Frozen Shoulder: Symptoms, Causes, Stages, Treatment & Test

A frozen shoulder (medical term: adhesive capsulitis) is a painful condition that affects the shoulder joint. It involves pain and stiffness in the shoulder joint leading to limited movement. 

The shoulder is a ball-and-socket joint comprising three bones: the humerus (upper arm bone), the scapula (shoulder blade), and the collarbone (clavicle). 

1. The humerus head fits into the shallow socket of the scapula. 
2. Strong connective tissue, known as the shoulder joint capsule, surrounds the joint. 
3. Synovial fluid lubricates the shoulder joint and capsule to help the shoulder move easily. 

Usually, the shoulder capsule has folds that expand and contract as the arm moves in various positions. However, in a frozen shoulder, the capsule becomes inflamed, a band of scar tissue (adhesion) develops, and there is less synovial fluid to keep the joint lubricated. This further causes pain and restriction in shoulder movement.

Frozen shoulder, depending on its causes, can be of the following two types:

1. Primary adhesive capsulitis: This condition may affect both shoulders and remain resistant to most forms of treatment. The cause of primary adhesive capsulitis is not known. It may result from changes in the immune system or hormonal imbalances. 
2. Secondary adhesive capsulitis: This type of frozen shoulder is acquired and develops from a known cause, such as stiffness after a prolonged period of immobility, shoulder injury, or surgery.

Frozen Shoulders Stages

Most people with a frozen shoulder experience worsening pain and a loss of mobility. The pain and immobility can be divided into the 4 stages of a frozen shoulder. A physical therapist can help determine what stage a person is in. The 4 stages of a frozen shoulder include:

1. Pre-freezing: The patient may have had symptoms for one to three months but find it difficult to identify the problem as a frozen shoulder. 
2. Freezing: The symptoms last from six weeks to nine months, with a progressive loss of shoulder movement. 
3. Frozen: The stage lasts from two to six months, during which the shoulder remains stiff, and it becomes difficult to perform daily activities, such as washing hair, reaching for a seat belt, etc. 
4. Thawing: This recovery stage can last from six months to two years. The shoulder's ability to move begins to improve.

The primary frozen shoulder symptoms include pain (a dull ache) and stiffness in the shoulder muscles at the top of the arm, making it difficult or impossible to move the shoulder. The frozen shoulder symptoms usually vary among the 4 stages of a frozen shoulder. 

Pre-freezing Stage

1. Pain even while not using the shoulder
2. Increased sharp pain during shoulder movement
3. Loss of motion during external rotation, raising the arm or reaching behind the back
4. Persistent pain day and night

Freezing Stage

1. Stiffness in the shoulder
2. Pain in the shoulder with movement
3. Increasing pain that worsens at night
4. Increased inability to move the shoulder

Frozen Stage

1. Pain may reduce, but the stiffness persists
2. More difficulty in moving the shoulder

Thawing Stage

1. Pain reduces
2. The ability to move the shoulder improves
3. Normal strength and range of motion return

Frozen shoulder causes are unknown. However, a frozen shoulder is most often caused by the inflammation of the tissues (shoulder capsule) surrounding the shoulder joint. Some probable causes of the condition include

1. Shoulder immobilisation after an injury or surgery
2. Conditions that lead to inflammation of the muscles and tendons (such as bursitis or rotator cuff tendonitis)

Some groups are more at risk of developing this frozen shoulder. Common risk factors that increase the chances of getting a frozen shoulder include:

1. Age: Adults, commonly between 40 to 60 years old, are more likely to have a frozen shoulder. 
2. Gender: The condition is more common in women than men. 
3. Shoulder injury: Restriction of shoulder movement due to an injury or surgery of the shoulder can increase the risk of a frozen shoulder. Examples of these injuries include rotator cuff tears and fractures of the collarbone, shoulder blade, or upper arm. 
4. Systemic diseases: Certain systemic diseases that affect the entire body can increase the risk of developing a frozen shoulder. These diseases include
   1. Diabetes
   2. Hyperthyroidism (overactive thyroid)
   3. Hypothyroidism (underactive thyroid)
   4. Stroke
   5. Cardiovascular disease
   6. Parkinson's disease

A frozen shoulder can be prevented only when it follows an injury that makes shoulder mobility difficult. The chance of developing the condition can be prevented or reduced by following tips:

