Frozen Shoulder - Adhesive Capsulitis

What is Frozen Shoulder?

Frozen shoulder or adhesive capsulitis is a common source of shoulder pain. 

While frozen shoulder is commonly missed or confused with a rotator cuff tear/injury or other shoulder injury, it has a distinct pattern of symptoms resulting in severe shoulder pain, loss of shoulder function and eventually stiffness.

In basic terms, it means that your shoulder pain and stiffness is a result of shoulder capsule inflammation (capsulitis) and fibrotic adhesions that limit your shoulder movement.

What Causes Frozen Shoulder?

The condition often results from a predisposing injury to a structure within the shoulder joint. This then leads to an inflammatory response which impacts on the shoulder joint's fibrous capsule. This fibrous capsule is usually elastic in nature and provides a great deal of motion in the normal joint, however, as this structure becomes inflamed, pain with movement ensues and stiffening of the normal elastic capsule occurs.

This clinical presentation is often seen in a sub-group of the population that generally includes, however is not limited to, individuals between 40 and 60 years of age. Clinically, 2% of the population will be diagnosed with Adhesive Capsulitis across their lifetime, with the condition most prevalent in those with diabetes (11%). Women are also more likely than men to develop Adhesive Capsulitis for a variety of reasons.

What are Frozen Shoulder Symptoms?

Frozen shoulder has three stages, each of which has different symptoms. 

The 3 Stages are:

  1. Freezing – characterised by pain around the shoulder initially, followed by a progressive loss of range of movement. Known as the RED phase due to the capsule colour if you undergo arthroscopic surgery.
  2. Frozen – minimal pain, with no further loss or regain of range. Known as the PINK phase due to the capsule colour if you undergo arthroscopic surgery.
  3. Thawing – gradual return of range of movement, some weakness due to disuse of the shoulder. Known as the WHITE phase due to the capsule colour if you undergo arthroscopic surgery.

Each stage can vary in length of time from person to person.

How is Frozen Shoulder Diagnosed?

Frozen shoulder can be diagnosed in the clinic from your clinical signs and symptoms. 

A clinical diagnosis of frozen shoulder can be determined by a thorough shoulder examination. Your physiotherapist/doctor will ask about what physical activities you are having difficulty performing. 

Common issues include:

  • Unable to reach above shoulder height
  • Unable to throw a ball
  • Unable to quickly reach for something
  • Unable to reach behind your back eg bra or tuck shirt
  • Unable to reach out to your side and behind. eg reach for seat belt
  • Unable to sleep on your side.

In some cases you may be referred for X-rays or MRI to rule out other causes of shoulder pain. X-rays are not able to diagnose frozen shoulder. MRI or preferably MRA can provide a definitive diagnosis. A double-contrast shoulder arthrography is the traditional diagnostic method, although this is usually not required if you have a skilled shoulder practitioner assessing you.

Frozen shoulder is commonly misdiagnosed or confused with rotator cuff injury by inexperienced shoulder practitioners. It is important to get an accurate diagnosis since the treatment and recovery vary considerably.

Frozen Shoulder Physical Examination

Your physiotherapist will ask you to perform shoulder movements. Frozen shoulder has a distinct capsular pattern of stiffness:

Lateral Rotation > Flexion > Internal Rotation.

Normally, your rotator cuff strength will still be normal with the exception of pain inhibition. 

Frozen shoulders are commonly non-tender on palpation examination due to the pathology being quite deep. 

Quick movements are very painful with patients very keen to avoid any fast movements such as reaching or throwing and catching.

Who is Likely to Suffer from Frozen Shoulder?

It can be primary, with no known cause, or secondary, associated with an underlying illness or injury.

There are a number of risk factors predisposing you to developing frozen shoulder. 

These include:

  • shoulder trauma,
  • surgery,
  • diabetes,
  • inflammatory conditions,
  • inactivity of the shoulder,
  • autoimmune disease,
  • cervical cancer, and
  • hyperthyroidism.

Approximately 20% of people who have had a frozen shoulder will also develop frozen shoulder in their other shoulder in the future.

Frozen Shoulder Treatment

The management of this condition can include the use of medications to assist with pain relief and inflammation, as well as exercise rehabilitation. In some cases other interventions such as injections (hydrodilatation) and surgery may be required if significant change from more conservative measures fail.

Hydrodilatation

Hydrodilatation is an injection administered by radiologists whereby fluid under pressure is injected directly in to the joint. This fluid pressure helps to break down some scarring and contraction of the capsule. Cortisone in the fluid suppresses the inflammation of the lining and contributes to the effect.

The injection has a high success rate at alleviating at least some of the pain and stiffness. It is often painful to have it administered however only momentarily so. If it is somewhat effective however the symptoms return then it can be repeated. If performed early in the disease process it can shorten the time frame to natural resolution of the condition.

For more information, please contact your physiotherapist.

Josh Banky is a Physiotherapist. He works at Lifecare Prahran Sports Medicine on Monday, Tuesday Wednesday and Friday. The clinic is close to suburbs including Malvern, South Yarra, Richmond, Caulfield and Hawthorn, and has early and late appointments for all your Sports Medicine and Sports Physiotherapy needs.  You can find more on Josh on our practitioners page