What to Know About a Frozen Shoulder

When 47-year-old hypothyroidism sufferer Simon Perry noticed raising his left arm was mildly painful, he was unable to recall incurring an injury. Ten weeks later, he was in his doctor's office, his shoulder stiff and sore to the degree he avoided using his arm.

"I never knew about frozen shoulder until I Googled my symptoms," says Perry. "It's one of those things you've not heard of, but once you mention it to others, chances are they've either had it or know someone who has."

According to the University of California San Francisco orthopedics department, five to twenty percent of people will develop frozen shoulder (FS), primarily women between 40 and 60. Its Japanese name even translates as "50-year-old shoulder." 

Medically known as adhesive capsulitis, inconsistencies in scientific studies and disagreement amongst medical professionals on best management practices complicate it.

Sufferers experience differing combinations and severity of symptoms; the onset can be gradual or sudden after an injury, surgery, a period of inaction or even nothing. FS typically starts with the insidious onset and progressive worsening of shoulder pain, lasting beyond three months. It is usually worse at night – resulting in sleep disruption – and when the arm is moved. 

The joint progressively loses active and passive range of motion (ROM), becoming increasingly stiff and more painful until the sufferer can barely lift their arm. The stiffness arises via fibrosis, the thickening of tissues in the joint capsule, leading it to contract, leaving less room for movement. 

Most often, the non-dominant arm is affected, with external rotation usually the first movement compromised. As it progresses, the ROM in all directions can become severely limited, impacting work and daily life. Even showering and dressing can require assistance. 

As Perry says, "A few months after symptoms began, I couldn't sleep on my left side. My left arm movement was weak and severely limited. The pain was striking. It stopped me interacting as physically with my children. I could only use my right hand to wash in the shower or carry groceries. Hot and cold packs didn't work."

FS lasts 30 months on average, usually progressing in 3 stages:

• Freezing (2–9 months) – inflammation-related pain dominates as the shoulder capsule tightens and ROM decreases.
• Frozen (typically 4–12 months) – stiffness persists while inflammation-related pain typically subsides.
• Thawing (12–42 months) – ROM increases as the joint gradually releases.

Not everyone experiences all stages, and progression can be variable.

While there is no specific test for FS, it is diagnosed according to clinical symptoms, medical history, physical examinations of ROM and imaging to eliminate other causes, such as rotator cuff tears. An anesthetic injection into the shoulder joint is sometimes also used diagnostically to rule out impingement.

While the cause of FS is unclear, studies have identified a higher risk among those with:

• Diabetes — a 10-20% lifetime risk, plus an increased likelihood of both shoulders simultaneously being affected
• Shoulder injury resulting in immobility or reduced mobility of the shoulder joint
• Thyroid problems, particularly hypothyroidism
• Stroke
• Heart disease
• High blood cholesterol
• Dupuytren disease
• Parkinson's disease
• Cancer

Dr. Allan Mishra, an adjunct clinical associate professor of orthopedic surgery at Stanford University, says, "About 75% of my patients with frozen shoulder are women. The hormonal changes during menopause may play a role in [its] development. Some evidence suggests hormonal therapy may reduce the risk of developing FS…but more work needs to be done to confirm initial studies. Patients with diabetes are also at higher risk for longer lasting and more serious cases." 

Theresa Marko, physical therapist and spokesperson for the American Physical Therapy Association (APTA) concurs, "Given the high prevalence of diabetes and prediabetes in patients with adhesive capsulitis, fasting glucose testing may be considered [in those patients with FS]."

It's important to keep using the arm – as pain allows – and seek treatment. A 2021 review stated FS may persist beyond three years and never resolve without treatment. 

Mishra says, "A combination of treatments is typically used to treat frozen shoulder. These include anti-inflammatory medications, heat and stretching exercises. Injection therapy may be needed for patients who fail initial treatment. Rarely is surgery required to address the condition definitively." 

According to Marko, "A physical therapist will provide a thorough evaluation and determine what stage you are in and create an individualized treatment program. The program will be tailored to your specific needs and will aim to restore your movement."

Non-surgical treatment includes physiotherapy (PT):

• Supportive management (freezing stage) – analgesics, heat/ice packs, gentle range-of-motion exercises, hands-on therapy.
• Structured PT (frozen and thawing stages) – stretching and strengthening exercises, manual therapy.
• Corticosteroid injections (if PT alone is ineffective) – administered into the joint, give short-term improvements compared with no treatment; a combination of injections and PT show limited improvements compared to either alone.

For patients presenting intolerable symptoms and minimal improvements after 6-12 weeks of non-surgical treatment, the American Academy of Family Physicians suggests seeing an orthopedic surgeon. Surgical options are:

· Hydrodilatation – a saline, corticosteroid and anesthetic combination injected to expand the joint. Limited studies have produced conflicting results on efficacy.

· Arthroscopic capsular release (ACR) – keyhole surgery whereby the shoulder is freed by cutting the tight tissues surrounding it.

· Manipulation under anesthetic (MUA) – surgery whereby the shoulder is manipulated to stretch and tear tightened tissues. 

Researchers in 2022 noted at three months, outcomes of ACR were worse compared to PT with corticosteroid injection or MUA. However, at 12 months, none was clinically superior, but ACR was higher risk than MUA.

Perry took Ibuprofen to reduce pain and swelling, followed by PT. When he couldn't complete any exercises due to pain and limited movement, the physiotherapist pared the exercises back to a single movement. 

He thinks PT made no difference. He was referred to an orthopedic doctor who administered a corticosteroid injection. "Within days, my ROM improved by fifty percent, and within the next few months, most of the rest came back," he said. Three years later, Perry says his shoulder is pain-free, although he's doubtful he got his full ROM back. 

Residual pain and stiffness occur in about 10% of FS sufferers post-recovery. Writing in 2022, medical authors note that the recurrence of FS in the same joint is rare, but up to 20% of patients can develop the condition in the other.

In their 2021 review, researchers hypothesized today's sedentary lifestyles and reduction in manual work – particularly among women – have led to an underuse of the arms, contrary to their evolutionary design, resulting in weakness, lower-than-intended ROM and a predisposition for developing FS. 

To ensure shoulders stay healthy, the obvious thing is keeping them strong and operating in their full ROM. Mishra says, "[FS] may be prevented by executing a consistent set of stretching exercises. Keeping your shoulder warm in the wintertime with a heating pad may also help prevent the condition from developing." 

"I always recommend a stretching routine, especially as you age," says Marko. "Although it may not prevent FS, it certainly can't hurt to have that already established. If you've had FS before, your physical therapist will advise on a maintenance routine and likely make sure you've had updated blood and hormone work from a PCP."

To prevent or treat FS, perform each exercise three times daily. Consistent effort is the key to improvement. Consult your physician before attempting these exercises.

1. Shoulder Circles

• Bend over at your waist. Put the opposite hand on a table or countertop
• Let your arm dangle, then rotate it ten times clockwise
• Then, rotate it ten times in a counterclockwise direction

2. Shoulder Blade Squeezes

• Squeeze your shoulder blades together slowly
• Release and repeat five times

3. Touchdowns

• Hold a light stick (broomstick or golf club) with both hands
• Start with hands on the stick at waist level
• Slowly raise the stick to eye level with your elbows straight
• Use your unaffected arm to help raise your affected arm
• Repeat five times

Indi Bains is a writer and editor whose essays and articles on health, history, science, and travel have appeared in National Geographic, Atlas Obscura, Mental Floss, and other publications. You can find more of her work here: www.indibains.com Read More