1. Maintaining a good posture: Good posture can help keep the shoulder joint in proper alignment and reduce the risk of injury.
2. Keep moving: Regular exercise and range-of-motion exercises can help prevent a frozen shoulder by keeping the joint flexible.
3. Avoid injury: Avoid shoulder injuries and immobilisation by wearing proper protective gear when playing sports or other physical activities.
4. Manage underlying conditions: If a person has a medical condition that increases the risk of a frozen shoulder, he/she should work with the doctor to manage it effectively.
5. Maintain a healthy weight: Being overweight can put extra strain on the shoulder, so maintaining a healthy weight can help prevent a frozen shoulder.
6. Avoid overuse: Repetitive motions and overuse of the shoulder can increase the risk of a frozen shoulder, so be mindful of excessive use.
7. Get physical therapy after injury or surgery: If the person has had an injury or surgery that has immobilised the shoulder, he/she should start physical therapy as soon as possible to prevent a frozen shoulder from developing.
8. Stretch and strengthen shoulder muscles: Stretching and strengthening the shoulder muscles can help maintain flexibility and stability, reducing the risk of a frozen shoulder.

If an individual is at risk of developing a frozen shoulder, it's important to discuss preventive measures with the doctor. They can help determine the best approach for individual needs.

To diagnose a frozen shoulder, the doctor will first discuss the symptoms and review the patient's medical history. Frozen shoulder tests for the diagnosis include

1. Physical exam of the arms and shoulders: During a physical exam, the doctor will evaluate pain and compare the active and passive range of motion.
   The active range of motion is achieved when the patient moves their shoulder. The passive range of motion is achieved when the doctor moves the patient's shoulder in all directions.
   Patients with a frozen shoulder have a limited range of active and passive motion. 
2. Imaging tests: Doctors can usually diagnose a frozen shoulder with signs and symptoms alone. However, they may perform imaging tests such as a shoulder X-ray to help rule out conditions like arthritis.
   The doctor may also conduct advanced imaging tests, like Magnetic Resonance Imaging (MRI) and ultrasound, to look for problems such as rotator cuff tears. 

How to Prepare for a Doctor’s Consultation?

If a person experiences frozen shoulder symptoms, they might first consult their primary care provider. Sometimes, they may be referred to a doctor specialising in muscles and bones (physiatrist or orthopaedist).

While preparing for the doctor consultation, here are some things that the patient can do:

1. Take a prior appointment.
2. Note the symptoms and when they began.
3. Write down the medical history and family history.
4. Enlist all the medications and supplements they take.
5. The doctor may ask you some questions. Here is a list of questions that the patient can expect from the doctor during the appointment:
   1. When did you first notice the symptoms?
   2. Does anything worsen the symptoms?
   3. Have you ever injured your shoulder? If yes, how?
   4. Do you have diabetes or other medical conditions?
   5. Have you had any recent surgeries on the arm or shoulder?
   6. Did you have to keep your shoulder still because of an injury or surgery recently?
6. Make a list of all the questions for the healthcare provider. Here are some of the questions that the patient can ask the doctor during the appointment:
   1. What is the cause of my symptoms?
   2. How can I prevent progression?
   3. Are there any risks involved?
   4. What are the treatment options? 
   5. Which one do you suggest?
   6. Will I need surgery?
   7. Can it be managed without surgery?
   8. What is the recovery time?

The two main goals of frozen shoulder treatment are to control shoulder pain and increase the range of motion in the shoulder. Treatment usually involves pain relief methods initially.

The doctor may recommend therapy and surgery to regain motion if the problem persists. The treatment options for a frozen shoulder include:

Frozen Shoulder Treatment without surgery

Below are some of the non-surgical treatment methods for a frozen shoulder.

