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What is the difference regular injuries and sports injuries?

“I have some shoulder pain and was wondering what is the difference between a regular injury and sports injury? Do I see a regular physiotherapist or a sports physiotherapist?”

- Joel

Hi Joel,

The terminology used by physiotherapists can ben confusing sometimes. Body parts other than the main body trunk such as your spine and hips are referred to a peripherals by physiotherapists. So a shoulder injury such as yours is a peripheral injury.

Regular peripheral and sports injuries over-lap significantly. You can get knee ACL injury from incidents that are not sports related even though ACL injuries are common seen in athletes.

The main difference in approach in treating regular injuries and sports injuries are

• the speed of recovery
• the intensity of the treatment

Speed of Recovery

The pace of sports therapy is generally much quicker and more aggressive. This is due to the demands of the sports. The longer the athlete is down and out from training, the harder and longer it is for them to return to peak performance as their conditioning can deteriorate quite quickly. So treatment sessions tend to closer together and more frequently, several times a day in some cases.

Regular therapy would be spread out over a longer period of time to allow the body to heal more gradually.

Intensity of Treatment

Also, the demands of the sports can place a lots of stress on the injuries body part. As such the treatment such as strength and conditioning are generally more intensive to build up support – stronger muscular balance and finer motor control to prevent re-injury.

Such treatments is generally not called for with regular injuries as high-stress is not expected to the placed on the injured body part.

Another source for shoulder pain: Could it be the AC joint?

Rotator cuff tears, frozen shoulder and impingement are all very common and well known conditions that may produce dysfunction at the shoulder. Less common but still potentially problematic and therefore another important consideration when determining the source of shoulder pain is the Acromion clavicular (Ac) joint.

Anatomy
The clavicle (collar bone) has 2 joints a medial (to sternum) and lateral end (to the acromion of the scapula-shoulder). The Ac joint refers to the lateral articulation with the acromion of the scapula. The joint is stabilised via the acromioclavicular, coracoacromial and coracoclavicular ligaments and the upper and middle fibers of trapezius muscles aswell as well as the deltoids.

Anatomy: Image from Orthoinfo.aaos.org
click for larger view

Injuries
Ac joint dysfunction is a result of a sprain, dislocation, fracture or osteoarthritis at this joint

Dislocation and sprain
The Ac joint is usually injured by a direct fall onto the top of the shoulder, cycling injuries, or associated with over head throwing (Javelin) athletes. The shoulder blade (scapula) is forced downwards and the clavicle (collarbone) appears prominent. The degree of injury at the joint is classified by the separation of the joint and damage to ligaments supporting it. A sprain suggests ligament injury whereas a dislocation refers to the clavicle moving upwards and backwards out of its normal alignment. The degree of this separation between the clavicle and acromion is graded on a 6 point scale, with grade 3-4 or higher requiring surgery.

The altered position of the clavicle, disrupts the normal rotation action of thr clavicle that is required to achieve end range forward flexion (overhead ROM). Pain will occur as a result of over stretched/ ruptured ligamemts (depending on the severity) and a stretched joint capsule. As a protective mechanism, pain tends to lead to altered postures which may comtribute to neck pain and altered muscles activity of muscles that attach to the clavicle; such as the pecs, trapezius and  sternocleidomastoid.

Fracture
The fracture may occur at the distal end of the clavicle following contact sports injuries, bicycle and car accidents.

Arthritis
The incidence of arthritis at this joint has been shown to be about 50% in MRI studies of elderly populations, however these people may be asymptomatic.
Just like any arthritis this refers to degeneration of the cartilage at the ends of the clavicle and acromion. Normal day-to-day activities that require repetitive arm motion can cause cartilage loss (primary osteoarthritis). In addition arthritis may be due to cartilage degeneration after an injury to the joint (post traumatic arthritis). Regardless of the cause, predominately the normally smooth cartilage, as well as the meniscus between the bones breakdown leading to pain, due to increased friction and thus creating an inflammatory response at the joint.

