Frozen Shoulder Treatment

The connective tissue surrounding the shoulder joint like a bag is the joint capsule. In frozen shoulder, medically called adhesive capsulitis, the capsule thickens, loses flexibility and contracts as if adhering to the humeral head. This causes both pain and marked restriction of movement. As the space inside the joint narrows, the arm cannot move beyond a certain point, however hard the person tries.

Frozen shoulder occurs in two forms. In the primary (unknown-cause) form, there is no clear trigger; it is most common between 40–60 years of age and in women. The secondary form has an underlying factor: diabetes, thyroid disease, the period after shoulder or breast surgery, prolonged use of an arm sling after a fracture, or immobility after a stroke. It is both more common and potentially more persistent in people with diabetes.

Although people may describe "shoulder calcification" or "tight muscles", frozen shoulder affects the capsule rather than cartilage or muscle. This changes treatment: restoring movement is the priority.

Frozen shoulder generally progresses through three stages, with different predominant symptoms. Stage duration varies between people; the overall process usually lasts months.

• Freezing (painful) stage: pain predominates and worsens at night; movement gradually becomes restricted.
• Frozen (stiff) stage: pain decreases somewhat, but movement restriction becomes more pronounced and daily tasks harder.
• Thawing stage: movement returns gradually, supported by regular exercise.
• Marked difficulty combing hair, scratching the back, reaching a back pocket or putting on a jacket
• Inability to lie on the shoulder and interrupted sleep at night
• Early, marked restriction of outward arm rotation, as when opening a door

No. 'My shoulder will not move' can have several causes, so examination first distinguishes the type of restriction. Frozen shoulder is characterised by limitation of both active and passive movement: the patient cannot lift the arm, and the doctor encounters a firm stop when trying to move it beyond a certain point. Outward rotation is lost particularly early.

By contrast, in a rotator cuff tear, the patient struggles to raise the arm but the doctor can usually lift it; pain and weakness predominate. In shoulder impingement, limitation is pain-related and occurs at a particular angle. Joint osteoarthritis, previous fractures, prolonged immobility and neck-related pain can also restrict movement. Examination and, when needed, imaging establish the distinction.

Diagnosis relies mainly on examination. Forward elevation, sideways elevation, and internal and external rotation are measured; restriction of both active and passive movement is typical of frozen shoulder. A history of diabetes, thyroid disease and shoulder surgery is sought; blood glucose testing may be requested if diabetes status is unknown.

X-rays are usually normal in frozen shoulder, but are taken to exclude other causes such as osteoarthritis, an old fracture or tendon calcium deposits. MRI is not needed for everyone; it is requested when the diagnosis is uncertain or an associated tendon tear is suspected. Measurement of movement angles by the doctor is central to diagnosis.

Most patients with frozen shoulder are treated without surgery. Treatment has two aims: controlling pain and gradually stretching the capsule to restore movement. Regular exercise at the correct intensity is the key factor; forcing movement far beyond the pain limit can prolong the process.

• Gradual stretching and pendulum exercises repeated several times a day
• Supervised range-of-movement rehabilitation and teaching home exercises
• Painkillers and anti-inflammatory medicines; heat to prepare for exercise
• An intra-articular cortisone injection during the phase of significant pain
• Managing coexisting diabetes and thyroid disease
• Adjusting sleeping position and pillow support to reduce night pain

Surgery is discussed when movement has not improved over months despite regular exercises and injections, and restriction seriously affects work and daily life. This applies to a small proportion of frozen shoulder patients.

Two approaches are used: controlled movement of the shoulder under anaesthesia to loosen the capsule (manipulation), and arthroscopic capsular release, in which selected areas of the thickened capsule are released under camera guidance. In both, the key factor is the intensive exercise programme that starts immediately afterwards; stiffness can return if the gained range of movement is not maintained with exercise. People with diabetes are advised from the outset that the process may take longer.

A common mistake in frozen shoulder is stopping arm use completely because of pain; immobility causes further capsular contraction. Use the arm daily without forcing it far beyond the pain limit and keep up exercises. Exercising after a warm shower can make stretching easier.

Putting the painful arm into a jacket first, keeping items within reach instead of on high shelves and placing a pillow under the painful arm at night can make daily life easier. For people who need a sling for a long time after a fracture or surgery, early movement within the doctor's instructions may help reduce the risk of frozen shoulder. At AC CLINIC in Altınordu, Ordu, the exercise programme is adapted to your stage and progress is monitored by measuring movement at follow-up appointments.