What Is Frozen Shoulder?
A common but painful condition of the shoulder joint that disproportionately affects women, orthopedic experts explain how to diagnose and treat frozen shoulder.
It may start with a nagging pain near your shoulder, almost as if you’ve pulled a muscle. But over the next few weeks to months, the pain becomes more intense, and your range of motion becomes so limited that even reaching for simple objects becomes a struggle.
These are the symptoms of frozen shoulder, known medically as adhesive capsulitis, which is when inflammation occurs in the capsule that covers the shoulder joint. This capsule is composed of fibrous tissue that tightens and thickens into adhesions, or scar tissue, causing pain and severely limiting your range of motion for an extended period of time.
“Your capsule creates a waterproof enclosure for the joint that holds the joint fluids inside. When it gets tight and thick, it’s like a shirt doubling in thickness and shrinking in the dryer,” explains Dr. Nicole Belkin, chief of orthopedic surgery and rehabilitation and regenerative medicine at NewYork-Presbyterian Hudson Valley Hospital. “It becomes too small for the joint and so can’t accommodate movement.”
Because the symptoms of frozen shoulder can appear similar to other shoulder conditions such as a rotator cuff tear, tendonitis, or bursitis (when small fluid-filled sacs that cushion the joints and bones swell), it’s important to get a proper diagnosis from a physician. Health Matters spoke with Dr. Belkin and Dr. Morgan Busko, a sports medicine physician at NewYork-Presbyterian/Columbia University Irving Medical Center, to understand the symptoms and causes of frozen shoulder and how to treat it.
How is frozen shoulder diagnosed?
Frozen shoulder is diagnosed by an orthopedic specialist, such as a sports or rehab medicine physician or an orthopedic surgeon, who will review your medical history and perform a physical exam. A patient may also undergo an X-ray to rule out other ailments that may show up on imaging, such as osteoarthritis or calcific tendonitis, when calcium deposits form around the tendon. Less frequently, high-quality MRIs may also be used to rule out tears in the rotator cuff or cartilage and can sometimes pick up on the thickening in the tissue.
The physical exam performed by the physician is to assess both a patient’s active and passive range of motion. “Losing your own ability to move your shoulder in all planes of motion is what we mean by losing active range of motion, like when people say, ‘I can’t reach forward or I can’t reach behind my back anymore,’” says Dr. Busko. “But losing passive range of motion is when the doctor is trying to move your arms in these planes, and we cannot get your shoulder to go beyond a certain point. It truly does feel stuck.” The loss of both passive and active motion is a distinguishing sign of frozen shoulder.
Another hallmark is that the stiffness itself may not cause pain when your arm is still, “but when you try to perform a normal movement with the arm, like scratch your back or reach an overhead cabinet, not only is it hard to do, it can also be very painful,” adds Dr. Belkin.
What causes frozen shoulder?
Most causes of frozen shoulder are idiopathic, meaning the cause is unknown. However, certain underlying conditions can increase risk for frozen shoulder, most notably thyroid conditions such as hypothyroidism and poorly managed diabetes. In fact, some research shows those with diabetes are nearly four times as likely to develop frozen shoulder as those without diabetes. Having an immobilized shoulder for an extended period, such as due to injury or recovery from surgery, may also trigger frozen shoulder. A small percentage of frozen shoulder patients may also get it in their opposite shoulder, typically within five years.
Although men can get frozen shoulder, of the 2% to 5% of the population that will have frozen shoulder in their lifetime, up to 70% of those affected are women, with the majority roughly between the ages of 40 to 60. This is why more researchers have been studying the link between estrogen loss during perimenopause and menopause and its impact on the musculoskeletal system.
“There are a lot of variables at play, but biologically speaking, there is a hormonal difference in how the body handles inflammation,” Dr. Belkin says. “And while there’s a paucity of dedicated research to understanding why some things affect women more than men, we can extrapolate from the research that does exist that estrogen has an effect on making soft tissue loose and flexible. So, when we lose estrogen, we lose flexibility.”
While there isn’t a definitive study that has shown menopause increases risk for frozen shoulder, one recent study did find that menopausal women on hormone replacement therapy (HRT) had a decreased risk of developing frozen shoulder than those who weren’t on HRT. “During and after menopause, when estrogen levels drop dramatically, it can lead to stiffness in any joint, and in particular we see a rise in frozen shoulders during these years. Most doctors and physical therapists would agree that there is a correlation,” says Dr. Busko. “So for women in menopause dealing with significant pain in multiple joints or who have significant symptoms of frozen shoulder, you can talk to your doctor about hormone replacement therapy.”
