Frozen shoulder: Causes, Symptoms, and Treatment

Frozen shoulder (or shoulder stiffness) is one of the degenerative changes of the shoulder joint. The joint is restricted in its mobility due to inflammation and shrinkage of the joint capsule.

The “frozen shoulder” is a restriction of movement of the shoulder joint due to inflammation of the joint capsule, which causes shrinkage of the capsule.

If the joint capsule has shrunk, the shoulder joint is restricted in its freedom of movement.

There are various forms of frozen shoulder. Pain is an accompanying symptom. Primarily, cortisone treatment is sought as therapy. However, if the joint does not respond to this treatment, or if the disease tends to relapse, an operation may be considered. This involves cutting open the joint capsule. After a few weeks, the joint is ideally free to move again. Patients should, however, remain cautious during sports activities for a while. First of all, the joint has to be strengthened by physiotherapy, and renewed stiffening prevented.

Therapy is often difficult and should be carried out by doctors who have specialized in this disease, as in many cases, a dour movement restriction and painfulness can remain.

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Causes of frozen shoulder

Frozen shoulder is usually the result of repeated unexplained irritation or inflammation of the synovial fluid. The problem takes place inside the joint.

Primary shoulder stiffness:

It begins with inflammation of the synovial membrane and occurs primarily in women between the ages of 40 and 60. Since this is painful, those affected usually tend to take it easy on the joint and move it as little as possible. This sparing adds to the fact that the joint is inflamed and leads to shrinkage of the joint capsule.

The mobility of the joint is now restricted. The stiffness of the shoulder may regress spontaneously. It usually proceeds in phases.

One risk factor is diabetes.

Secondary shoulder stiffness:

Secondary shoulder stiffness can occur as a result of prolonged immobilization of the joint (plaster, bandage), injuries, e.g., shoulder dislocation, wear and tear or a calcified shoulder or surgery. Inflammation can also be a possible trigger.

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Shoulder stiffness after surgery

One reason for the development of shoulder stiffness is that an operation has taken place in the shoulder area. This can be an operation to reduce the symptoms of shoulder soreness (impingement), osteoarthritis, or torn tendons (rotator cuff rupture). A more common reason is also surgery for a fracture of the head of the humerus, for example, after a fall.

After the operation, it is part of the post-operative treatment that the arm is first kept still and worn in an arm splint or bandage. Depending on the surgery, this may be indicated for between 3 and 6 weeks. The main risk of immobilizing the arm is the development of shoulder stiffness. Due to the lack of movement and stretching of the capsule and the ligaments in the shoulder, shrinkage, and adhesions occur in them.

Therefore, it is a central concern of the surgeon and physiotherapists postoperatively that the arm is not worn in the bandage longer than necessary. Early passive exercise of the arm by a physiotherapist allows the arm to be moved without affecting the surgical result, but at the same time reduces the risk of stiff shoulder.

If the arm is not exercised adequately, the patient runs the risk of a stiff shoulder. It is, therefore, important that patients perform regular and structured exercises for the arm according to the instructions of their doctor or physiotherapist.

In addition to shoulder operations, post-operative shoulder stiffness can also occur after operations on and in the skull, abdomen (abdomen), or thorax (chest). However, this is very rare and is not one of the more frequent complications of such operations. Shoulder stiffness after breast surgery, e.g., for breast carcinoma (breast cancer), is also rarely described. With all these operations, however, it is also true that good and regularly performed exercises for the shoulder significantly reduce the risk of a stiff shoulder.

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Phases of frozen shoulder

Shoulder stiffness typically occurs in 3 phases:

  • Stiffening
  • Stiffness
  • Resolution

Untreated shoulder stiffness lasts for 18 – 24 months, but can take considerably longer in individual cases.

Symptoms of frozen shoulder

The complaints are, as the name suggests, stiffness of the shoulder. The joint cannot be lifted beyond a certain point, as this requires the “reserve” of the joint capsule.

In a healthy shoulder, the joint capsule has a few reserve folds to guarantee that the arm can be moved sideways and upwards by as many degrees as possible (so-called abduction). If this reserve of joint capsule tissue is missing due to shrinkage of the capsule, it is easy to explain that the mobility of the arm is limited.

Diagnosis of a stiff shoulder

The extent of shoulder stiffness can be easily checked. The arm is lifted sideways away from the body. Care must be taken to ensure that the shoulder blade does not move with the arm; otherwise, the movement will not come from the shoulder joint alone. Rotation, i.e., turning the arm inwards and outwards, is also restricted.

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Therapy of frozen shoulder

Initially can be treated with a cortisone – step-by-step regimen. This lasts for three weeks, and the dose of cortisone is higher at the beginning of the treatment than at the end.

The cortisone is supposed to inhibit the inflammation and thus also relieve the pain. Painkillers can also be given additionally, if required. Only when the cortisone treatment has been completed, and the pain has been relieved can physiotherapy be started.

