Wednesday, May 13, 2020

Frozen shoulder (Adhesive Capsulitis) by William Dao

What is the injury?

Frozen shoulder is a gradual and progressive shoulder condition whereby inflammation, scarring, thickening and tightening of the connective tissue (joint capsule) around the shoulder joint results in severe pain and significant loss in range of movement of the shoulder. It affects approximately 3% of the population.

A frozen shoulder can occur on its own or along with other shoulder conditions such as Subacromial impingement/bursitis, Rotator Cuff tear/tendinopathy and Acromioclavicular joint disease.



How did I get this injury?

Frozen shoulder often presents with a gradual onset of pain and stiffness in the shoulder. It is often painful lifting your arm above shoulder height or reaching behind the back e.g. washing hair, doing up a bra strap or reaching for the wallet in the back pocket. It is commonly bothersome at night affecting one’s sleep. There is no clear or known cause for a frozen shoulder and how it begins. It is often more common in females than males and for those aged between 40 and 65.

It can occur after a shoulder injury or post-surgery, particularly if the arm has been immobilised for a period of time. Especially, for patients who are exceptionally protective of their arm/shoulder and avoid prescribed exercises post-operatively.
It is also more common for those who have diabetes, cardiac disease, hypothyroidism and hyperthyroidism, have had a stroke or have Parkinson’s disease. The incidence of frozen shoulder for those who have diabetes can be 10-20%. There has also been some occurrence after open-heart surgery or breast cancer treatment.
For those with a frozen shoulder in one shoulder, there is a 5-34% chance in having it in the other shoulder at some point. Approximately, 14% of cases will have it in both shoulders at the same time.


How long will it take to fix?

There are 3 overlapping phases of frozen shoulder:

A. Freezing/painful phase – Pain is often described to be unbearable and there is no particular position of comfort. It commonly affects sleep due to the presence of night pain. Restriction in range of movement becomes increasingly obvious due to pain limitations and the actual “thickening” or “tightening” of the joint capsule. The particularly painful period can last 2-9 months but the freezing can continue up to 12 months.


B. Frozen/Stiffening phase – Pain begins to reduce but progressive stiffening occurs to its maximal stiffness stage where some people are unable to move their shoulder at all because of the “tightened” joint capsule. This phase can last up to 12-18 months.


C. Thawing/Resolution phase – The capsule starts to “loosen” and range of motion gradually improves. This phase is typically not painful. It can take more than 24 months.
It can take 2-3 years before your shoulder feels normal again. Unfortunately, for some, symptoms may never completely subside which is why it is important to understand the condition, listen to your body and adhere to all professional advice from your Doctor or Physiotherapist to give it the best chance.


What do I need to do to Fix it?

There is no solid evidence to suggest that any particular treatment, conservative or surgical, to be 100% effective for frozen shoulder. However, we also know that many people don’t have full restoration of range of motion and strength without some form treatment. There is some research that shows some treatments can provide some short-term benefits with pain relief and some range of motion gains. Management in each phase of your Frozen shoulder is different.

• Freezing/Painful phase: Pain relief is the biggest focus during this phase. It is crucial to not aggravate the frozen shoulder. If pain is unbearable and affecting your sleep, seek medical advice for pain relief/analgesics. Try to support the arm with a pillow whilst sleeping if it is affecting your sleep or have forearm support on your office chair to reduce the gravitational load to your arm. Try to minimise pain provoking activities during this painful phase e.g. limit driving, take time off work as able, reduce over-head activities etc. Very gentle hands-on Physiotherapy treatment, dry needling and taping may assist with pain relief and temporary movement gains during this phase. We will also look at the neck, thoracic spine and scapular to address any stiffness in these areas that may contribute to the shoulder.

• Frozen/Stiffening Phase: We will continue with gentle hands-on Physiotherapy treatment in this phase (along with dry needling and taping as required). We will also implement more supported range of motion exercises and stretches to maintain and improve the range of movement in the shoulder as pain permits. We may implement some basic strengthening exercises around the shoulder and shoulder blade to the neglected muscles due to pain and stiffness.



• Thawing/Resolution phase: In this phase, we can start to push through range of motion more. We will continue with hands-on treatment with a stronger focus on end-range movements. We will also start to implement more advanced strengthening exercises for core, scapular and rotator cuff (shoulder) muscles. As long as the pain is settling, this is the phase where all the “fixing” happens to help regain a strong and functional shoulder/arm… Our primary goal is to reduce the duration of symptoms and to shorten the 2-3 year prognosis of this condition.

If pain is unbearable, persists despite analgesics/Physiotherapy and continues well beyond the expected time frames, we may refer you to either a Sports Physician or Orthopaedic specialist for their input.

It is very important to remember that the key to management is to be patient as we know it takes a long time to get better. It is a self-limiting condition but there are several treatment options to fix the problem. Now that you have a better understanding of the condition, remember to listen to your body and to adhere to all professional advice from your Doctor or Physiotherapist.

Here are some exercises you can start with during the Painful/Freezing phase to maintain as much movement in your shoulder as pain permits:


i. Shoulder pendular exercise


ii. Shoulder flexion/ elevation active assisted range of movement exercises


iii. Shoulder external rotation active assisted range of movement exercises

If you have any further questions on Frozen Shoulders or any of our other blogs then please email us at or come and see us at Fix Physio Sydney in Sydney CBD