What is Frozen Shoulder? An Explainer for Africans

 

By: Rukhsar Jabbar. M.Sc. Physiotherapy. Freelance Health Writer. Medical review by: The DLHA Team

A young black maleholding his left shoulder presumably because of pain. Image by master1305 on Freepik. 

 

Highlights 

• Frozen shoulder, is marked by pain and a significant reduction in shoulder movements (range of motion, ROM).

• The most common symptoms include mild shoulder stiffness, severe pain that often worsens at night especially when lying on the affected side, and a near-total loss of both passive and active shoulder external rotation.

• Frozen shoulder, or adhesive capsulitis, often occurs due to prolonged shoulder immobility after an injury or surgery. Risk factors include diabetes, thyroid disorders, etc.

• Frozen shoulder can be separated into three stages for effective treatment.

• Most people with frozen shoulder respond well to conservative treatments, with up to 90% of cases improving without needing surgery.

 

What is Frozen Shoulder?

Frozen shoulder (FS), also known medically as adhesive capsulitis, is one of the most common yet challenging clinical conditions that bone doctors (orthopedic surgeons) encounter.

Frozen shoulder is defined as "a condition of uncertain etiology, characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder." [1]

The condition is marked by pain and a significant reduction in shoulder movements (range of motion, ROM).

It affects an estimated 2%–5% of the general population globally and can be both painful and disabling. FS most commonly occurs in individuals in the 40’s to 60’s age group and is commoner in women than in men. [1]

This article aims to provide an overview of frozen shoulder, its stages, and the treatment of different stages of the disorder. 

 

How do I Know I Have Frozen Shoulder?

You likely have Frozen Shoulder (FS) if you complain of-

• A gradual onset of shoulder discomfort and stiffness without any previous history of injury, infection, or inflammation. 

• Experiencing poorly localized shoulder pain that is most bothersome at night, especially when lying on the affected side. 

• General restriction of both active and passive movements of the shoulder (range of motion, ROM) in at least two directions

• Loss of outward rotation with the arm positioned beside the chest. [2]

These symptoms are likely to significantly impair your quality of life, as they interfere with your ability to perform regular daily activities.

About 60% of people suffering from the condition gradually regain their full shoulder movements within a year or more, while 40% will experience chronic limitations that hinder daily tasks.

Interestingly, the quality of life is directly related with the degree of motion loss in the affected shoulder; thus, effective therapy can enhance both physical function and overall quality of life. [3]

 

Causes and Risk Factors of Frozen Shoulder

The cause of frozen shoulder is not fully understood. However, some risk factors have been identified as follows:

• Diabetes mellitus: In the general population, the prevalence of frozen shoulder is approximately 0.75%; however, in those with diabetes, the frequency is significantly higher. According to one study, 13.4% of people with diabetes have frozen shoulder. [4]

• Stroke: Frozen shoulder is more common in those with weakness of the upper limb after a stroke than in the general population. The muscle of the weak shoulder is more prone to injury and inflammation in elderly stroke patients. [5]

• Thyroid disorder: An association has been reported between frozen shoulder and high thyroid gland function (hyperthyroidism). High cytokine levels is seen in both conditions. Cytokines are signalling proteins that are secreted by certain cells of your immune system that help to control inflammation in the body. It is possible for one to precede the other or for them to happen simultaneously. [6]

• Shoulder injury: Any harm to the shoulder, such as fractures, dislocations, or muscle tears, leading to pain and limited movement. This can contribute to frozen shoulders.

• Dupuytren disease: Patients with frozen shoulder have an 8-fold higher incidence of Dupuytren's disease compared to the overall population. Additionally, there are metabolic associations: both disorders have a markedly higher frequency of hyperlipidaemia and diabetes mellitus, as well as cytokine abnormalities. [7]

• Rheumatoid arthritis: Severe (Chronic) rheumatiod arthritis (RA) can cause frozen shoulder through inflammation of surrounding joint tissues including the rotator cuff, tendon, cartlage. Mild RA isnot likely to cause the condition.

• Parkinson disease: There appears to be an association between frozen shoulder and Parkinson's disease (PD) as FS is commoner in people with PD than in the general population. One of the first indications of Parkinson's disease (PD) may be frozen shoulder, which occurs before significant motor symptoms are noticed. [8]

• Cancer: Cancer of the shoulder may contribute to frozen shoulder.