Signs and Symptoms
Arthritis
Pain and stiffness of the joint is a common symptoms as is catching and “clicking” at the shoulder. Usually, these complaints are worst with overhead activity or with positioning the arm across the body. These are both common positions of the arm- from daily activities such as brushing your hair or reaching your back pocket, putting a shirt on, to sports activities such as a golf swing.

Dislocation and sprain
Pain initially may be widespread throughout the shoulder until the acute phase resolves, following this stage the person will demonstrate specific tenderness at the site of the end of the clavicle. Swelling and depending on the the extent of the injury a step-deformity may be visible. This is an obvious lump where the joint has been disrupted (as in the case of a dislocation) and is seen in more severe injuries. Similar to arthhiritis the individual will report pain on moving the shoulder, especially with overhead activities and across your body motion.

Treatment
Acute injuries will respond to ice therapy, anti-inflammatory medications and a sling is often used.
Electrotherapy could be utilised to prevent the formation of scar tissue in the ligament and promote healing and decrease swelling.

Exercise therapy to restore strength and range of motion of both the neck and shoulder is vital. Strengthening exercises include lateral rotator work, as well as shoulder blade pinching exercises.

Taping can be applied to offload and realign the Ac joint.

Mobilisation of the Ac joint (clavicle) at painful ranges is also a common intervention used by physiotherapist to restore normal and pain free alignment.

If your not too sure whats causing your shoulder to hurt- book in to see a therapist for a shoulder assessment and treatment.

Gym Users – Are you OVER-working the PECS?

If your gym workout is giving you neck and shoulder pains,  you could be  over-training your chest muscles. The key is a balanced training program that focuses on several muscle groups to prevent muscle imbalance developing and the consequent dysfunction

The effects of over developing one muscle group i.e. your chest muscles (pectorals) in the gym, whilst neglecting your back muscles, often affect your posture resulting in neck, back, and shoulder pain

To understand why this occurs, you must be familiar with the notion that most joints in our body have two or more separate and opposing sets of muscles acting on the joint. Take the elbow as an example.

When the biceps contracts and shortens, it bends the elbow joint. As the elbow bends, the opposing triceps, must relax and lengthen to allow this movement to occur. And vice-versa, for the elbow to straighten; the triceps contracts and shortens and the biceps must relax and lengthen.

To gain a well rounded physique you must consider strengthening more than just one, if not all the muscle groups. An over developed muscle (group) will create more tension on one side of the joint. Over developed muscles are also often tighter (shorter) than normal.  The balance between muscles at the joint is lost, pulling the joint away from its mid-line and changes the angle of rotation at the joint.

Muscle balance at a joint
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Muscle imbalance at a joint
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The Shoulder

The shoulder is a more complicated joint, however the same principles apply.

From personal experience as a physiotherapist, one of the most common mistakes in the gym is over-training the chest muscles.  This causes an imbalance between the muscles at the front of the body and those at the back. The shoulders with time are pulled forwards as the chest muscles get stronger, bigger and shorter, making the posture more rounded, creating pain and potential pathology.
Lateral postural Picture

Rounded posture with over-developed Pecs
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Why is a rounded posture problematic?

Rounded postures place the shoulder joint in a unbalanced position away from the ideal centred position. This unbalanced position leads to increased compression at the shoulder, resulting in pain and reduced function:

• Compression of muscles and other structures at the front of the shoulder joint, may cause pain in the neck, and or down the front of the shoulder and side of the arm. Pain is usually worse with overhead activities. If the compression of the tendons continues for long enough, tears of the tendons (rotator cuff) may occur.
• Rounded postures often lead to neck pain. A large number of muscle that attach to the shoulder also attach to the neck at the other end. If these muscles are affected (lengthened and weakened by the pull of the shoulders) the neck often tends to rest into a head forward ‘chin-poke’ position. This increases the pressure on the neck joints and also other pain sensitive structures around the neck that can cause symptoms (Szeto, 2005).
• The shoulder’s range of movement is significantly reduced as a result of having less space for the joint to move. (Bullock et al, 2005)

Additional contributing factors leading to rounded shoulders

Modern Lifestyles
Think about all your daily activities; washing your face and hair, driving, sitting at the computer.  People are becoming chair-shaped, and this keeps the shoulder in a rounded position.

