Frozen Shoulder Physiotherapy Treatment: How To Get Better

This article is even more personal than normal for my good self as I am one of those lucky people to have, and recovered from, a frozen shoulder. Hopefully that experience will add a little more real world experience to this article.

To help you understand if your lack of shoulder mobility is truly frozen we need to look more closely what it is, what the symptoms are and the risk factors that lead to you getting the condition.

What Is Frozen Shoulder?

Technically it is tension in the joint capsule (the bit that keeps the joint in place and keeps the lubricating oil inside) which causes significant loss of range of motion of the shoulder joint (glenohumeral) which will normally result in pain. It’s Latin name is Adhesive Capsulitis.

An important point to note is that the rotator cuff muscles (amongst others) are continuous with the joint capsule so issues with within the rotator cuff muscles can mimic the symptoms of a frozen shoulder.

Equally the nerve which makes all the muscles around the shoulder work can be affected – usually by bio-mechanics elsewhere – and this limits the movement of the shoulder. There can also be myofascial (muscles and connective tissue) limitations elsewhere which don’t allow to shoulder to fully “express” itself in terms of movement. These less severe issues can instil further fear and pain avoidance movement patterns into our bodies. This is why it’s important to consider the whole body when trying to investigate whether some has a frozen shoulder.

Symptoms of Frozen Shoulder

More often than not frozen shoulder will develop gradually over a period. This period can be for no reason at all (idiopathic). More commonly though this will come after a specific injury or post-surgery (secondary).

There’s an excellent in depth article here that give lots of detail on frozen shoulder if you want to go into very technical detail. What I found most useful in this article is it’s categorisation of the 3 phases of frozen shoulder which certainly seem to fit my own personal frozen shoulder from a few years back:

• Freezing phase: Duration varying from of 10 to 36 weeks. The main symptom is pain, especially during the night, with little response to anti-inflammatories. The range of motion begins to reduce.
• Frozen phase: Duration of 4 to 12 months. Pain gradually diminishes while stiffness persists, especially external rotation – that is with elbows tucked into your side with arms at 90 degrees and moving your hand away from the mid-line of your body.
• Thawing phase: Lasting between 12 and 42 months, possibly up to 7 years. In this phase, stiffness gradually disappears and range of motion is gradually recovered.

These recovery times are quite long in the physiotherapy world. Problems don’t normally take this long to resolve. But don’t fear. These times can be greatly reduced by doing the right things over a period of time. And we’re not 100% sure you have frozen shoulder just yet. It is more likely to be a rotator cuff or other biomechanical problem.

My own personal experience was freezing phase about 8 weeks, frozen phase about 5 months and the thawing process has been about 30 months to date. That said most of the thawing took place over about 6 months and I’m just left with about 5 degrees limitation in external rotation despite the shoulder being 100% functional.

For one client I have been seeing recently this process is almost over after just 6 months. So you get a real sense of the varying nature of this condition.

Causes Of Frozen Shoulder

Let’s consider risk factors in developing frozen shoulders. Diabetes is a big factor. Yours truly is a type 1 diabetic. According to this research those of us in the D-Team (as we sometimes refer to ourselves as) are 5 times more likely to develop frozen shoulders. 30% of people with frozen shoulder have diabetes. It’s a big factor!

Other risk factors are summarised nicely in this research and include:

• Hypothyroidism
• High weight
• Low weight
• Being British!
• Family history
• Being over 40 years old
• High stress levels
• Previous injury around the shoulder or elbow
• Cardiovascular disease

A few here immediately catch my eye. Let’s take high stress. Regular readers will know my simplistic overview of some very complex pain science is that stress is the volume control on the pain we feel. Without oversharing (!) this was certainly very much the case as my shoulder was freezing up.

We discuss this link between stress and pain in our previous article What Is Pain? But with frozen shoulder this correlation is even more important. You see increase stress causes our back ground inflammation to increase. Just as is the case in diabetes. This increased inflammation leads to increased tension at a physiological level. The capsule starts to tighten.

This would also explain why post-surgery and post injury can be starting points for frozen shoulder as the inflammation caused by the trauma could contribute to the stiffening of the joint capsule. Particularly if you’re a stressed out diabetic!

Before we move on I can’t let the British thing go! I’m not sure what research methods were used to find this out but it does seem to be the case. Us Brits do have a reputation for being uptight and certainly not letting our emotions out. Which itself can be a cause of much stress. Perhaps this is why? Who knows. Regardless, it’s an interesting finding.

Do You Really Have Frozen Shoulder?

