What is a frozen shoulder?
frozen shoulder is a condition characterized by inflammation, scarring and
tightening of the connective tissue surrounding the shoulder joint, usually
resulting in a marked loss of shoulder movement.
shoulder joint is a ball and socket joint. The shoulder blade gives rise to the
socket of the shoulder, whilst the ball arises from the top of the humerus
(upper arm bone). Surrounding the ball and socket joint is strong connective
tissue holding the bones together known as the shoulder joint capsule (figure
- Anatomy of Frozen Shoulder
the shoulder joint capsule may become inflamed with subsequent tightening and
scarring of the shoulder joint capsule. When this occurs the condition is known
as a frozen shoulder and usually results in a marked loss of shoulder range
shoulders most commonly occur in people over 40 years of age and typically
affect women more commonly than men. They can generally be divided into 3
phases, each of which can last a number of months:
– In this first phase of a frozen shoulder, the shoulder typically becomes
painful with most movements. The shoulder may also start to stiffen during this
This second phase of this condition is characterized by a marked loss of
movement of the shoulder, coinciding with scarring of the shoulder joint
capsule. Patients typically experience difficulty when elevating the arm or
taking their hand behind their back. Pain may decrease noticeably during this
– In this final phase, the shoulder spontaneously begins to 'loosen' up and
movement to the shoulder is gradually restored.
Causes of a frozen shoulder
the exact cause of a frozen shoulder is not exactly known, it is thought to
occur following injury or damage to the shoulder joint or adjacent soft tissue.
In these cases, a frozen shoulder is more likely to develop if the initial
injury is not treated appropriately. This often occurs due to inadequate rest
from aggravating activities or adopting a 'no pain no gain' attitude. A patient
may also have an increased likelihood of developing the condition following
excessive immobility (i.e. not moving the shoulder, particularly after injury or
surgery) or if they suffer from other auto-immune diseases or diabetes.
Signs and symptoms of a frozen
symptoms associated with this condition usually develop gradually over time.
Patients typically experience a dull ache that may increase to a sharper pain
with certain movements or activities. Pain tends to be focused deep in the
shoulder, however may occasionally be experienced in the upper arm, upper back
and neck. Patients may also experience stiffness in each of these regions.
pain associated with a frozen shoulder may increase with any movement of the
shoulder and with activities placing stress on the shoulder joint. These
activities may include: arm elevation, lifting, carrying, pushing or pulling,
lying on the affected side and taking your hand behind your back (e.g. putting
on a bra). Patients with a frozen shoulder often experience pain at night or
upon waking in the morning. As the condition progresses from the painful phase
to the frozen phase, pain may reduce significantly.
from pain, patients also typically experience marked stiffness and significantly
reduced range of movement of the shoulder. This typically affects all shoulder
movements, but is most noticeable with rotation and elevation. This may present
as difficulty elevating the affected arm or an inability to take the hand behind
the back. As this condition progresses from the frozen phase to the thawing
phase, range of movement gradually increases with a subsequent reduction in
joint stiffness. Patients may also develop muscle wasting in the affected arm,
as the condition progresses, through lack of use.
a frozen shoulder generally affects only one side, some patients may develop the
condition in both shoulders.
Diagnosis of a frozen shoulder
thorough subjective and objective examination from a physiotherapist is usually
sufficient to diagnose a frozen shoulder. Further investigations such as an
Ultrasound or MRI scan may be required to assist diagnosis.
Treatment for a frozen shoulder
a frozen shoulder is established, little can be done to accelerate its course.
The best treatment is therefore prevention. Many patients may be able to avoid
developing this condition by ensuring they receive appropriate treatment for any
shoulder injury they incur and diligently adhering to rehabilitation protocols
as outlined by the treating physiotherapist. Once a frozen shoulder is
established, treatment is aimed at minimizing pain and maintaining range of
movement and function.
cases of frozen shoulder eventually settle well with appropriate physiotherapy.
The success rate of treatment is largely dictated by patient compliance. One of
the key components of treatment is that the patient rests sufficiently from ANY
activity that increases their pain. Activities which place large amounts of
stress through the shoulder should be minimized, these include: overhead
activities, throwing, heavy lifting, heavy pushing or pulling and sleeping on
the affected side. Rest from aggravating activities ensures that the body can
begin the healing process in the absence of further tissue damage. Once the
patient can perform these activities pain free, a gradual return to these
activities is indicated provided there is no increase in symptoms.
symptoms or adopting a 'no pain, no gain' attitude is likely to cause further
tissue damage and prolong recovery. Immediate, appropriate treatment in patients
at risk of developing a frozen shoulder or, who have the condition, is essential
to ensure the fastest recovery.
with this condition usually benefit from following the R.I.C.E. regime. The
R.I.C.E regime is beneficial in the initial phase of the injury (first 72 hours)
or when inflammatory signs are present (i.e. morning pain or pain with rest).