Pain Response
Your body’s response to pain is another factor.  When you have neck and shoulder pain we often adapt a rounded posture.  This initially is good protective mechanism to prevent further damage for the first few days post-injury, however in the long term this posture keeps the shoulder in a poor/compressed position and will hinder healing.

How to correct your rounded posture?

As a guide, when looking from a side view your shoulders should be fairly central compared to the trunk, and the head should be central on the shoulders.  A ‘plumb line’ from the centre of the ear should fall through the centre of the shoulder.

Correct posture in sitting
click for larger view

To get into this position roll your shoulders all the way forwards, then all the way back (your shoulder blades should touch), then find the mid-point between these two position.  When you have this, gently tuck your chin in, so that your head is positioned on top of your shoulders.

Workout program to prevent the over-training

Weight-training:
If you work the chest 2 x weekly, doing 6-9 sets of 12 repetitions, then do the same amount of work, at the same load and intensity for the opposing muscle groups – the upper back muscles.  Most chest exercises involve pushing – therefore to balance this and work the upper back you must include pulling type activity.  Some ideas are provided below.

• Lat pull down
• 45 degree angle lat-pull down
• Seated row
• Bent over row
• Pull ups
• Shoulder external rotation

Stretching
As well as strengthening (which contracts and thereby shortens muscles), you should ALWAYS stretch all the muscles you have trained (lengthen the shortened muscles ) at the beginning and end of your workout to reduce tightness of these muscles. In this scenario it is therefore strongly recommended to stretch both the pecs and back muscles.

Pec stretch
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• Hold 30 seconds
• rest 30 seconds
• repeat x 3 (4 x daily)

References:

1. Brukner and Khan. Sports Medicine
2. Bullock, M., Foster, N., Wright, C., (2005). Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Manual Therapy 10, 28–37
3. Kwok Tung Lau, Ka Yuen Cheung, kwok Bun Chan, Man Him Chan, King Yuen Lo, Thomas Tai Wing Chiu (2010). Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Manual Therapy 15 . p457-462
4. Szeto, G., Straker, L., O’Sullivan, P., (2005). A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work—2: Neck and shoulder kinematics. Manual Therapy. Vol 10. p 281–291

Shoulder pain in office workers

A shoulder impingement is common amongst athletes involved in overhead sports. Ironically the same condition can happen in someone who leads a more sedentary lifestyle. A common scenario is where someone reaches out for a stack of documents or a heavy object that weighs too much for the shoulder muscles.

A deskbound worker's posture are the main factors that will give rise to such shoulder problem. These factors are similar to those predisposing factors of shoulder pain in overhead activity athletes.
 

The image below demonstrates a slouched sitting posture with a forward head posture typical of someone who spends long hours at their desk. A few factors to notice in someone with a shoulder pain, is the position of the shoulder blade, rounding of the shoulder, and poking of the chin.

Image 1. slouch desk posture
click for larger view

Narrowing of shoulder joint space from a slouched position

Try slouching your upper body and raising up your arm as high as you can, compare this to sitting or standing upright and reaching high up. You will find that it takes more effort in the former scenerio and you may feel a pinch or a block in the shoulder as you go towards the end of range. This is because the shoulder joint space (subacromial joint) is narrower in a slouched position.

Muscle Imbalance

In slouched sitting, the shoulder blade is rested on the rib cage in a forward tilt orientation. Overtime, this develop into a muscle imbalance where the muscles in front (pectoralis minor) are tightened, and the muscles at the bottom of the shoulder blade (lower trapezius) are stretched and thus weakened. As the lower trapezius is one of the vital muscles to stabilise the shoulder blade, weakness will increase instability and poor control of the shoulder joint leading to overuse of the rotator cuff muscles to compensate for the instability.