So if your shoulder isn’t moving, you’ve had a previous shoulder injury, you’re stressed and diabetic it’s looking more likely that you have a frozen shoulder rather than anything easier to fix. But it’s not cut and dry just yet. To get more of an idea your next port of call should be your local physiotherapy and sports therapy practice. Anyone know any good ones?

Reason being such clinics (others apart from our own do exist) have tests they can do to assess your rotator cuff and shoulder movement and compare that with previous ones we’ve seen. They also just feel different. With experience you just get a sense that something very obvious is blocking the movement.

If we treat your structures further afield that can cause rotator cuffs to over work in an unfrozen shoulder we will see an increase in range of motion and reduction in pain. If multiple types of treatment are not working this is more suggestive of a frozen shoulder.

MRI scans at this point can be useful to rule out anything else mechanical that needs addressing but actually for truly diagnosing adhesive capsulitis this research here suggests it’s only 50% accurate. Perversely, you may have a thickening of the joint capsule but that may not be what is causing the limitation in movement! Surgery is an option which may, or my not help. But should you operate when you’re not sure you’re operating on thing that is causing the problem? Nothing is this line of work is black and white.

Which reminds me of a really interesting client I saw some years ago. He was very much presenting with symptoms of frozen shoulder yet when we re-aligned his body and didn’t even get really close to the shoulder his arm magically popped into a good position. To me this confirmed it was not a true case of frozen shoulder.

However, within days, or sometimes hours, the stiffness would return. He was absolutely convinced surgery was required. He did have a good point having had successful surgery on the other shoulder previously. Sure enough surgery did help and it only took a couple of post-surgical treatments from us to get a complete resolution.

I’m still not convinced that shoulder was frozen though! Just because I’ve seen so many frozen shoulders where no matter what you do it doesn’t make a difference. But his belief was strong. I don’t know whether it was the surgery or just placebo.

Would You Trust A Sports Therapist With A Frozen Shoulder?

Beliefs and fears can be important factors in many cases of frozen shoulder. Many people subconsciously protect the shoulder for fear of making things worse – which actually makes it worse. There was certainly an element of this in my own frozen shoulder.

Any sports therapist or physio will tell you that post qualification we all turn into hypochondriacs! Quickly referencing any pain in our bodies with the text book definitions. Thankfully my interest in pain science helped me get through that phase sometime ago. But with this condition something sneaked past my resilience and deep down in my subconscious I was worried.

You see I have always been a sporty guy. Hence the sports therapy. Being active, like so many of us, is important for my mental wellbeing. I’ve always been a swimmer. That’s my thing. But what if I couldn’t swim? What if this was permanent? This was the catastrophising that was going on in deep recesses of my brain. I was a afraid of a labral tear. All those things I was telling my clients not to do, I was doing, and more. With increased stress levels I needed my sport more than ever. I was pushing through it too much whilst subconsciously protecting my fear of a mechanical issue. Unsurprisingly my shoulder froze. I really should have known better.

But the lessons hardest learnt can sometimes be the most valuable ones. This wasn’t the first time I’d pushed through things. Out of the previous time came a career change into sports therapy and that’s work out pretty well. Out of this one came better self-care and a greater empathy and understanding of my clients in pain… especially those with, or fearing, frozen shoulder!

So what was the turning point for me? When someone showed me my shoulder could actually move. When a very nice personal trainer took me through their approach to increase the range of motion and I saw it improve. It was far from perfect but it was the turning point. I had a word with myself, as did Mark, and I  stopped fearing it any labral damage or the need for surgery.

To finish the story the shoulder is now the best it’s been in decades – barring missing the 5 degrees of external rotation I mentioned previously. What really helped me to thaw the shoulder out was relaxing. It was during the first COVID lockdown that the thawing started to accelerate. After the initial stress of not being able to work I had down time. I had time to do lots of yoga. I really didn’t have much else to do of an evening, there’s only so much TV I can watch.

And this is an important consideration for dealing with any long standing injury that we try to get across to our clients. Setting up the conditions from how you can move on from these injuries. We talked all about this in our COVID wellbeing article which has now been turned into simply a wellbeing article. With lots of practical ideas, some more involved than others, of how to calm our nervous systems to ultimately feel less pain.

Sorry, that went on a bit. I try to minimise the amount I talk about myself in these articles but I’m hoping you’ve found value in those lessons that I re-learned and has given you motivation and hope for your own individual cases.

What Is The Best Treatment For Frozen Shoulder?