The therapy of therapy-resistant frozen shoulder consists of a minimal surgical intervention to restore mobility and freedom from pain. This is achieved by cutting open the joint capsule and removing inflamed tissue as necessary. This operation is performed arthroscopically. In this closed variant, a camera is inserted into the joint from the outside in addition to surgical equipment. This allows “minimally invasive” surgery.

After the operation, movement should be resumed as quickly as possible to prevent the capsule from shrinking again or becoming stuck.

However, surgery does not guarantee a complete restoration or re-stiffening of the joint.

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Exercises

An essential part of healing a stiff shoulder is the regular and conscious movement of the shoulders. It is not enough to do movement exercises 1-2 times a week together with physiotherapy. Here it requires independent and daily exercise of the shoulder.

In the beginning, warming up the shoulder is important. You can start by lifting and circling the shoulder. Then the stretched arms are lifted to the side and forward and lowered again. The exercises should be performed for 30 seconds each. All movements in which the shoulder is first moved without too much force are helpful. In the beginning, these movements are probably very difficult, painful, and perhaps also demotivating. But the mobility will improve steadily.

Besides, stretching exercises of the shoulder are very important, because only in this way can the tissue and the shoulder achieve more range of motion. To stretch the shoulder, the chest and back muscles, as well as the arm, neck, and shoulder muscles, must be stretched regularly. It is recommended to stretch between 5 and 10 minutes every day.

The next step is to strengthen the muscles. Here you can train with a Theraband or light weights. If there are other problems, such as tears in the rotator cuff, then the exercises should be carried out in consultation with the team treating the patient. Exercises for strengthening are, for example, side lifting (lifting the dumbbells sideways), front lifting (lifting the dumbbells in front of the body with stretched arm), shoulder pressing (slowly stretching the dumbbells over the head). But also the training of the inner and outer rotation is relevant. These are well trained with a Theraband.

Push-ups and back-extension or corresponding exercises on machines help strengthen the entire upper body. Together with the physiotherapist, an individual plan is usually worked out, which includes all exercises that can also be done alone at home or in the gym.

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Kinesiotape for stiff shoulders

Taping the shoulder is also useful for stiff shoulders. Kinesio taping can be learned and performed by anyone. However, it is usually more complicated to tap the shoulder because there are many different structures. For shoulder stiffness taping, about five adhesive strips are needed, namely I- and Y-tapes. The exact procedure is shown in various video explanations on different platforms on the Internet.

Medication

Especially in the first phase of shoulder stiffness, therapy with cortisone injections can relieve pain and reduce the inflammatory process. These injections are injected into the shoulder by the doctor over 2 – 4 weeks. During the entire period of shoulder stiffness, taking painkillers is an important part of the treatment for most patients. A wide variety of painkillers such as ibuprofen, diclofenac, aspirin, or paracetamol can be taken. However, NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen and diclofenac are particularly suitable, as they have an anti-inflammatory effect as well as an analgesic. If these painkillers are not sufficient, it can be discussed with the treating physician whether painkillers of the next level can be prescribed, the so-called low-potency opioids (e.g., tilidine or tramadol)

Duration of frozen shoulder

Frozen shoulder usually goes through three phases. Depending on the cause, severity, and type of treatment, the frozen shoulder will ideally disappear between 9 and 18 months. If there are additional causes, such as arthrosis or defects in the rotator cuff, healing may be delayed. In non-ideal cases, it can take several years for the frozen shoulder to heal completely.

The first phase, the initial or inflammatory phase, is characterized by pain that also occurs at night and lasts for about 9 – 12 months.

In the second phase, also known as the stiffening phase, patients complain of a loss of movement and are often no longer able to perform everyday tasks and movements. This phase can last between 4 and 12 months.

The last and third phase is called the thawing phase and can last several years in the worst case. It involves the mobility of the shoulder slowly returning. Right physiotherapeutic treatment is a central component here. There may well be phases in which progress is better or worse.

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How long are you on sick leave?

If you have a stiff shoulder, it is not necessary to write a note of sickness or incapacity to work. However, if the patient is physically demanding or has to carry out work that requires regular and complex movement of the shoulder, then it must be discussed with the attending physician to what extent an incapacity to work can be certified or whether a temporary assignment in other areas of activity can be arranged with the employer. If a frozen shoulder operation has been performed, the patient is usually written off as unfit for work for 3 – 4 weeks. Then, depending on the pain, it must be tested how quickly the patient can return to work.

The complete healing process can vary greatly from one individual to another. Therefore, good cooperation with the doctor and the physiotherapists is important here.

Prognosis

The stiffness of the shoulder can spontaneously disappear by itself. After an operation, several weeks of rehabilitation are necessary to restore full mobility slowly. Patients can also take part in sports but should consult their doctor beforehand about any sports (tennis, etc.) that put a strain on the shoulder.

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