1. Home Remedies for frozen shoulder: Home remedies are the first line of treatment that can help alleviate the symptoms of a frozen shoulder. Some of the home remedies include
   1. Hot and Cold Compress: These can help reduce pain and swelling. Alternating between hot and cold compresses is the most effective way to use this treatment method. 
   2. Massage: Massaging the affected area can help improve circulation and reduce pain and stiffness.
2. Medications
   1. Pain Relievers: Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Motrin, Advil), aspirin, and acetaminophen (Tylenol, Panadol) can help relieve pain and inflammation in the shoulder.
   2. Steroid Injections: To manage more severe pain and swelling, the doctor may suggest injecting a corticosteroid, such as cortisone, directly into the shoulder joint.
3. Physical Therapy
   A physical therapist will teach stretching and range of motion exercises to help recover the shoulder movement. The following are the common frozen shoulder exercises taught by a physical therapist:
   1. External Rotation: The patient would need to stand in the doorway and bend their affected arm's elbow to 90 degrees to reach the doorpost.
      Keeping the arm in place, they must rotate their body and hold the position for 30 seconds. They will be asked to relax and repeat.
   2. Forward Flexion: The patient will be asked to lie on their back with their legs straight. They must use their unaffected arm to lift the affected arm overhead until they feel a gentle stretch.
      After holding for 15 seconds, the patient will begin lowering the arm to start position. They will be asked to relax and repeat.
   3. Crossover Arm Stretch: The patient must gently pull the affected arm across the chest just below the chin without causing pain. They will be asked to hold the position for 30 seconds, relax, and repeat.
4. Alternative Medicine
   1. Acupuncture: During the procedure, the doctor inserts hair-thin, flexible needles in the skin at certain trigger points for 15 to 40 minutes.
      Acupuncture is a natural frozen shoulder treatment that helps improve blood flow to the area, reduce pain and inflammation, and increase the range of motion.
   2. Transcutaneous Electrical Nerve Stimulation (TENS): It is a nerve stimulation therapy that administers low-voltage electrical currents to key points on a path followed by a nerve. The method helps provide pain relief. 

Frozen Shoulder Treatment with Surgery

If the treatments mentioned above do not relieve shoulder pain and stiffness even after a year, the doctor may suggest the following procedures:

1. Shoulder Manipulation under Anaesthesia: During this procedure, the doctor administers general anaesthesia to put the patient to sleep and feel no pain.
   The doctor will force movement of the affected shoulder, causing the joint capsule to stretch and loosen the tightened tissue. The procedure helps in improving the range of motion.
2. Shoulder Arthroscopy: The doctor inserts small pencil-sized tools through tiny incisions in the shoulder during this surgery. They use these tools to cut through the tight parts of the joint capsule. The surgery is often combined with manipulation under anaesthesia to get better results.

Surgery Name	Surgery Cost
Manipulation under Anaesthesia	₹ 50,000 to ₹ 70,000
Shoulder Arthroscopy	₹ 45,000 to ₹ 2,00,000

Please Note: The selection of the treatment approach is based on the patient's condition, the stage of the frozen shoulder, and the doctor's opinion.

A frozen shoulder can last a year to three years, causing several problems. If left untreated, a frozen shoulder may result in the following complications:

1. Persist pain
2. Loss of mobility
3. Reduced range of motion
4. Muscle trouble that can worsen over time
5. Complete immobilisation
6. The full-range motion may never return

When to See a Doctor?

Patients should visit their healthcare professional when they experience frozen shoulder symptoms:

1. Pain
2. Stiffness
3. Difficulty sleeping
4. Decreased ability to perform everyday activities
5. Decreased strength

Since inflammation is the primary factor in frozen shoulders, patients should eat foods that help reduce it. While there is no proven dietary option to prevent the onset of a frozen shoulder, an anti-inflammatory diet may help with pain relief and speed up recovery in some patients. Furthermore, it might help to limit the intake of sugar, simple carbohydrates, and saturated fat. 

Foods to Include in Frozen Shoulder Diet

1. Fruits with anti-inflammatory properties (berries, pineapple, red grapes, etc.)
2. Vegetables with antioxidants (broccoli, cabbage, cauliflower, etc.)
3. Oily fish (high levels of Omega-3 fatty acids)
4. Nuts and seeds
5. Spices like turmeric and ginger (have anti-inflammatory properties)
6. Extra-virgin olive oil (contains a chemical oleocanthal with effects similar to ibuprofen)

Frozen shoulder is a condition that may cause symptoms such as pain, stiffness, and immobility of the shoulder. While the exact cause of a frozen shoulder is unknown, it is more common in women between 40 and 60.

A frozen shoulder goes through phases before you get completely relieved of your pain and lack of motion. There are several treatment options for the condition, although they may take time to show complete results. 

If you are experiencing persistent frozen shoulder symptoms, consult an expert at HexaHealth for an early diagnosis TODAY! Our team will help you manage pain and inflammation with simple methods like medications, physical therapy, and home remedies. If the pain persists, we will guide you through the surgical options and help you connect with the best surgeons near your preferred location.