The Stiff Shoulder
“I can’t style my hair.” “It hurts to put my shirt on.” “I can’t wash my back.”
If you have a stiff shoulder, basic day-to-day activities can become challenging. Adding significant pain to that problem can make a stiff shoulder nearly debilitating. Adhesive capsulitis is a specific type of shoulder stiffness that can result in painful limitations. This diagnosis can develop after a trauma or surgery to the shoulder (secondary), but can also develop without a known reason (primary). Primary adhesive capsulitis will be discussed here.
Primary adhesive capsulitis occurs when the capsule around the shoulder contracts and results in reduced ability to move the shoulder and arm. Both active and passive ranges of motion are limited, meaning stretching the shoulder and reaching movements are equally restricted. Although primary adhesive capsulitis does not have a known cause, there are a few factors which make someone more predisposed to this condition. Women are more affected than men and the common age range of patients is between 40 and 60 years old. The most frequently identified comorbidity for this diagnosis is diabetes mellitus, which is found in 10-36% of all cases.
Adhesive capsulitis involves four stages: Pre-adhesive (initial) stage, freezing stage, frozen stage, and thawing stage. A typical course of adhesive capsulitis can last up to two years. In the initial phase (0-3 months), individuals begin to experience shoulder pain and a reduced ability to move the arm comfortably; especially with reaching overhead, behind the back, and out to the side. In the freezing stage (3-9 months), the shoulder becomes more painful, usually accompanied by a ‘nagging’ pain at night, and the tightening of the shoulder is more apparent during movement. In the frozen stage (9-14 months), shoulder pain reduces to a degree; however, the shoulder range of motion becomes considerably restricted with reaching movements, as well as with stretching. Finally, during the thawing stage (15-24 months), the shoulder begins to loosen and range of motion returns, with many individuals regaining full movement of the arm.
Although dealing with adhesive capsulitis can be a long and frustrating process, physical therapy can help during most, if not all, of the stages. In the face of the opioid crisis, physical therapists are being utilized more and more as pain management clinicians. Heating modalities, electrical stimulation, cold laser therapy, and other modalities can help to relax irritable tissues during the early stages of adhesive capsulitis, allowing improved tolerance with arm movement. As pain levels begin to subside, the individual’s available shoulder range of motion will be assessed by the physical therapist to help develop an appropriate exercise and stretching program. A physical therapist may also incorporate various manual techniques, such as massage, manual stretching, and joint mobilizations into the treatment. It is important to note that exercises and other treatments should not significantly increase a patient’s pain level, as this may lead to poorer outcomes.
If you have been dealing with a nagging shoulder problem and have experienced an increase in shoulder stiffness, you should schedule a consultation with an orthopedic doctor, or if available, a Direct Access physical therapist (a physical therapist who is able to evaluate and treat patients without an initial MD prescription). Having a good understanding of your shoulder symptoms, treatment options, and prognosis is a critical first step into regaining the confidence needed to return to your prior activity level.
*Information sources
-Evaluation and Treatment of the Stiff Shoulder. A monograph by Nancy Henderson, PT, DPT, OCS; Ryan Decarreau, PT, DPT, SCS, ATC, CSCS; Haley Worst, PT, DPT, OCS; and Jay B. Cook, MD. Academy of Orthopaedic Physical Therapy, 2018.
-Manske R, Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med. 2008 Dec: 1(3-4); 180-189.
-Added clinical commentary by John Battles, PT, DPT, OCS