years. Evidence suggests, however, that earlier interventions tend to have better results. That may leave you at a disadvantage if you decide later that you need help.
- Medication: Some people just want help to manage the pain. In this case, your GP will be able to prescribe medication to help you cope. This won’t change the loss of function that comes with frozen shoulder, however.
- Injection: A corticosteroid injection into the shoulder reduces inflammation and pain. This is most effective if done within the first three to six weeks. The injection usually only provides relief for around six weeks, but for some people, that’s sufficiently helpful.
- Manual therapy: The goal of manual therapy is to reduce pain and inflammation in the shoulder joint, and to maximise good function in other areas of the body. Given that there’s often a systemic component to frozen shoulder, a therapist can often work with you to look at how you can improve your overall health. They can also suggest suitable exercises and give advice on altering your daily activities, so you don’t aggravate the pain. It’s important to find a therapist that has experience of working with frozen shoulder.
- Extracorporeal Shockwave Therapy (ESWT): This relatively new method is showing promise in the treatment of frozen shoulder. A trained clinician uses a device that applies soundwaves to the body. These stimulate a natural process of healing and has been shown to speed up recovery times.
- Invasive procedures: These are sometimes recommended for more severe or persistent cases. Your doctor may suggest hydrodilatation, where fluid is injected into the joint to stretch the capsule. Alternatively, shoulder manipulation can be performed under general anaesthetic. This helps to loosen the shoulder. However, there is a risk of other damage, such as fracture. Finally, surgery can remove some of the scar tissue that develops inside the joint.
The Woodside Clinic approach to frozen shoulder
When treating frozen shoulder, .your osteopath’s or physiotherapist’s aim is to alleviate pain and maximise function as far as possible. And, just as when treating any condition, this involves assessing and treating other areas, not just the painful area.
This is because there will be a knock-on effect elsewhere in the body. And, in a similar way, if other areas, such as the neck or upper back, are restricted, this will limit the capacity of your shoulder to cope.
Your osteopath or physiotherapist will talk with you to get an understanding of your level of pain and function, and how the condition is affecting your daily life.
They will examine your shoulder and other areas of your body. This will give them an idea about how far your condition has progressed. It also gives some information about other factors that could be influencing your shoulder.
They will work to reduce spasm in the muscles around the shoulder, easing tension and helping you relax.
It’s important to keep your shoulder moving as far as you’re able. It’s easy to develop a fear of moving because of the pain, but evidence shows that guarding your shoulder can worsen your experience of the condition.
Your osteopath/physiotherapist will work with you to encourage movement according to your stage, pain levels and ability. They will give you advice on how to exercise your shoulder within your limits. There’s no benefit in pushing through the pain – gentle movement is enough to help joint health and function.
Your therapist can also help you look at other areas of your life that might be impacting your shoulder and advise you on helpful changes you can make. As we increasingly understand frozen shoulder to be one aspect of a whole-body issue, it seems appropriate that treatment should be as holistic as possible.
Looking for treatment for your frozen shoulder?
At Woodside Clinic, we have osteopaths and physiotherapists experienced in the treatment of frozen shoulder. If you wish, you can choose to combine manual therapy with nutritional therapy or shockwave therapy to maximise your health and speed your recovery.
Get in touch today – you can book online here.