There are 4 phases classified within a frozen shoulder.
Pre Phase 1
Phase 1 – Freezing
Phase 2 – Frozen
Phase 3 – Thawing
An assessment based on range of movement and pain will help understand which phase you are in.
Initially we are looking for a reduction in night pain and sharp, catching pain. Initial relief often only lasts one to two days post treatment, then symptoms slowly return. With each successful treatment, we would expect to see a longer resolution of symptoms. There will be an improvement in sleeping and the sharp, catching pain is largely gone and usually a decrease of analgesia/NSAIDs.
Once you have reached this stage, we would like to introduce some strengthening exercises. It is imperative that you stay within the pain-free range and don’t overdo it as this just seems to aggravate the shoulder. Exercises should initially be introduced every other day and ice used post exercise if there is any soreness. When done correctly, there should be no pain either during or after the exercise.
Once the pain has gone, the range of motion starts to return. Once the pain is gone, this usually indicates moving from Phase 1 to Phase 2.
What to do with your shoulder on a daily basis is important both for managing pain and increasing the rate of recovery. The instinct we have when something is hurting is not to use the painful area. Where as this may be appropriate for other problems such as a fracture or ligament sprain, it is not for a frozen shoulder.
Although instinctively all frozen shoulder sufferers want to cradle their arm in the sling position, it is very important to avoid doing this as it compounds the problem. Immobilising the arm, as tempting as it may seem, just causes greater shortening and stiffness and in the long term will slow down recovery. Try to keep the arm straight allowing the arm to hang alongside your body. In this position, the weight of the arm acts as a gentle traction force, stretching the biceps tendon and slightly separating the shoulder joint.
Wherever possible it is important to try and use the arm as normally as possible, but within the pain-free range, avoiding those activities that you know will cause that sharp catching pain. Try swinging the arms when walking, don’t just hold the arm rigid. Try putting your arm on the sofa when you are sitting. If you are standing, try sliding your arm up the wall, but remember to keep your arm relaxed. Don’t be afraid to move your arm, you will not make it worse, just try to avoid tweaking the tendon.
When walking through a busy supermarket or going on public transport, it may be difficult not to remain tense and protective towards the shoulder for fear of someone knocking into you. However, whenever possible it is important to allow the shoulder to relax and straighten the arm when walking. The tension caused by fear of pain will only compound the problems.
This is what to do when walking…
- Relax the shoulder down
- Straighten the arm
- “Let it Swing” swinging the arm along the side of your body like you would under “normal” circumstances. It may feel odd initially but if you persevere, you will soon get used to it.
- Breathe and relax
- Swinging the arm during a very acute phase may be painful, so achieving the first two points is enough. Just remember that the pain is not due to an injury (in which case immobility would be appropriate), but largely due to the immobility, so movement will actually make it better! The more you move your arm within the pain-free range, the larger the pain free range will become.
Night pain and sleeplessness are some of the worst aspects of the frozen shoulder, especially in the early days. At first, you will probably not be able to tolerate pressure on your affected side. As your symptoms ease however, you will find you can gradually ease into some type of position. The degree of night pain is directly proportional to the amount of inflammation within the joint. Some comfort and relief may be obtained by…
Lying on your back, with a pillow lengthways under the affected arm(s) and shoulders supporting them.
Lying on the good side with a pillow or towel over your waist and under the arm. Try to avoid sleeping with the arm above your head. This inhibits shoulder tissue repair which mainly occurs at night.
Lying on your back with a good neck pillow.
- Ice can be particularly beneficial in the acute, freezing phase (1) when the inflammation is most active. You may feel sceptical about this, but so many people have enthusiastically describe the relief they felt from applying ice to their shoulders that it is worth trying.
- Wrap some crushed ice or frozen peas in a towel and place over the front of the shoulder joint.
- Leave it there for 5 to 10 minutes
- Let the area rest without ice for 5 to 10 minutes and repeat.
The cycle can be repeated four to five times and can be done several times during the day. You can also apply the ice to the back of the shoulder joint, the top, the side or other areas where there is acute pain. It is a good idea to ice the front of the shoulder even if it is not painful. When ice is not appropriate (at work etc), then cold sprays or gels may be useful.
