Challenging myths about . . . frozen shoulder

The spontaneous and sudden pain of frozen shoulder can appear as quickly as overnight and last much longer if you attempt to self-medicate without addressing the issue at hand. Which of course, is what many people tend to do as the excruciating shoulder pain affects their day-to-day lives with an expectation that it will simply get better by itself. The truth is, waiting too long with frozen shoulder is not worth the pain when early intervention can get you back on track. The problem with seeking help for the condition is largely down to the misconceptions and puzzle of frozen shoulder.

“As a chartered physiotherapist specialising in shoulders, I see a lot of frozen shoulders,” says Eoin Ó Conaire, lead chartered physiotherapist at Evidence-Based Therapy Centre in Galway. “Around 10-15 per cent of the people who come to see me with shoulder pain have frozen shoulder. It is the second most common shoulder complaint after rotator cuff-related shoulder pain. There are some common myths that I encounter in clinical practice.”

Ó Conaire helps to debunks these myths surrounding this painful and common shoulder condition.

1) Myth - Frozen shoulder is one of those made-up pains

“Frozen shoulder is actually a very specific diagnosis,” says Ó Conaire. “Deep in the shoulder joint, the very first layer of soft tissue (deeper than the muscles, tendons and ligaments) is a loose elastic sleeve of soft tissue called the glenohumeral joint capsule. In frozen shoulder, the capsule is infiltrated by cells that aren’t usually present. These cells – called fibroblasts and myofibrils – first of all make the capsule raw, irritated and painful, and then over time change the entire texture of the capsule to make it thick, inelastic and eventually it shrinks or contracts. This is why in the early stages of frozen shoulder moving the shoulder and therefore pulling on the capsule causes pain and then in the later stages as the contracted capsule blocks the movement and causes restriction.”

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Ó Conaire explains that there are two main symptoms of frozen shoulder – pain and restriction of movement. “The pain can be very severe, is located in the shoulder but also typically radiates down the arm (often as far as the back of the hand),” he says. “The restriction of movement manifests as a difficulty raising the arm past shoulder height or rotating the shoulder outwards. Key clues that shoulder pain may be related to a frozen shoulder are that the pain is worse at night and there is increasing difficulty with activities such as reaching out of the car window to take a car park ticket out of the machine.”

As Ó Conaire says, “The pain and restriction of frozen shoulder are most certainly not made up.”

2) Myth - Frozen shoulder only happens in winter or because I didn’t move my arm enough

“These are other common misconceptions that many patients sometimes have,” says Ó Conaire. “In fact, it is only in recent years that we have started to understand more why frozen shoulder happens and the reason might surprise you. Frozen shoulder does not usually develop because of an injury to the tissues or from not moving the arm enough. It has what we call a ‘systemic’ cause. In other words, things going wrong in someone’s underlying metabolism bring about the changes in the joint capsule.”

Ó Conaire explains that when protein molecules join with sugar molecules in the blood a substance called haemoglobin AC1 is formed, and this in turn causes a cascade of physiological events in people with diabetes or other issues with the metabolism causing the characteristic changes to the joint capsule.

“Whenever I diagnose a person with a frozen shoulder,” says Ó Conaire, “I explain to them that it is a ‘mini warning sign’ that all is not well in their system. This may be linked to poor diet, lack of exercise, sleep deprivation, stress or other lifestyle factors. About 3-5 per cent of the population will get a frozen shoulder at some stage in their lifetime and for people with diabetes, this figure rises dramatically to 25-30 per cent. In Japan, it is known as ‘the 50-year-old shoulder’ because it so commonly occurs around this age. Research indicates that it typically occurs between the ages of 49 and 62 but we are starting to see more and more people in their 40s with the condition.”

With lifestyle likely to play a significant part in the development and persistence of Frozen Shoulder, and research suggesting that stress, anxiety, depression, and feeling overwhelmed are contributing factors to the condition, Ó Conaire and other shoulder specialists, noted a significant increase in the number of Frozen Shoulders about nine months after the first Covid-19 lockdown. “We don’t know the precise reasons for this yet, but it may well be connected to the changes in lifestyle factors for many people around this time,” says Ó Conaire.

3) Myth - Frozen shoulder gets better by itself

“Strictly speaking this is not a myth because in the vast majority of people frozen shoulder will slowly get better over time, going through a very painful stage, followed by a very restricted stage and eventually a resolution stage,” says Ó Conaire. “However, this can be a very lengthy process, with one study showing that the average duration of symptoms was 30 months. The good news is that there are a number of treatment approaches that can help shorten and reduce the symptoms of frozen shoulder.”

Avoiding a wait-and-see approach and getting an early diagnosis will help to not only understand the condition but also find an appropriate treatment.

“Generally speaking, in the early stages if the pain is severe and causing sleep disruption, a corticosteroid injection guided into the shoulder joint can give excellent pain relief and improve sleeping,” says Ó Conaire. “However, it does not help with the restriction. Physiotherapy, however, can be very effective in helping to regain the full movement and function and the combination of injection followed by physiotherapy is a very powerful one. Not everyone needs an injection, particularly if the shoulder is not too painful and can tolerate physiotherapy exercises. Most importantly, anyone with a suspected frozen shoulder should see a chartered physiotherapist or their GP for a full assessment, diagnosis and discussion of what is the best treatment pathway for them.”

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