• Complex regional pain syndrome: This long-term pain condition affecting a limb after an injury or surgery is marked by intense pain, swelling, and skin changes. [9] The pain may cause reflex reduction in the use of a shoulder and indirectly contribute to frozen shoulder.

 

Staging of Frozen Shoulder

Frozen Shoulder can be separated into three stages: [10]

Stage 1: Freezing stage or stage of slow development of shoulder discomfort with progressive loss of motion.

Stage 2: Frozen stage or stage of gradual reduction of pain, plateauing of stiffness with equal active and passive ROM, and

Stage 3: Thawing stage or stage of gradual recovery of motion and elimination of symptoms. 

 

Freezing stage (Stage 1)

The first stage of a frozen shoulder typically lasts for two to six months. This stage is marked by a gradual onset of moderate-to-severe pain and partial restriction of shoulder movement. It involves extensive inflammation of the structures of the shoulder joint.

In the early stages of a frozen shoulder, it can be mistaken for rotator cuff disorder because both conditions involve painful loss of range of motion. However, unlike frozen shoulder, where the range of motion worsens over time, rotator cuff disorder does not show a progressive decline in movement with each follow-up visit. [2]

 

Frozen stage (Stage 2)

This stage of frozen shoulder can last between four to twelve months. It is marked by varying levels of pain and stiffness. In the early part of this stage, individuals tend to experience more pain, while in the later part, stiffness becomes more prominent than pain.

This stage involves a gradual reduction in inflammation and the onset of significant thickening and scarring (fibrosis) of tendons, muscles and capsule of the shoulder leading to considerable restriction in the range of motion. [2]

 

Thawing stage (Stage 3)

This stage of frozen shoulder can last from six to twenty-six months. It is marked by a gradual decrease in stiffness and minimal discomfort. It involves a slow recovery of movement and a gradual resolution of inflammation and fibrosis, resulting in little pain. [2]

 

Management of Frozen Shoulder

Treatment plans of frozen shoulder in clinical practice vary based on its stage. The plans are based on these two approaches: [11]

• Conservative or non-surgical
• Surgical (when conservative management fails to resolve symptoms satisfactorily)

Most people with frozen shoulder respond well to conservative treatments, with up to 90% of cases improving without needing surgery.[2] 

A. Non-surgical management based on the stage of FS

The non-surgical (conservative) treatment of frozen shoulder is based on these two principles:

• Alleviate pain and inflammation
• Improve functional mobility

 

I. Freezing stage 

In this stage, any underlying or co-occurring medical conditions like diabetes mellitus and thyroid dysfunction, must be adequately addressed as these conditions can worsen the severity of a frozen shoulder when poorly managed. [2]

Pain and inflammation management: Athough it is traditional to give oral non-steroidal anti-inflammatory pain killers (NSAIDs) like ibuprofen, naprosen, diclofenac or celexicob during the initial freezing stage of frozen shoulder, available evidence indicates that these drugs have no effect on the course of frozen shoulder when used alone. [11]. 

For this reason NSAIDS are combined with oral or intra-shoulder (intra-articular) injection of  corticosteroids. Used alone, oral or intra-articular corticosteroids are also very effective in relieving pain and inflammation, improving range of motion (ROM} and function outcome in FS.[11]

 

Functional mobility Improvement: The following are some of the exercises that help to relieve pain, improve flixibility as well as functional mobility and ROM at the freezing stage of FS. [12] See figure 1. 

Figure 1: Illustration of frozen shoulder exercises that help improve mobility. Click on image to enlarge. Image credit: jqbaker/istock

 

1. Pendulum exercise of arm: While standing, slant your head forward a little and hang your affected arm loosely. Draw a small, soft circle with your arm that is roughly one foot in diameter. Ten circles in each direction should be finished once a day. Gradually increase the width of the circle as your symptoms improve, but don't overdo it. 