Long hours in the slouched position also develop stiffness in the joints of the upper back. This means that even if you get away from the desk, the upper back is so stiff that it's "stuck" in this slouched posture, coupled with the muscle imbalance, a person will find it increasingly more difficult to correct their posture even when in an upright standing stance, further increasing the risk of shoulder pain.

Rounded shoulder makes muscles inefficient

In a rounded shoulder, the ball of the shoulder joint will not be able sit well in the socket of the shoulder as there will be a inward rotation of the ball in the socket. Imagine a golf ball balancing on a tee, when the ball joint is not sitting well in the socket, muscles around it will have to work a lot harder to pull the ball into the socket to maintain stability. The excessive efforts from the muscles makes it tires and wears it down faster.

Frozen shoulder: are your exercises targeting on the frozen part?

Do you suffer from a  frozen shoulder?

Have you tried performing shoulder exercises to improve the mobility but still experience pain even after all the effort?

Do you notice in the mirror that you could lift your arm higher but at the same time your shoulder movement looks strange?

If you have answered yes to the above questions, continue to read on and find out what could have happened here?

Let’s start by having a quick revision of the construction of the shoulder joints…

The shoulder joint is formed by a ball (humeral head) and a socket (glenoid fossa), and this is why this joint is also called GH (gleno-humeral) joint. The ball represents one of the ends of the arm bone (namely humerus), and the socket is well located on the outside border of the shoulder blade (namely scapula).

Source: Peak Orthopaedics and Spine click for larger view Source: East Twitch Fitness click for larger view

The scapula is attached to the spine and rib cage by muscles and the connection is called ST (scapulo-thoracic) joint. Arm lifting is achieved by a combination of the lifting of the arm bone, and upward turning of the scapula (which is clockwise turning for the left scapula, and counter-clockwise turning for right scapula). In another word, the lifting is achieved by the combination of GH joint and ST joint. With a full shoulder lifting of 180 degrees, the GH joint contributes about 2/3 to the total movement (about 120 degrees) and the ST joint contributes for the remaining 1/3 of the movement (about 60 degrees).

In frozen shoulder, the joint that is frozen is the GH joint, while the ST joint remains “unfrozen”. Since we know that the two joints move together to achieve arm elevation, it’s not hard to conclude that if the GH does not move enough, the ST move extra! This is where the movement problem starts. The shoulder blade usually moves extra in the following a few ways: it elevates extra, it tilts forward extra, it upward rotates extra, or the combination of those extras.

This is why…

When the arm raises (either to the front or from the side), the shoulder shrugs excessively; the hand attempts to reach behind the back, the shoulder tilts forward excessively. The results of these movements are that the relative position between the scapula and arm bone is disrupted, causing the tendon of the rotator cuff to be irritated or compressed. This can be found as one type of secondary impingements of the rotator cuff.

The bring home message here is that during frozen shoulder rehabilitation exercises, it is important not only to focus on how high you arm is rising, but also to look at which joint is contributing to the movement.

What's next?

The followings are some recommendations to help you perform your shoulder movements more effectively.

Rehabilitating Shoulder Motion after Surgery

Imagine you were driving your car and you heard a screeching noise coming from your front wheel. It turns out that the alignment was out and that the wheel was scrapping against some part of the car. Your mechanic said that he could trim-off the bit of the car that the wheel was scrapping against. That would eliminate the noise. You agreed and the noise was soon gone. Would you now happily continue to drive on or go, "Wait a minute! What about the wheel misalignment? Aren't you going to fix that too?"

click for larger view

A new study from the Henry Ford Hospital found that shoulder motion after rotator cuff surgery remains significantly different when compared to the patient's opposite shoulder. What was more troubling was that patients were very satisfied with the surgical outcome (which is good) but no longer appear to be concern about the functional long-term shoulder joint stability (which is bad).

