FROZEN SHOULDER OVERVIEW

Frozen shoulder is the term used to describe a stiff shoulder joint that has temporarily lost the ability to move freely; most people with frozen shoulder have difficulty reaching overhead and reaching to the low back. The stiffening is the body's natural response to inflammation that develops in or near the shoulder. Stiffening is a protective reflex that protects the shoulder from further injury.

In 95 percent of cases, frozen shoulder is totally reversible, although full recovery may take several months. Stretching exercises are the treatments of choice for frozen shoulder.

FROZEN SHOULDER TREATMENT

Limit activity — During recovery, you should limit overhead positioning, reaching, and lifting. These restrictions can be eased as pain decreases and flexibility increases.

Pain relief — If needed, a non-prescription pain medication such as acetaminophen (Tylenol®), ibuprofen (eg, Advil®, Motrin®), or naproxen (eg, Aleve®) can be taken. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".) No more than 4000 mg of acetaminophen is recommended per day. Anyone with liver disease or who drinks alcohol regularly should speak with his or her healthcare provider before taking acetaminophen.

Ice the joint — Apply an ice pack or bag of frozen vegetables to the shoulder for 15 minutes every four to six hours to reduce pain and inflammation.

FROZEN SHOULDER STRETCHING EXERCISES

Heat — Heat helps prepare the tissues for stretching and should be performed prior to exercise sessions. The preferable method of heating is in a warm shower or bath for 10 to 15 minutes. Local heat (for example with a moist heating pad or a towel warmed in a microwave) is an alternative, but generally is not as effective.

Weighted pendulum stretch — Range-of-motion exercises are recommended early in the recovery period. These exercises are intended to help maintain joint mobility and flexibility of the muscles and tendons in the shoulder. Pain should not exceed mild levels with any range-of-motion/flexibility exercise. Anyone who feels sharp or tearing pain while stretching should stop exercising immediately and consult with a healthcare provider.

The weighted pendulum stretching exercise performs two functions:

• Gently stretches the space in which the tendons pass to relieve pressure on the tendons
• Prevents the development of a frozen (stiff) shoulder

This exercise can be started almost immediately after a shoulder injury, or after receiving a steroid injection into the shoulder joint. This exercise should be performed after heating for five minutes once or twice per day. The exercise is performed as follows (figure 1):

• Relax your shoulder muscles.
• While standing or sitting, keep your arm vertical and close to your body (bending over too far may pinch the rotator cuff tendons).
• Allow your arm to swing forward to back, then side to side, then in small circles in each direction (no greater than 1 foot in any direction). Only minimal pain should be felt.
• Stretch the arm only (without added weight) for three to seven days. Progress this exercise by adding 1 to 2 pounds (0.5 to 1 kg) each week and gradually increasing the diameter of the movements (not to exceed 18 to 24 inches or 45 to 60 cm).
• After a few weeks this exercise should be supplemented or replaced by other exercises to target specific areas of tightness/restriction. The pendulum stretch may be recommended as a warm up for more localized flexibility exercises and/or strengthening exercises.

When performed correctly the pendulum exercise should not result in more than mild discomfort. If more pain is felt, consult a healthcare provider for instructions.

Passive stretching exercises — Passive stretches (ie, stretches done without actively contracting any shoulder muscles) should be performed after the pendulum stretch exercise. These exercises should further loosen the tightened shoulder capsule and muscles and restore normal range of motion. These exercises should be performed in sets of 10 to 20 once or twice a day for several months. The goal of these exercises is to stretch the shoulder to the point of tension but not pain. Severe discomfort is unusual and suggests overstretching.

Armpit stretch — Use your good arm to lift the affected arm onto a shelf, dresser, or any object that is chest high (picture 1). Gently bend at the knees, opening up the armpit. Try to push the affected arm up a little farther with each stretch.

Finger walk — Face a wall about three-quarters of an arm's length away (picture 2). Using only your fingers (not your shoulder muscles) raise your arm up to shoulder level.

Towel stretch — Take a 3-foot-long towel, grasp it with both hands, and hold it at a 45 degree angle (picture 3). Use the upper, good arm to pull the arm toward the lower back. This can be repeated with the towel in the horizontal position.

FROZEN SHOULDER STRENGTHENING EXERCISES

Muscle toning exercises may play a role in recovery from frozen shoulder, particularly if tendonitis occurred before developing a frozen shoulder. Your healthcare provider will advise you if these exercises are necessary. (See "Patient information: Rotator cuff tendinitis and tear (Beyond the Basics)".)

The joint should be warmed with cardiovascular exercise or a warm pack and stretched with range-of-motion exercises before beginning strengthening exercises. Following a two to three minute rest, 10 to 15 sets of each strengthening exercise should be done once per day, holding each for five seconds. Flexible rubber tubing, a bungee cord, or a large rubber band is recommended for each exercise (figure 2).

Outward rotation exercise — Hold your elbows at 90 degrees, close to your sides; holding a towel between your torso and the inside of your elbow will cue you to keep your elbow by your side. Hold one end of a rubber band in each hand and rotate the affected lower arm outward two or three inches, holding for five seconds (picture 4). Repeat 10 to 15 times.

Perform the exercise through all available pain-free ranges of motion. Keep the shoulder blades squeezed down and back while performing this exercise.

Inward rotation exercise — Hold your elbow at 90 degrees, close to your side. Hook the rubber band onto a door handle and grasp with only one hand. Rotate your forearm towards the body two or three inches and hold for five seconds (picture 5). The forearm swings like a door. Repeat 10 to 15 times.

Abduction exercise — Bend your elbow to 90 degrees. Place the rubber band near the elbows and lift your arms up four or five inches away from the body, holding for five seconds (picture 6). Repeat 10 to 15 times.

Mild soreness should be expected with these exercises. Sharp or severe pain may indicate a flare of the underlying problem; stop these exercises for a few days if this occurs.

IF PAIN AND STIFFNESS CONTINUE

If pain and stiffness are still present after completing a course of physical therapy, a repeat examination may be recommended to determine if another problem, such as rotator cuff tendinitis, is present.

If there is no other cause for symptoms, one of the following treatments may be recommended.

Steroid injection — Injecting a steroid into the shoulder joint may help to speed recovery over the short term, especially if a course of physical therapy is done after the injection.

Following the steroid injection, it is important to limit activity, treat pain as needed, and begin stretching and strengthening exercises. (See 'Frozen shoulder treatment' above.)

Joint dilation — Injecting fluid into the shoulder joint may increase joint space and improve motion. This technique may be performed if motion does not improve with physical therapy.

RETURN TO ACTIVITIES AFTER TREATMENT

If a steroid injection is given, it is important to protect the shoulder for 30 days by limiting reaching, overhead positioning, lifting, pushing, and pulling. Other regular activities, work, and sports should be avoided until the shoulder can move in all directions and muscle strength has improved by at least 75 percent.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Frozen shoulder (The Basics)
Patient information: Rotator cuff injury (The Basics)
Patient information: Separated shoulder (The Basics)
Patient information: Shoulder impingement (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient information: Rotator cuff tendinitis and tear (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Evaluation of the patient with shoulder complaints
Frozen shoulder (adhesive capsulitis)
Radiologic evaluation of the painful shoulder
Shoulder impingement syndrome

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Academy of Orthopaedic Surgeons

     (http://orthoinfo.aaos.org/)

• National Institute of Arthritis and Musculoskeletal and Skin Disease

     (www.niams.nih.gov)

• American Physical Therapy Association

     (www.apta.org)

• Arthritis Foundation

     (www.arthritis.org)

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