Frozen Shoulder Symptoms

Answer: 

Without treatment, most, but not all cases of a frozen shoulder will follow a typical pattern of symptoms which have traditionally been described as “freezing”, “frozen” and “thawing". The freezing stage is characterised by high levels of pain and gradual reduction in range of motion (stiffness). The frozen stage characterised with persistent loss of range of motion but improved pain levels and the thawing stage a gradual return of the shoulder range of motion. To find out more about typical timeframes please scroll down this page to How long does a frozen shoulder last?

The more recent advents of the terms "pain dominant" and "stiffness dominant" frozen shoulders have been used in an attempt to standardise the way clinicians treat a frozen shoulder. The standard this has aimed for is to offer an early form of steroid injection for painful frozen shoulders to reduce inflammation and to offer gentle rehab exercises for stiff (but less painful) frozen shoulders. For more information about the best treatment for frozen shoulder symptoms please go to frozen shoulder treatment.

Explanation:

Many articles have described a distinct pattern of symptoms which develop in a frozen shoulder. The first reports on this condition were based on descriptions from surgeons based on what they observed while operating on cases of frozen shoulder. In later years, histology samples (looking at the shoulder tissues and cells of these tissues under a microscope) were described as well. Findings from these research papers and other studies observing patients symptoms have concluded that typical frozen shoulders undergo distinct symptom stages as we describe here:

Frozen Shoulder Stage 1: Freezing (pain dominant):

The "freezing" - or "pain dominant" stage of a frozen shoulder is characterized by high levels of inflammation within the soft tissue capsule and ligaments of the shoulder joint. Many histological studies (studies which look at the cells and tissue under a microscope) have found high levels of blood vessel (vascular) infiltration to the shoulder capsule as well as a high number of mononuclear cells (cells involved in an immune system response). Due to the inflammation patients often suffer with high degree of pain, especially night pain. The movements of the shoulder at this stage will begin to gradually stiffen due to fibrosis of the shoulder joint capsule.

Frozen Shoulder Stage 2: Frozen (stiffness dominant):

The "stiffness dominant" stage of a frozen shoulder signifies the reduction of the active inflammation of the shoulder joint capsule and ligaments. However, the prolonged inflammation of the shoulder capsule and ligaments during the freezing/ pain dominant stage results in a tough, inflexible soft tissue capsule - essentially it leaves the shoulder capsule and ligaments with scar tissue. Thus, in this stage frozen shoulder pain improves but the shoulder movements remain very stiff.

In this stage of a frozen shoulder, high numbers of cells known as fibroblasts which are involved in tissue repair during and following inflammation have been demonstrated in the shoulder capsule. Furthermore, the type of soft tissue being made appears to be a tougher and stiffer type than normally found in the shoulder capsule and ligaments (collagen type 2). This stage can be likened to the tough, raised scar that you feel on your skin several weeks and months after you have cut yourself. 

Frozen Shoulder Stage 3: Thawing (resolution):

As it's name implies the "resolution" stage of a frozen shoulder signifies the process in which the tougher form of soft tissue collagen in the shoulder is slowly remodelled to form a more normal, flexible joint capsule. As with other injuries such as a deep cut to the skin or a badly sprained ankle this stiffness will resolve over several months so patients will notice a gradual increase in their range of motion again over this period of time. In most cases of frozen shoulder, the range of motion will not get back to completely normal but will not disable activities of daily living.

Articles:

Cho, C.H., Song, K.S., Kim, B.S., Kim, D.H. and Lho, Y.M., 2018. Biological aspect of pathophysiology for frozen shoulder. BioMed Research International, 2018. Link to article 

Hand, G.C.R., Athanasou, N.A., Matthews, T. and Carr, A.J., 2007. The pathology of frozen shoulder. The Journal of bone and joint surgery. British volume, 89(7), pp.928-932. Link to article 

Neviaser, J.S., 1945. Adhesive capsulitis of the shoulder: a study of the pathological findings in periarthritis of the shoulder. JBJS, 27(2), pp.211-222. Link to article 

Neviaser, R.J. and Neviaser, T.J., 1987. The Frozen Shoulder Diagnosis and Management. Clinical Orthopaedics and Related Research (1976-2007), 223, pp.59-64. Link to article 

Reeves, B., 1975. The natural history of the frozen shoulder syndrome. Scandinavian journal of rheumatology, 4(4), pp.193-196. Link to article 

Singh et al (2015) looked at a far greater number of patients (783) and also specifically published figure for 56 patients diagnosed with a frozen shoulder. Again, they concluded that frozen shoulder pain is felt in the outer aspect of the deltoid region and upper arm.

These studies of differing methods all confirm that the most likely site of pain in a frozen shoulder is the deltoid region and upper arm. However, this referred somatic pain pattern may be similar in many other common shoulder conditions including shoulder impingement, shoulder bursitis and rotator cuff pain and tears so it should not be used for diagnosis. To find out more about how a frozen shoulder can be diagnosed follow this link - How is a frozen shoulder diagnosed?