"Although patient satisfaction is generally very high after surgical repair of a torn rotator cuff, the data suggest that long-term shoulder function — in particular, shoulder strength and dynamic joint stability — may not be fully restored in every patient," says Michael Bey, Ph.D., director of Herrick Davis Motion Analysis Lab at Henry Ford Hospital. "We found that the motion pattern of the repaired shoulder is significantly different than the patient's opposite shoulder," Dr. Bey says. "These differences in shoulder motion seem to persist over time in some patients."

This is unsurprising as motion pattern is habitual. A pattern formed during the painful period will simply persist, even after the reason it formed in the first place is no longer there. A habitual pattern can only be replaced with another habitual pattern. Here is where your therapist plays a major role is helping you get the right motion pattern; both the external movement pattern as well as the muscle firing pattern to achieve the movement.

Unfortunately, this trend to resolve pain while pushing the resolution of the underlying problem is increasing. Too often this is a result of us simply not comprehending the consequences down the road. Fixing the motion of the shoulder is not an expensive endeavour but does require discipline and commitment on your part.

Reference:

1. Henry Ford Health System (2011, January 16). Shoulder function not fully restored after rotator cuff surgery, follow-up study finds.

This articles originally appeared in ShoulderStability.com

Scapular (Shoulder blade)Stability

In the last article, we discussed instability of the humeral head position as a result of poor control or strength the lower rotator cuff muscles. In this article, we will look at another area of instability which is just as important, if not more in painful shoulders. Scapular instability or poor scapular control will often lead to shoulder pain and are often associated with impingement syndrome as well. Like any stability muscles in the body, e.g. the Transversus Abdominus in lower back, Vastus Medialis Oblique (VMO) in the knee or the rotator cuff in the shoulder, once there is pain or dysfunction, these stabilizer muscles tend to “switch off” until they are deliberately retrained. With the stabilizers not functioning optimally, the mechanics of the joint i.e. how it moves will change.

click for larger view

In the painful shoulder, the scapular position will often be different from the non painful side. If the outline of the scapular is traced out, you will notice that the scapular is downwardly rotated. This is usually obvious when comparing the shoulder position. The side with the downwardly rotated scapular will have the droopy shoulder. The control of the scapular is also poor and this can be seen in the quivering shoulder blade when the arm is raised sideways and lowered very slowly.

The shoulder consists of a ball and socket joint, held intact passively by the labrum, the capsule and ligaments to keep the structure stable. The socket is part of the scapula and as such, with a downwardly rotated (tilted downwards) scapular, the socket is now rotated downwards. This means that it is no longer in an optimal position to contribute to stability leading to shoulder mechanical dysfunction.

This downward rotation or tilt is due to muscle imbalance in the surrounding the scapular. The muscles that encourage or maintain upward rotation are the Upper Trapezius, the Middle Trapezius, the Lower Trapezius and the Serratus Anterior. These muscles are usually weak and have poor endurance hence downward rotation of the scapular occurs. With the scapular in a downward rotation, other muscles around the scapular get progressively tighter, aggravating and perpetuating the downward rotation. These muscles are the Levator Scapular and the Rhomboids. This explains why these two muscles are always painful when massaged.

Therefore with treatment of a painful shoulder, it is imperative that the scapular position and control are assessed together with the shoulder joint. It is not sufficient that deep tissue release is done over the Levator Scapular and the Rhomboid since without retraining the muscle control around the scapular, the Levator Scapular and the Rhomboids will eventually tighten up again. As part of the rehab plan for long term recovery, the physiotherapist must retrain the specific muscles and the pattern of movement so that there is an alternative to the current poor activation of muscle and movement pattern.

Shoulder Impingement

There are many conditions that can result in shoulder pain. Some of these conditions include the more traumatic ones like subluxations, fractures, tears in the rotator cuff muscles or the labrum (a structure that forms the socket) through an injury. The more insidious shoulder pain are usually frozen shoulder and impingement syndrome. In this article we will discuss the mechanical causes of an impingement syndrome, particularly the subacromial impingement syndrome.