This primarily involves resting from aggravating activities, regular icing ,and
keeping the arm elevated (i.e. sleeping on the opposite side). Anti-inflammatory
medication may also benefit those with a frozen shoulder by reducing the pain
and swelling associated with inflammation.
with this condition should perform pain-free flexibility and strengthening
exercises as part of their rehabilitation to ensure an optimal outcome. The
treating physiotherapist can advise which exercises are most appropriate for the
patient and when they should be commenced. Exercises to improve posture and
upper back flexibility are also important. In the final stages of
rehabilitation, a gradual return to activity program is indicated as guided by the
Prognosis of frozen shoulder
cases of frozen shoulder tend to settle after a number of months. In severe
cases, symptoms may be present for 18 months or longer. Usually the painful
stage of a frozen shoulder lasts 2 - 6 months. The frozen phase approximately 4
-12 months, whilst the thawing phase may last an additional 4 - 18 months.
some cases, patients may experience ongoing and permanent restriction in
movement following completion of all three stages. However, most cases of frozen
shoulder will have a good outcome.
Contributing factors to the
development of frozen shoulder
are several factors which can predispose patients to developing a frozen
shoulder. These need to be assessed and where possible, corrected with direction
from a physiotherapist. Some of these factors may include:
- a history of recent
- a history of recent
- inappropriate treatment
following shoulder injury or surgery (particularly inadequate or excessive
- a history of diabetes
- a history of auto-immune
- age > 40 years
- poor posture
Physiotherapy for frozen shoulder
treatment for a frozen shoulder is vital to hasten the healing process and
ensure an optimal outcome. Treatment may comprise:
- soft tissue massage
- electrotherapy (e.g.
- joint mobilization
- dry needling
- ice or heat treatment
- exercises to improve
flexibility, strength and posture
- activity modification
- postural correction
- anti-inflammatory advice
- devising and monitoring an
appropriate return to activity plan
Other intervention for frozen
appropriate physiotherapy management, some patients with this condition do not
improve adequately or require other intervention to ensure an optimal outcome.
When this occurs the treating physiotherapist or doctor can advise on the best
course of management. This may include further investigations such as X-rays,
ultrasound, CT scan or MRI, pharmaceutical intervention, corticosteroid
injection, hydrodilatation, manipulation under anaesthetic or referral to
appropriate medical authorities who can advise on any intervention that may be
appropriate to improve the condition.
Exercises for frozen shoulder
following exercises are commonly prescribed to patients with this condition. You
should discuss the suitability of these exercises with your physiotherapist
prior to beginning them. Generally, they should be performed 3 times daily and
only provided they do not cause or increase symptoms.
Shoulder Blade Squeezes
this exercise by standing or sitting with your back straight. Your chin should
be tucked in slightly and your shoulders should be back slightly. Slowly squeeze
your shoulder blades together as hard and far as possible provided it does not
cause or increase symptoms (figure 2). Hold for 5 seconds and repeat 10 times.
– Shoulder Blade Squeezes
this exercise by leaning forwards with your good forearm supported on a table or
bench (figure 3). Keeping your back straight and your shoulder relaxed, gently
swing your affected arm forwards and backwards as far as possible pain-free.
Repeat the exercise swinging your arm side to side as far as possible pain-free.
Repeat 10 times each provided there is no increase in symptoms.
– Pendular Exercises (right side)
exercise by leaning forwards with your good forearm supported on a table or
bench (figure 4). Keeping your back straight and your shoulder relaxed, gently
swing your affected arm in circles clockwise as far as possible pain-free.
Repeat the exercise swinging your arm counter clockwise. Repeat 10 times in each
direction provided there is no increase in symptoms.
– Pendular Circles (right side)
this exercise by standing tall and facing a wall. Place your hand on the wall
and use your fingers to slowly finger-walk up the wall as far as possible
provided there is no increase in symptoms (figure 5). Repeat 10 times.
– Wall Crawl (left side)
Hand Behind Back
this exercise by standing tall, with your neck and back straight (figure 6).
Gently take your hand behind your back and up your spine as far as possible
provided there is no increase in symptoms. Repeat 10 times.
– Hand Behind Back (left side)
External Rotation with Stick
this exercise by standing tall with your back and neck straight and your
shoulders back slightly (figure 7). Keeping your elbow by your side and bent to
90 degrees, use a broom handle to gently push your hand to the side as far as
you can go without increasing symptoms. Repeat 10 times.
– External Rotation with Stick (right side)