Firstly get over the name of it! As we mentioned the name is quite scary and that in itself can lead to protection, pain and limitation. Trust that it will get better. Rule out anything that you fear it could be by going for conservative treatment with someone like ourselves or a more medical route and get a scan done. The idea being to give you confidence you’re not making it worse. Which, as a rule, you won’t be.

Traditional treatment options are considered in this article which suggests that steroid injections may be more useful than traditional physiotherapy in the short term but not much difference in the long term.

Generally we try to avoid steroid injections due to a link with increased risk of tendon rupture. But if you’re desperate it could be an option for you.

As alluded to above we prefer to create conditions to optimise the thawing out. This is a combination of wellbeing ideas we linked to above and correcting the physical pressures on the joint capsule using our bio-mechanical knowledge. As a happy combination of the two we find that the nervous system is calmer when the body is better aligned. It’s almost as if the body is fighting with itself. We feel calmer in our bodies and so they sit in a happier, calmer space.

This alignment work starts with the rotator cuff, the most likely culprit and then works out from there. Especially if you have history of other aches, pains, niggles or previous traumatic injury.

This research suggests that joint mobilisation has moderate short and long term evidence for being a help. Which we have seen clinically. But if we can release off as many reasons as possible for the joint getting tight in the first place then less mobilisations are required and we find normal range and function is restored sooner.

As with many conditions if conservative physiotherapy shows no sign of improvement then surgery can be considered. We spoke about one excellent example of what surgery can achieve but results are not guaranteed. In fact according to this excellent and very honest piece by a surgeon there is no decent evidence to suggest that there is any advantage over non-surgical.

That’s not to say that it doesn’t help in many cases it’s just to say that the amount of comparative research is insufficient. As a rule of thumb if surgery doesn’t scare you and you believe it will help then it could be the right choice for you.

Frozen Shoulder Exercises

As you can tell from the information above our approach is a very holistic mind and body one. Reduce sensitivity, create space for the joint to go back to what it should be doing.

There’s a good article here from Harvard with some nice ideas for that early very painful / frozen phase of injury. I particularly like the Pendulum, Finger Walk and the Armpit stretch.

Please make sure all of these exercises and the ones we mention below are done in a pain free manner and do not proceed if you find them in any way aggravating the condition. Generally speaking if it makes it worse you’re pushing too far into the stretches.

We’d prefer everyone to get individually checked but here’s a few ideas for you to try out that we commonly find help frozen shoulders. This first one below you may not be able to get the arm as high as I’m showing here. If that is the case just work within a range that is comfortable:

When tight the lats will cause the rotator cuff to work too hard. We’d like these to loosen to stop the rotator cuff being so tight and therefore the capsule. The lat stretch immediately below is probably better for later stage rehab so below this is the banana stretch which will stretch muscles that lead into the lats. Obviously you won’t be able to reach your arm overhead so just keep the arms down by the side to make your banana shape:

These are some thought starters for movement for you to try to get some movement back into your shoulder. From my own personal and professional experience I would say it’s more important to focus on calming the nervous system and looking after yourself as well as you’re able. In my case yoga and not working was a useful part of that! We don’t often have that luxury. But just do what you can from wellbeing ideas page. Choose what you think will work for you and what you think you’ll be able to do on a (relatively) consistent basis.

How Long Does It Take To Recover From Frozen Shoulder?

The point of this article was to encourage you to check out if you truly have frozen shoulder. If you haven’t great. The recovery should be much less. If you do have frozen shoulder it will take longer. But trust in the fact that it will resolve.

Usually within 1-2 years. It can be longer. But it’s often shorter. And remember from what we’ve written above you’re not a casual bystander in this process. If you are able to implement some of the work we mention in this article and add to that professional assessment and guidance your return to full function should be much quicker.

One final example of the power of the brain in all this. A very fit man I used to know from one of my many swimming clubs only ever swam backstroke with one arm. As I gained confidence in my new profession the best part of 20 years ago I started to ask questions as I was unaware of a condition that could last over 30 years!

As I pried a little deeper it became clear that he had had some physio back in the 70s for a frozen shoulder and the well-meaning physio had called it frozen shoulder and told him it that it will never work properly again. So this man believed him and so modified his activities so the shoulder was never able to do that movement again.

I hope this article has given you the confidence to choose the next best steps in your recovery from your shoulder condition whether it be frozen or otherwise. If you’d like to speak to us about your frozen shoulder, rotator cuff issue or anything else to see if we might be able to help click here and fill out the form to ask to speak to a therapist and we’ll call you back a soon as we’re able.