NB: Never apply ice directly to the skin as it burns and can leave brown marks.
In the early stages of a frozen shoulder, applying direct heat is not a good idea, though a warm bath may be helpful. Heat packs/hot water bottles that are not too hot can be applied in the second and third phases, and this is particularly beneficial prior to attempting any stretching exercises. If you find that heat does give you temporary relief, then an alternating cycle of five minutes ice, five minutes warmth, ending with five minutes ice can be tried. It is very important to end the cycle with ice.
The benefits of maintaining a good posture are something that we try to emphasise to our patients. Round shoulders and long term poor posture causes the shoulder muscles and joints to work inefficiently and can lead to a “pinching” of the tissues, causing further damage. The neck muscles are also vulnerable in frozen shoulder as they often go rigid in a frozen shoulder where they are used to hitch the shoulder.
Although the pain of a frozen shoulder can be constant, the demands of life do not necessarily let up. At work you may spend a long time in the same position or perform some repetitive tasks. Here are some tips on how to get through the day with the least amount of discomfort….
Avoid carrying heavy bags or cases for long distances. This has been demonstrated to precipitate tears in the supraspinatus, one of the important rotator cuff muscles.
If you are driving all day, or keeping your arm in a fixed position, take regular breaks where you can move your arm around to encourage circulation to the muscles of the shoulder.
When working in front of the computer screen, take regular breaks. Get up and walk away from your work station and the PC for a couple of minutes every half an hour. This is important for the same reasons as above.
Make sure your chair has good back support and preferably adjustable arm rests
Adopt the ‘ideal’ work posture if you are sitting at a desk
Maybe that is the last thing you want to be doing when the arm is hurting, but it really will help long term! The only thing to avoid is the “catchy” type of pain that I am sure you are familiar with. Whatever you normally do with the arm, try to keep doing it as long as it is not too painful. Things like brushing your teeth, shampooing your hair or using your knife and fork. Although it may be difficult, these little things will help to keep the shoulder free and more mobile.
- Rest the hand on a table or chair back palm up
- Allow the weight of the arm to rest of the hand, causing slight compression at the shoulder joint. It is as though you were about to lean your body weight on you hand, while only applying a fraction of the force.
- Breathe deeply and slowly. It helps to apply the pressure as you breathe out.
Reposition the shoulder
This is excellent for resetting the shoulder position.
- Do everyday if possible
- Place a thick towel or the floor and lie on it, face up
- Place pillows under both elbows and forearms
- Rest the hands on your stomach, palm downwards (if that is not possible, just rest the arms on the pillow)
- Stay in this position for twenty minutes. Try putting on some relaxing music.
- Very slowly the muscles at the front of the chest should relax, allowing the shoulders to drop backwards towards the floor.
- You may not be able to get the hands flat for a while, but eventually you will. If necessary, you can place a cushion on your abdomen an rest the hands there. Gradually try to lower this suchion to a few towels and eventually nothing.
- When your shoulder has started to “defrost” in the second and third phase, you might be able to place the arms at 45° angle from the body. If possible, turn your palms up.
This is another exercise for resetting your shoulder position and posture. The good thing about this exercise is that it can be done everywhere, and does not require any equipment.
- Turn your hands palm outwards – slowly
- Try to squeeze your shoulder blades together, automatically bringing your shoulders backwards.
- Keep your shoulders where they are but let your hands roll back to your sides.
- Hold that position for 30 seconds.
- Rest and repeat.
As soon as the night pain is gone, it is a good idea to get into the water. At first it may not feel like you are swimming, but do not despair, you are still doing your shoulder the world of good. The resistance of the water will help mobilitly and improve the strength of the shoulder.
- Try to go when it is quiet in the pool
- If you cant swim, then simply walk up and down using your arms to help you.
- Don’t try to swim 50 laps. You are swimming to help your shoulder, not win the Olympics.
- Rest after every lap.
- Vary the type of stroke you use after each lap.
- Concentrate on trying to move the shoulder as much as possible rather than swimming fast or far.
- Don’t overdo it!! Easy does it, stop well before you are tired or when the shoulder is hurting.
- Water aerobics classes may also be useful so check if there is a class in your area.