Articles:

Bayam, L., Ahmad, M.A., Naqui, S.Z., Chouhan, A. and Funk, L., 2011. Pain mapping for common shoulder disorders. pathology, 14(5), p.9. Link to article 

Gerber, C., Galantay, R.V. and Hersche, O., 1998. The pattern of pain produced by irritation of the acromioclavicular joint and the subacromial space. Journal of shoulder and elbow surgery, 7(4), pp.352-355. Link to article 

Singh, S., Mohammad, F., Gill, S., Kumar, D. and Kumar, S., 2015. Role of pain mapping in shoulder disorders. International Journal of Orthopaedics, 2(3), pp.323-327. Link to article 

Answer: 

Published studies indicate that the majority of frozen shoulder cases will significantly improve with regards to pain levels, function and range of shoulder range of motion without active treatment. However, several caveats to this exist:

• The timeframe to maximal improvement from a frozen shoulder may be as long as 2-3 years in most cases.

• A significant percentage of frozen shoulders (studies range from approximately 20% - 50%) may cause mild pain or functional deficit long term.

• A small percentage of frozen shoulders may cause significant long term pain or disability (<10%).

Given the long time frame to recovery and significant nocturnal pain and disability during the early stages it is generally accepted that a steroid injection or hydro-dilatation procedure should be offered to patients. For more information about these treatments please scroll to the dedicated frozen shoulder treatment section.

Explanation:

The general consensus among doctors and physiotherapists (which arises from their teaching as an undergraduate) is that a frozen shoulder will improve without treatment. Most clinicians will give a rough estimation of 18 months from initial onset of symptoms to full resolution with this timeframe broken down in to 6 month blocks for each of the 3 stages which we discuss in the section above on this page.

However, the available studies indicate that this traditionally recognised view regarding timeframe to recovery may be too short and that significant numbers of frozen shoulders will develop some mild long term symptoms. 4 such studies are discussed here...

Reeves, et al was the first study to look at this question in 1975. They performed a prospective study which managed to follow up 41 frozen shoulders and concluded that the mean average duration to full recovery was 30.1 months. They also reported a slight restriction in shoulder range of motion persisted long term in more that 50% of the frozen shoulders evaluated and 3/41 frozen shoulders reported significant deficit in shoulder function.

Similarly, Shaffer et al (1992) found that when a long term follow up on 62 cases of frozen shoulder was conducted (over 2-11 years from initial onset) 50% had mild stiffness or pain in the shoulder ongoing. Clinically assessed shoulder range of motion  was also restricted at the long term follow up (compared with the other shoulder) in 30% of the frozen shoulders.

Using the Oxford Shoulder Score as a measure of shoulder symptoms, Hand et al (2008) published a study with a greater sample size (269 frozen shoulders). There was a mean average of 4.4 years after initial onset of symptoms to follow up. Their data reported only 59% of patients had "normal" or "near normal" shoulders at follow up. However, only 6% of patients reported severe long term symptoms. Timeline to peak of symptoms from initial onset was documented at 1-3 years.

Lastly, in 2020 and titled "Is frozen shoulder completely resolved at 2 years after the onset of disease?", Kim et al investigated this question with a sample size of 234 frozen shoulders. As a mean average, pain scores (VAS) reduced from 6.7 to 1.5. A satisfaction grading system known as the subjective shoulder value used more widely in the USA reported the following:

• very satisfied 43.2%

• satisfied 29.1%

• fair 15.8%

• unsatisfied 8.5%

• very unsatisfied 3.4%

Articles:

Hand, C., Clipsham, K., Rees, J.L. and Carr, A.J., 2008. Long-term outcome of frozen shoulder. Journal of shoulder and elbow surgery, 17(2), pp.231-236. Link to article 

Kim, D.H., Kim, Y.S., Kim, B.S., Sung, D.H., Song, K.S. and Cho, C.H., 2020. Is frozen shoulder completely resolved at 2 years after the onset of disease?. Journal of Orthopaedic Science, 25(2), pp.224-228. Link to article 

Reeves, B., 1975. The natural history of the frozen shoulder syndrome. Scandinavian journal of rheumatology, 4(4), pp.193-196. Link to article 

Shaffer, B., Tibone, J.E. and Kerlan, R.K., 1992. Frozen shoulder. A long-term follow-up. JBJS, 74(5), pp.738-746. Link to article 

Answer: 

A frozen shoulder causes inflammation, pain and stiffness in the soft tissue capsule of the shoulder joint (glenohumeral joint) as well as changes to the sub acromial area (bursa and rotator cuff tendons above this joint). These structures do not cause neck pain themselves. 

However, neck pain is a common clinical complaint from patients with a frozen shoulder. Therefore, it is probable that the compensatory movements adopted due to the shoulder stiffness places extra stress on the joints and soft tissue of the neck and causes pain in these cases. 

Explanation:

For a full explanation of where frozen shoulder pain is felt please scroll up this page to the section - Where is the pain in a frozen shoulder?