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The pathogenesis of adhesive capsulitis, or frozen shoulder, is multifactorial but it has been hypothesized that it is an inflammatory response to injuries.
Frozen shoulder occurs more frequently in people with diabetes (both type 1 and 2) (1) and those with chronic arthritis, and it may affect only one or both the shoulders at the same time.
Shoulder immobility during the recovery phase of a shoulder or chest injury/surgery or secondary to a stroke could predispose a person to a frozen shoulder.
Those that underwent a mastectomy or open-heart surgery develop frozen shoulder years later. (2)(3) Regardless of the underlying cause of a frozen shoulder, the treatment is the same.
How Does Frozen Shoulder Occur?
Think of an accordion. When the accordion is made smaller, it has many folds in it. Similarly, when the shoulder joint is down at your side, all of the connective tissue on the underside of the shoulder joint fold up.
In a frozen shoulder, the folds stick together and do not unfold easily to allow full range of motion. This causes great pain and severe restriction of movement of the shoulder joint.
Different Stages of Frozen Shoulder
When the shoulder does freeze, it happens in three stages.
- Freezing, painful stage: Some stiffness and significant pain are felt in the shoulder joint.
- Frozen, adhesive stage: The condition has peaked, causing less or no pain. However, the shoulder joint is extremely stiff.
- Thawing stage: Loosening of the joint happens, less pain is felt, and range of motion begins to return.
Each stage lasts several months. If conservative treatment fails, a shoulder surgery called manipulation is required.
Things You Can Do at Home to Get Relief
Certain exercises can improve the range of motion of the shoulder but you must always warm up the joint before performing any such exercise.
You can do so by applying moist heat in the following manner:
- Wet a towel and place it in the microwave on high for 7–8 minutes. Be careful – the wet towel will be VERY HOT. Use a potholder.
- Put the hot wet towel in a plastic bag. Cover the top of the plastic bag with another dry towel, so heat does not escape. Wrap another dry towel around the plastic bag.
- Place this warm compress on your shoulder for 10–15 minutes. You may use another layer of the towel on your shoulder if the compress is too hot to avoid burning yourself.
After you warm the shoulder up, you can then perform the exercises below to restore the range of motion and function of the shoulder joint.
Helpful Exercises for Frozen Shoulder
When doing the exercise, stretch to the point that you feel a strong stretching sensation in the shoulder but no pain.
Note: Never force a stretch to the point of pain.
1. Pendulum Stretch
Tips to keep in mind:
- When performing pendulum exercises, move your body such that your arm swings freely. The affected hanging arm is not to be actively moved. If you were wearing a necklace or tie, that necklace or tie would swing.
- The instructions require the arm to swing clockwise and counterclockwise, but the swing may also be directed front to back and side to side rather than just in circles.
2. Finger Walk
Tips to keep in mind:
- Try to walk further up the wall each time the exercise is performed.
- This exercise should be performed with your body adjacent to the wall at a 90° angle so that your arm is reaching up to the side during the finger walk and not just facing the wall.
3. Cross-Body Arm Stretch
4. Arm Circles
5. Towel Stretch
Tips to keep in mind:
- The upper end of the towel should be held by the GOOD arm, while the frozen, painful arm should be holding the bottom of the towel. Use your top arm to pull upward as much as is comfortable.
6. Armpit Stretch
7. Back Clasp
We thank Phoenix Rehab and Physiotec for these explanatory images.
8. Assisted Shoulder Flexion
Sets: 10 Reps: 10 Hold: 5 seconds
- Lie on your back with knees bent and hold the stick firmly with both hands.
- Keep your shoulder blades together while you slowly bring the stick over the head as far as possible, helping yourself with the good arm.
- Maintain the position and relax.
- Most of the work should be done by the GOOD arm; the affected arm should just go along for the ride.
Note: A stick the length and weight of a cane would be great. A cane is what physiotherapists always use in the clinic, but if someone doesn’t have a cane at home (most people don’t), they can use a broomstick handle.
9. Assisted External Rotation
Sets: 10 Reps: 10 Duration: 5 seconds
- Lie on your back with your knees bent and place each hand at either end of the stick.
- Keeping the affected elbow against the body at all times, move your hand away from the body and increase the mobility by pushing the hand with the stick.
- Maintain the position, return to the initial position, and repeat.
10. Abduction With Stick
Sets: 10 Reps: 10 Hold: 5 seconds
- Lie on your back with knees bent and place each hand at each end of the stick.
- Slowly move the affected arm away from your body and increase the mobility by pushing the stick with the good arm.
- Push the arm up as high as possible.
- Maintain the position, lower your arm, and repeat.
11. PROM External Rotation
Sets: 10 Reps: 10 Hold: 5 seconds
- Sit with your affected forearm supported on a table.
- Keep your elbow by your side. Use your good arm to push the stick and externally rotate your affected arm away from your body.
- Pull with your good arm to return to the starting position.
