Frozen Shoulder

Frozen shoulder is a condition characterised by stiffness and pain in the shoulder joint. It can develop gradually and make it difficult to perform everyday activities. Understanding frozen shoulder, its causes, symptoms, and treatment options is crucial for effective management and recovery.

What Is Frozen Shoulder (Adhesive Capsulitis)?

Frozen shoulder, or adhesive capsulitis, results from the gradual loss of movement in the shoulder joint, a ball-and-socket joint comprising the humeral head (ball) and the glenoid (socket). Normally, this joint allows a wide range of motion, but in frozen shoulders, it becomes stuck, significantly limiting mobility.

What Causes Frozen Shoulder?

The condition is often caused by inflammation of the tissues surrounding the joint, leading to scar tissue formation and tightening of the joint capsule. While the exact cause is not always clear, it can be associated with prolonged immobility due to injury, surgery, stroke, or mastectomy.

Certain medical conditions are also believed to increase the risk of frozen shoulders. These include diabetes (affecting 10-20% of those with frozen shoulders), thyroid disorders, Parkinson's disease, and heart disease.

What Are the Symptoms of a Frozen Shoulder?

Frozen shoulder develops in three distinct stages, each presenting unique symptoms:

• Freezing Stage - This initial phase lasts between 2 and 9 months. At this stage, shoulder movement becomes increasingly painful, with discomfort often intensifying at night. As the pain worsens, the range of motion gradually diminishes.
• Frozen Stage - Spanning 4 to 12 months, this stage sees pain begin to subside, but stiffness sets in, making movement significantly more restricted. Daily tasks like grooming, dressing, or reaching overhead become noticeably difficult.
• Thawing Stage - Over 6 months to 2 years, the shoulder slowly regains mobility, as strength and flexibility gradually return to near-normal levels.

How Is Frozen Shoulder Diagnosed?

Frozen shoulder is primarily diagnosed through a physical examination and assessment of symptoms. During the exam, a healthcare provider will ask the patient to move their arm in various directions to check for pain and measure the active range of motion.

Then, the provider will move the patient's arm while the muscles are relaxed to assess the passive range of motion. A key diagnostic feature of frozen shoulder is a significant limitation in both active and passive shoulder movements.

Specific diagnostic criteria include:

• A loss of external rotation by at least 50% compared to the unaffected side or less than 30 degrees.
• Reduced range of motion in at least two other planes by at least 25% compared to the other side.

Imaging tests such as X-rays, ultrasound, or MRI are not usually required to diagnose frozen shoulders, but are often used to rule out other conditions like arthritis or rotator cuff tears. X-rays help exclude bone-related problems, while MRI and ultrasound provide detailed images of soft tissues to identify other injuries if needed.

In some cases, an anaesthetic injection may be used to numb the shoulder and better evaluate the range of motion, helping distinguish frozen shoulder from other causes of stiffness.

What Are the Treatment Options for Frozen Shoulder?

There are a variety of treatment options available for frozen shoulders, depending on the severity and stage of the condition.

Non-surgical Treatments

Non-surgical management is the primary approach for frozen shoulder, focusing on pain relief and restoring shoulder mobility. Common non-surgical treatments include:

• Medications - Over-the-counter pain relievers and anti-inflammatory drugs such as aspirin, ibuprofen (Advil, Motrin), or naproxen can reduce pain and inflammation. In some cases, stronger prescription medications may be used.
• Corticosteroid Injections - Injecting steroids directly into the shoulder joint can decrease inflammation and pain, especially if administered early in the disease course.
• Physiotherapy - A physiotherapist guides patients through range-of-motion and stretching exercises designed to improve shoulder mobility and strength. Commitment to these exercises is crucial for recovery.
• Hydrodilatation (Hydrodistension) - This procedure involves injecting sterile fluid into the shoulder joint capsule to stretch it and improve motion. It may be combined with steroid injections and is used when other non-surgical treatments fail to provide relief.
• Hot and Cold Compresses - Applying heat can increase blood flow and reduce stiffness, while cold packs help reduce pain and swelling. Alternating between heat and cold is often recommended.
• Other Modalities - Transcutaneous electrical nerve stimulation (TENS) may be used to modulate pain perception, though more research is needed on its effectiveness.

These treatments often lead to improvement within 12 to 18 months, with full recovery possibly taking up to two or three years.

Frozen Shoulder Surgery

Frozen shoulder surgery is considered when the symptoms persist despite 3 to 6 months of comprehensive conservative treatment and when significant functional disability remains.

Surgical options include:

• Manipulation Under Anaesthesia (MUA) - This procedure involves a shoulder doctor forcefully moving the shoulder while the patient is under general anaesthesia. The primary goal is to break up restrictive scar tissue and improve the shoulder's range of motion.
• Arthroscopic Capsular Release - This is a minimally invasive surgical procedure where a surgeon uses small instruments and a camera inserted through tiny incisions to cut the thickened joint capsule. This action helps to release the tightness in the joint and improve mobility.
• Open Capsular Release - A more invasive surgical option, this procedure involves open surgery to directly access and release the contracted tissues of the shoulder capsule. It is used less frequently compared to arthroscopic methods.

How Can Frozen Shoulders Be Prevented?

Preventing frozen shoulder involves maintaining shoulder mobility and reducing risk factors through regular movement, proper ergonomics, and healthy lifestyle habits.

• Gentle, progressive range-of-motion exercises and stretching - Regularly moving the shoulder through its full range of motion helps keep the joint flexible and prevents stiffness, especially after surgery or injury.
• Specific exercises to maintain shoulder flexibility - Techniques such as wall walks, pendulum stretches, finger walks, cross-body stretches, and towel stretches can improve and preserve shoulder mobility.
• Use the shoulder regularly - Avoid prolonged immobility of the shoulder joint, as keeping it active reduces the risk of developing stiffness and frozen shoulder.
• Ergonomic workstation setup - Proper posture and ergonomics during work, particularly when working from home, help prevent muscle strain around the shoulder. This includes using supportive chairs, positioning computer screens at eye level, and taking frequent breaks to stretch.
• Avoid activities that cause pain or strain - While movement is important, forcing painful movements or engaging in strenuous activities that exacerbate shoulder pain should be avoided to prevent further injury.
• Healthy diet and lifestyle - Reducing inflammation through diet supports joint health. Focus on more fruits, vegetables, and anti-inflammatory foods like fatty fish, while cutting back on processed foods and stimulants.
• Early intervention - If shoulder stiffness or pain begins, early consultation with a healthcare provider and starting gentle therapeutic exercises can help prevent progression to frozen shoulder.

About Our Orthopaedic Surgeon

Dr James Tan Chung Hui

Senior Consultant
Orthopaedic Surgery, Sports & Exercise Medicine
MBBS (S’pore), MRCS (Edin), MMed (Orth), FRCS Orth & Tr (Edin)

Dr James Tan graduated from the NUS Faculty of Medicine and obtained a Master of Medicine (Orthopaedics). He is widely recognised as an orthopaedic surgeon in Singapore for his treatment techniques for shoulder pain and other shoulder conditions. With over 10 years of experience, he specialises in minimally invasive (keyhole) tendon and ligament repair, joint replacement, and muscle-tendon transfers of the shoulder joint.