2. Forward elevation of arm is assisted by a therapist.

3. External or outward rotation of the arm is assisted by a therapist.

4. Active assisted range of motion movement of the arm.

5. Bringing the arm close to the midline of the body (a.k.a. Cross body reach)

Before beginning these exercises, pain should be relieved with the application of an ice or heat pack. It has been demonstrated that increasing moist heat applied in addition to stretching increases muscular flexibility. It may also be beneficial for certain patients to take painkillers before physical therapy. [1]

Also, patients should perform range-of-motion exercises for a brief period (one to five seconds), ideally in a somewhat pain-free range.

Exercises using a pendulum can be performed in circular, flexion, or outward (abduction) motion.

Stretching aggressively beyond the point of pain can worsen a frozen shoulder and lead to worse consequences, especially in the early stages of the ailment.

Additionally, research suggests that patients should refrain from adopting a forward shoulder stance since it may impair their ability to move the upper arm forward or outward. [1]

 

II. Frozen stage

Similar to the freezing phase, a heat or ice pack can be applied during the frozen phase to relieve pain before commencing exercises. 

• It is important to continue doing stretches for the muscles in the chest and behind the shoulder.

• It's also advised to rotate before elevation activities, like an outward rotation stretch, to prevent aggravating pain and inflammation. Strengthening exercises are added at this point to keep the muscles strong.

• Performing exercises that do not involve movement related contraction of limb muscles, will reduce the worrying that your shoulder pain will become worse. [1]

• Exercises that involve pushing the wing bone backwards (scapular retraction) help to strengthen the wing bone muscles and gently stretch the chest muscles.

• If done within the range of motion, tightening of shoulder outward rotation can also be employed in forwarded and outward movement of the upper limb. However, caution should still be exercised when introducing vigorous exercises, as unduly aggressive treatment may worsen shoulder pain. [1]

 

III. Thawing stage

This stage is marked by little to no discomfort as ROM has been steadily improving over the previous few weeks. So, continued physical therapy (PT) remains the cornerstone of care at this point to gradually regain a "functional" shoulder range of motion before complete recovery. Surgical treatments are scarcely necessary at this point. [2]

The patient's range of motion gradually returns throughout the thawing process. Returning the shoulder to normal as soon as possible is essential to recovering strength and full range of motion. After a few months of limited movement, the shoulder becomes much weaker, which is why strengthening activities are crucial. Within tolerated bounds, the patient can undertake more mobility exercises and stretches than during the frozen period. Static contractions are another step up in the progression of strengthening exercises, which might lead to resistance band workouts, free weights, or weight machines. [1]

 

B. Surgical management

Only in cases when a patient has not responded significantly to an extended course of conservative treatment lasting six to nine months is it recommended to employ invasive surgical procedures (such as manipulation or surgical release of the capsule) to enhance function in individuals with primary FS.

The two surgical methods are arthroscopic capsular release (ACR) and manipulation under anaesthesia (MUA). [2]

• Manipulation under anaesthesia (MUA) – This procedure involves the doctor moving and stretching your shoulder joint while you're under general anesthesia. This helps break up the scar tissue that's limiting your movement and causing pain. It's usually done when other treatments like physical therapy haven't worked.

• Arthroscopic capsular release (ACR) - This is a minimally invasive surgery for frozen shoulder. The surgeon makes small incisions around the shoulder and uses an arthroscope, a tiny camera, to view inside the joint. Specialized instruments are then used to cut and release the tight shoulder capsule, which improves movement and reduces pain. [2]

 

C. Traditional African healers approach to Frozen Shoulder

Several traditional herbs and natural remedies are used across Africa for treating inflammation related pain and aches. So it is no surprise that these traditional remedies will be used in the treatment of FS. [12]

For instance in South Africa, the heated leaves of Withania somnifera, a plant from the Solanaceae family, are applied to different parts of the body as a pain reliever. [13] Then there's Devil's Claw (Harpagophytum procumbens), a fruit with a distinctive shape, native to the Kalahari Desert in Southern Africa. Historically, its tubers have been used to alleviate pain, especially joint pain. [14]

African ginger, found in over thirty African countries, is native to western and southern tropical Africa. Its widespread presence might be why it's used for various medical issues, including respiratory problems like coughs and influenza, as well as pain and inflammation. [15]

 

Conclusion

In summary, physiotherapy is vital for treating frozen shoulder. Physiotherapists provide personalized exercises, manual therapy, and education to enhance mobility and alleviate pain. This individualized approach aids patients in restoring shoulder function, improving their quality of life, and preventing recurrence. Emphasizing patient-centered care and evidence-based methods, physiotherapy is essential for effectively managing frozen shoulder and ensuring lasting well-being.