12. Passive Shoulder Flexion
Sets: 10 Reps: 10 Hold: 10 seconds
- Place a long towel or rope around the shower rod in your bathroom, and sit beneath it on the side of the bathtub. Hold one end of the rope in each hand.
- Use the rope as a pulley to help you use one arm to lift the other. Use one hand to pull the other arm straight up in front of you with the elbow straight.
- Pull your arm as high up as possible.
- Lower your arms.
Note: Do not arch your back. Keep your shoulders level and your back straight.
13. Passive Shoulder Abduction
Sets: 10 Reps: 10 Hold: 10 seconds
- Stand or sit under a shower rod or a ceiling hook.
- Place a long towel or rope around the shower rod or in a hook fixed on the ceiling, and hold one end of the towel or rope in each hand.
- Pull the tip of your shoulder backward and lift your arm upward and out to the side of your body as much as possible, while keeping your elbow straight and by pulling down on the towel or rope with your good arm.
- Maintain the position, lower your arm slowly, and repeat.
Note: Keep your shoulders at the same level and your body straight at all times.
14. Table Slide Flexion Palm Up
Sets: 10 Reps: 10 Hold: 5 seconds
- Sit next to a table with your forearm on the table, palm up, with your elbow straight.
- Bend your trunk forward from the waist as you slide the arm forward.
Note: Keep your back straight during the exercise.
15. Passive External Rotation
Sets: 10 Reps: 10 Hold: 5 seconds
- Stand and place your hand on the edge of a wall, keeping your elbow against your body.
- Turn your body the opposite way without lifting the elbow until you feel a stretch.
- Maintain the position and relax.
16. Elastic Retraction
Sets: 3 Reps: 10 Hold: 2 seconds
- Hold the tubing handles in each hand, your forearm parallel to the ground.
- With the elbows slightly in front of your trunk and palms facing each other, squeeze the shoulder blades together against the pull of the band.
- Return and repeat.
Note: Do not poke your chin or arch your lower back while you do the exercise.
17. Sleeper Stretch (IR and ER)
Sets: 10 Reps: 10 Hold: 10 seconds
- Lie on your side with your elbow on the ground positioned slightly lower than the shoulder, toward the belly.
- Set the scapula in the right position for the stretch by slightly leaning back at approximately 45°. Make sure your shoulder is retracted (not in a rounded position) and place the free hand on top of your wrist.
- Use the free hand to gently push down on the wrist, rotating the arm inward, until a comfortable stretch is felt in the shoulder.
- Reverse the motion by pressing the back of the hand toward the surface, rotating the arm outward.
- Hold for the prescribed time in each position.
18. Stabilization External/Internal Rotation
Sets: 10 Reps: 10 Weight: Varies Hold: 10 seconds
- Lie on your back with your knees bent.
- Place your arm out to the side at shoulder level with your elbow bent at 90°.
- Place your opposite hand on the shoulder to prevent it from going forward (lifting from the bed).
- Pull the tip of your shoulder backward and lower your hand toward your hip, trying to touch the floor without lifting your shoulder from the bed.
- Lift your hand toward your head as far as possible.
- Return to the starting position and repeat.
19. Shoulder Horizontal Abduction
Sets: 3 Reps: 10
- Lie face down with the affected arm down and thumb forward, keeping your shoulders down and back.
- Raise your arm to shoulder level and hand at shoulder height while keeping your elbow straight.
- Lower your arm and repeat. Progress by adding weight.
20. Shoulder Extension
Sets: 3 Reps: 10 Hold: 2 seconds
- Lie on your stomach with your arm hanging on the side of the bed/table with your palm facing back.
- Retract the shoulder back and down slightly and raise your arm backward to 90° (parallel to your body).
- Slowly lower your arm and repeat. Progress by adding weight.
21. Shoulder External Rotation
Sets: 3 Reps: 10 Hold: 2 seconds
- Lie on your stomach with your upper arm perpendicular to your body and your forearm hanging over the side of the bed.
- Move your hand in a circular motion up toward the ceiling as high as you can.
- Lower your hand.
- When you move your hand, keep your upper arm in contact with the bed and perpendicular to your body at all times.
- To progress, repeat with a weight.
22. Horizontal Abduction at 100°
Sets: 3 Reps: 10 Hold: 2 seconds
- Lie face down with your arm over the edge of the table and holding a weight.
- Lift the arm to the side with your arm externally rotated (thumb toward the ceiling).
- Lift your arm to 100° with respect to your torso, so the weight is aligned with your ear.
- Return to the starting position and repeat the exercise.
Note: Start with no weight.
23. Weighted Horizontal Abduction
Sets: 3 Reps: 10 Hold: 2 seconds
- Lie on your stomach while holding a weight in your hand.
- Let your arm hang off the edge of the bed, with the palm facing back (thumb-down) and the shoulders down and back.
- Lift your right arm up to shoulder level while keeping your shoulder blades squeezed and your thumb down.
- Slowly return to the starting position and repeat.
Note: Start with no weight.