What is an Subacromial Impingement Syndrome?

As the name implies, an impingement syndrome is a condition that results in pain and movement impairment because certain tissues are being impinged or compressed between 2 bony structures. One of the most common shoulder impingement occurs in the space under the acromion (see picture).

Source: Augusta Orthopedic Surgery
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The impingement is most significant when the arm is elevated sideways to about 90 degrees. The structures that are impinged are soft tissues that lie under the acromion- which are your supraspinatus tendon (which is part of the rotator cuff) , the subacromial bursa, which lies under the the acromion. The pain felt can also be magnified by the irritation of the ligaments that surrounds the area. An untreated subacromial impingement can eventually result in a tear in the Supraspinatus tendon.

What are the contributing factors?

The cause of an impingement is anything that reduces the space through which the soft tissues lie. A structural fault such as a bony spur present under the acromion can reduce that space. However the presence of the spur itself may not be a primary cause of the impingement. Often, it is more of a result of the inability of the ball (head of the humerus) staying centre in the socket and or together with the bony anomaly in the acromion that result in the impingement. Hence, we need to look at what in a normal pain free shoulder holds the ball centre in the socket and without it will result in space reduction in the space under the acromion.

These structures are primarily the rotator cuff muscles, specifically the Subscapularis and the Infraspinatus. These two muscles are positioned lower and their function is to provide a downward force. Together with the other rotator cuff muscles including Supraspinatus and Deltoid muscles, they work together to stabilize the humeral head in the centre of the socket. When the ball jams up into the acromion, mechanically this means that the ball has moved upwards away from the centre in the socket. This is a result of the muscle imbalance between the muscles that pull the ball up (Supraspinatus and Deltoid muscles)and the muscles that hold the ball down (the infraspinatus and the subscapularis). When there is an imbalance, the ball rides up and jams into the acromion, hence reducing that space.

What's next?

Knowing the above, amongst other exercises to correct faulty motor control patterns, the rehabilitation that you receive for a sub-acromial impingement must include the retraining of the lower cuff muscles- namely the Infraspinatus and Subscapularis.

Thawing Frozen Shoulders

In an earlier article, we look at what frozen shoulder was all about. In this article, we will look at some treatment options for frozen shoulders

What is the treatment for a frozen shoulder?

Flickr: nataliej

You can try taking over-the-counter painkillers such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDS) to help reduce pain and inflammation. If these do not provide sufficient relief, see your GP for a stronger prescription.

Applying heat the shoulder can also offer pain relief. This warms up the shoulder to make it easier to move, and easier to sleep at night.

Performing stretching exercises for the shoulder can also benefit in reducing stiffness in the shoulder. Diligent exercise can reduce the chance of severe restriction in the shoulder, which can aid in faster recovery from a frozen shoulder. These exercises will be taught by the physiotherapists.

Physiotherapy can help you in the recovery from a frozen shoulder. A physiotherapist can perform treatment techniques to increase movement in the shoulder joint, as well as reducing pain. They can also show you exercises that are specific to your condition and ensure you are performing them correctly.

Severe and unrelenting pain may require a cortisone injection. This is a steroid injection which may be effective in the reducing pain in the short term. Your GP or specialist will help you decide whether this treatment option is appropriate for your condition.

When conservative treatment fails, more invasive options can be considered. Shoulder distension is a technique where saline water is injected into the joint to stretch the shoulder joint to help allow it move more easily. Another option is manipulation, which can be performed to stretch out tightened tissues. This process is conducted under anaesthesia by an orthopaedic specialist to restore mobility in severely frozen shoulders. Surgery is the last resort for a frozen shoulder. During this procedure, scar tissue and adhesions are removed through arthroscopic surgery to allow the shoulder to move more freely.

What can I do to get better?