The 3 Phases of Frozen Shoulder
The way that frozen shoulder progresses can vary greatly by individual, but frozen shoulder generally goes through three stages:
Freezing | Gradual onset of pain; shoulder begins to lose range of motion | May last anywhere from six weeks to nine months. |
Frozen | Pain may ease, but range of motion is at its worst | May last four to 10 months |
Thawing | There is a gradual return to full range of motion. | May last six months up to two years. |
Dr. Belkin has seen cases in which frozen shoulder resolves in as little as 12 weeks or as long as 18 months. “It can take a long time because we have to first get through the inflammation, and everyone’s body handles inflammation differently, and then the pain can be a limiting factor in restoring the function of the shoulder,” she says. That’s why it’s important to get a diagnosis as soon as possible. She suggests consulting with an orthopedic specialist if you have a pain in your shoulder that doesn’t go away in three to five days.
Dr. Busko also points out that most patients may not be able to distinguish three distinct phases “because unfortunately, in all stages there is pain and range of motion limitation. But understanding the timeline is important so patients know not to give up on hope that they are going to get better, because the condition will be behind them at some point.”
How is frozen shoulder treated?
Treatment for frozen shoulder can entail a number of different options depending on whether there are other underlying conditions involved but the most common will involve anti-inflammatory treatments accompanied by physical therapy and at-home exercises.
To treat inflammation, options can include topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs). Corticosteroid injections in the shoulder joint can also help reduce inflammation and break up some of the fibrosis in the capsule, particularly when the pain interferes with sleep or a patient’s everyday life — although they may not be a good solution for those with diabetes since the corticosteroids can impact blood sugar.
Physical therapy, meanwhile, will likely be the most prolonged course of treatment. “I think it’s important to find a physical therapist that you work well with because it’s going to be someone you see on a regular basis for a long period of time,” says Dr. Busko. “Performing your range of motion and strengthening exercises at home is equally as important because it takes daily effort to get range of motion back. Consistency is really going to make a difference in the long run.”
Working with a physical therapist is effective because they can help with exercises that would be technically challenging to do by yourself, but there are stretches you can do on your own at home. Below are a few common ones that Dr. Belkin recommends.
Do you ever need surgery to treat frozen shoulder?
In rare instances, when other treatments have failed to help resolve frozen shoulder, a patient may resort to manipulation under anesthesia, when a doctor moves the arm at the shoulder joint manually through the planes of motion to help break up the scar tissue and loosen the joint, performed while the patient is under anesthesia. Even rarer is surgery, which can be done minimally invasively and entails cutting the thickened tissue around the shoulder joint. Using the shrunken shirt analogy, “it’s like undoing seams in a garment,” says Dr. Belkin. “We make a slit that releases the tissue all the way around and allows it to flex.”
While some patients may be tempted to rush into surgery to speed up recovery, “it’s a very rare exception that patients end up going on to surgery, and the decision is not just based on time,” she adds. “It can only be made after monitoring the patient for a while, seeing how they respond to other treatment, and periodically examining the shoulder. If a patient is still really acutely inflamed, the surgery can fail and the patient can still get frozen shoulder afterwards.”
Ultimately, patience, getting an early diagnosis, and perseverance in sticking to a physical therapy regimen is key to recovery. “I try to instill hope, because it can be a very difficult condition and it can feel like you’re doing all the right things and not seeing the progress you want,” says Dr. Busko. “But the vast majority of patients do get their full range of motion back, and one day you will hit that tipping point. Working on it from day one would be the most important takeaway.”
Frozen Shoulder Exercises
Wall Slides: Take a washcloth or towel and place your hand on top of it on a wall at shoulder height. Slide the washcloth up the wall until your forearms and elbows straighten, or as far as you can go without pain, then back down. Repeat 30 times. You can do this exercise both up and down and side to side.
Doorway Stretch: Place your arm parallel to the floor with your elbow bent upward at a 90-degree angle and rest it against a doorway. Lean your body gently through the door frame until you feel a gentle stretch through the shoulders and chest. Hold the stretch for 30 seconds, repeat three times.
Behind-the-Back Towel Stretch: Grasp one end of a long towel or back brush and place it over one shoulder, then hold onto the other end with your other hand for 30 seconds to give yourself a gentle back stretch. Switch sides, but when your good arm is on top, give a gentle upward pull to provide an even deeper stretch for your affected shoulder. Repeat for three sets.
Cross-body stretch: With your good arm, lift the affected arm and bring it across your chest, applying slight pressure to help it stretch.
A shower is a great place to do these stretches as the warm water can help loosen up muscles, ease pain, and help you feel more relaxed, adds Dr. Belkin.
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