24. Multifidus Activation
Sets: 3 Reps: 10 Weight: Varies Hold: 2 seconds
- Lie on your stomach at the edge of a firm bed or table and let your arm hang over the edge.
- Lift your arm toward your head without bending it. The thumb should be pointed upward.
- Return to the resting position and repeat with the other arm once you have changed sides of the bed or table.
- Progress by adding weight.
25. Shoulder Shrugs
- Sit or stand, depending on whatever is more comfortable for you.
- Once you have assumed your starting position, lift your shoulders toward your ears but only as high as you can without any exertion.
- Hold this position for 3–5 seconds.
- Slowly bring down your shoulders to the resting position.
- Repeat.
What Worsens Frozen Shoulder?
The worst thing you can do if you have a frozen shoulder is to not move the arm because it hurts. Keep your shoulder working and moving to avoid freezing.
The idea is to consistently take the joint to end range to remodel the connective tissue in the shoulder to its previous level of range of motion and flexibility.
Expert Answers (Q&A)
Answered by Dr. Shayan Hosseinzadeh, MD (Orthopedic)
Is frozen shoulder a symptom of Parkinson’s disease?
Frozen shoulder is a common musculoskeletal presentation among patients with Parkinson’s disease, but it is not usually among the primary symptoms. So if you have a frozen shoulder, you should not be worried about Parkinson’s disease.
People suffering from diabetes, hyperthyroidism or hypothyroidism, cardiovascular disease, and tuberculosis are also more prone to frozen shoulder.
Is turmeric helpful in treating frozen shoulder?
Turmeric, (4) omega-3 fatty acids, (5) magnesium, (6) and CoQ10 (7) have some anti-inflammatory effects and have been suggested as beneficial supplements. However, their efficacy in frozen shoulder has not been confirmed yet.
What is the difference between a frozen shoulder and rotator cuff injury?
Rotator cuff injury is a tendon and muscle pathology that produces a dull pain. This injury is often secondary to repetitive overhead motions or competitive sports activities and could lead to significant weakness.
Joint stiffness, which is a dominant symptom in frozen shoulder, is not present in rotator cuff injuries.
What is the best way to diagnose frozen shoulder?
A physical exam is enough for the diagnosis. Imaging modalities, including ultrasound, X-ray, and MRI, are mainly used to rule out other suspected pathologies such as a rotator cuff injury or arthritis, which can mimic the symptoms of frozen shoulder.
About Dr. Shayan Hosseinzadeh, MD: Dr. Hosseinzadeh is currently a senior research fellow at Harvard Medical School and an orthopedic surgery fellow at Boston Children’s Hospital.
After obtaining his medical degree and completing an orthopedic residency at Isfahan University of Medical Sciences (IUMS), he started his fellowship at Harvard Medical School.
Dr. Hosseinzadeh has authored several high-impact scientific papers and book chapters in the field of orthopedic surgery. His musculoskeletal research projects were presented at different national and international conferences and meetings.
He is also a CME editor for the Journal of Bone and Joint Surgery and a reviewer for BMC Musculoskeletal Disorders and Sports Medicine journals.
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Final Word
Different exercises have been suggested for frozen shoulder. The main principle is to stretch out the shoulder muscles to relieve the pain and improve the range of motion. Repeated gentle stretching of the shoulder in any direction could be the safest way to treat this condition.
Frozen shoulder tends to slowly get better after a period of deterioration. However, a full recovery could take up to 2–3 years. You can also undergo physical therapy that is focused on shoulder flexibility to help with the healing.
References
- Hsu C-L, Sheu WH-H. Diabetes and shoulder disorders. Journal of diabetes investigation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5009124/. Published September 2016.
- Pedersen AB, Horváth-Puhó E, Ehrenstein V, Rørth M, Sørensen HT. Frozen shoulder and risk of cancer: a population-based cohort study. British journal of cancer. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5520209/. Published June 27, 2017.
- Nagy MT, Macfarlane RJ, Khan Y, Waseem M. The frozen shoulder: myths and realities. The open orthopaedics journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785028/. Published September 6, 2013.
- Hewlings SJ, Kalman DS. Curcumin: A Review of Its’ Effects on Human Health. Foods (Basel, Switzerland). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5664031/. Published on October 22, 2017.
- Calder PC. Omega-3 fatty acids and inflammatory processes: from molecules to man. Biochemical Society transactions. https://www.ncbi.nlm.nih.gov/pubmed/28900017. Published on October 15, 2017.
- Ahmadi S, Naderifar M, Samimi M, et al. The effects of magnesium supplementation on gene expression related to inflammatory markers, vascular endothelial growth factor, and pregnancy outcomes in patients with gestational diabetes. Magnesium research. https://www.ncbi.nlm.nih.gov/pubmed/31099333. Published on November 1, 2018.
- Zhai J, Bo Y, Lu Y, Liu C, Zhang L. Effects of Coenzyme Q10 on Markers of Inflammation: A Systematic Review and Meta-Analysis. PloS one. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5268485/. Published on January 26, 2017.
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