It is advised that you see your doctor or a physiotherapist to diagnose your shoulder pain if you are unsure of the cause. If you suspect it is a frozen shoulder, some simple exercises can be performed to help prevent your frozen shoulder from worsening. These should be performed 3 to 4 times a day and should be relatively pain-free, especially if your shoulder is quite painful. See your doctor if your condition does not improve within 3-4 weeks.

Flexion

• In standing, hold a stick horizontally in front of you with hands shoulder-width apart
• With the arms straight, bring the stick from hip level towards the ceiling until you feel your pain come on
• Hold for 5 seconds and return to starting position
• Repeat 10 times

Extension

• In standing, hold a stick horizontally behind you with hands shoulder-width apart
• With the arms straight, bring the stick from hip level towards the ceiling until you feel your pain come on
• Hold for 5 seconds and return to starting position
• Repeat 10 times

External rotation

• Lie on your back and hold a stick horizontal in-front of you with your hands shoulder-width apart
• Bend the elbows to 90 degrees and keep them next to your body
• Using the hand on the pain-free shoulder, push the stick towards the affected side whilst still keeping your hands on the stick
• Hold the end position for 5 seconds and return to starting position
• Repeat 10 times

Internal rotation

• Stand holding a stick with the pain-free arm behind your head, and the affected hand behind your back holding the other end
• Using the pain-free arm, pull the stick up towards the ceiling until you feel the onset of pain in your affected shoulder
• Hold the position for 10 seconds and return to starting position • Repeat 10 times

What’s freezing up your shoulder?

There are many types of shoulder conditions, but one in particular can creep up on you without you remembering having hurt it. This condition is called Adhesive Capsulitis, or more commonly known as Frozen Shoulder.

What is a Frozen Shoulder?

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There are 3 stages in the development of a frozen shoulder which can take up to 2 years or more to complete.

Stage 1 – Freezing stage: During this stage, the affected shoulder gradually becomes more painful and starts to lose mobility. This stage can last from 6 weeks to 9 months.

Stage 2 – Frozen stage: Shoulder pain and stiffness is significantly noticeable during this stage. Daily tasks can be difficult to perform, and sleep disturbance is common as the pain is worse at night. This stage can last from 4 to 9 months.

Stage 3 – Thawing stage: The shoulder is not usually painful during this stage. The stiffness decreases as the shoulder starts to “thaw” out. This stage usually last between 5 months and 2 years.

How do you get a Frozen Shoulder?

The cause of frozen shoulder is poorly understood. It is thought that the joint capsule, the lining around the shoulder joint, becomes inflamed in a frozen shoulder. This inflammation causes adhesions and scarring to form within the capsule, resulting in pain and movement restriction. There is also a lack of fluid in the joint, further reducing joint mobility.

Research indicates that sometimes a frozen shoulder can develop after a trauma or injury to the shoulder. However, in many cases, there is no known cause. Apart from trauma, some other risk factors have been linked to frozen shoulder, including:

• Age and gender – frozen shoulder tends to affect people between the ages of 40 and 60 years old. It is also much more common in women than men
• Diabetes – diabetic people are more likely to develop a frozen shoulder, as well as take longer to recover due to poor blood circulation
• Other systemic diseases – heart disease and Parkinson’s disease are some examples of systemic diseases linked to developing a frozen shoulder.

How can I tell if I have a frozen shoulder?

Frozen shoulder is usually diagnosed by signs and symptoms which are assessed by a docotr or physiotherapist. People who have a frozen shoulder often complain of:

• Gradual worsening shoulder pain with no known cause
• Aching pain on top of the shoulder and often shooting into the upper arm
• Movement restriction without a loss of strength
• Inability to sleep on the affected shoulder and sleep disturbance when rolling on to it
• Difficulty with grooming and dressing as the condition progresses

A doctor or physiotherapist will also assess your movement and palpate the joint help confirm the diagnosis and rule out other shoulder conditions.

For treatment options of frozen shoulder, read our follow-up article on this topic, "Thawing Frozen Shoulders".