 

References

1. Chan HBY, Pua PY, How CH. Physical therapy in the management of frozen shoulder. Singapore Med J [Internet]. 2017 Dec [cited 2024 Jul 17];58(12):685–9. Available from here.

2. Pandey V, Madi S. Clinical guidelines in the management of frozen shoulder: an update! Indian J Orthop [Internet]. 2021 Feb 1 [cited 2024 Jul 16];55(2):299–309. Available from here.

3. Navarro-Ledesma S, Hamed-Hamed D, Pruimboom L. A new perspective of frozen shoulder pathology; the interplay between the brain and the immune system. Front Physiol [Internet]. 2024 Mar 29 [cited 2024 Jul 17];15:1248612. Available from here.   

4. Dyer BP, Rathod-Mistry T, Burton C, van der Windt D, Bucknall M. Diabetes as a risk factor for the onset of frozen shoulder: a systematic review and meta-analysis. BMJ Open [Internet]. 2023 Jan 4 [cited 2024 Jul 27];13(1):e062377. Available from here 

5. Verywell Health [Internet]. [cited 2024 Jul 27]. Why frozen shoulder is common in people with thyroid disease. Available from here.

6. Mezian K, Coffey R, Chang KV. Frozen shoulder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Jul 17]. Available from here

7. Smith SP, Devaraj VS, Bunker TD. The association between frozen shoulder and Dupuytren’s disease. Journal of Shoulder and Elbow Surgery [Internet]. 2001 Mar 1 [cited 2024 Jul 27];10(2):149–51. Available from here.

8. Gadgaard, N. R., Veres, K., Henderson, V. W., & Pedersen, A. B. Frozen Shoulder and the Risk of Parkinson’s Disease: A Danish Registry-Based Cohort Study. Clinical Epidemiology, 2024. 16, 447–459. doi:10.2147/CLEP.S463571. Available from here

9. El Hasbani G, Uthman I, Jawad AS. Is adhesive capsulitis of the shoulder a form of complex regional pain syndrome type I? Saudi Med J. 2020 Oct;41(10):1144-1145. doi: 10.15537/smj.2020. Available from here.

10. UConn Health Orthopedics and Sports Medicine. Shoulder. Frozen Shoulder [Internet, n.d.]. Cited August 2, 2024, Available from here.

11. Cho CH, Bae KC, Kim DH. Treatment strategy for frozen shoulder. Clin Orthop Surg [Internet]. 2019 Sep [cited 2024 Jul 15];11(3):249–57. Available from here. 

12. Harvard Health. 7 Stretching and strengthening exercises for a frozen houlder. [Internet. 2024 Aug. 1] Cited 2024 Aug. 2]. Available from here 

13. Bulia F. African herbal remedies: Traditional healing plants and their modern uses. Internet. [Last updated 2024 Aril 23]. Cited Jyly 28, 2024. Available from here

14. Aremu AO, Pendota SC. Medicinal plants for mitigating pain and inflammatory-related conditions: an appraisal of ethnobotanical uses and patterns in south africa. Front Pharmacol [Internet]. 2021 Oct 22 [cited 2024 Jul 28];12. Available from here. 

15. Wambugu SN, Mathiu PM, Gakuya DW, Kanui TI, Kabasa JD, Kiama SG. Medicinal plants used in the management of chronic joint pains in Machakos and Makueni counties, Kenya. Journal of Ethnopharmacology 2011;137(2):945–55. Available from here.

16. Aremu AO, Makunga N. The Conversation. 2022 [cited 2024 Jul 28]. Africa is a treasure trove of medicinal plants: Here are seven that are popular. Available from here.

 

 

Related: 

Understanding Neck Pain: Causes, Symptoms and Treatment

How to Deal With Joint Pains - Tips for Africans

Low back pain: Causes, Symptoms, Diagnosis, Treatment and Prevention

 

 

Published: August 5, 2024

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