Frozen Shoulder Diagnosis, Treatment and Cost

The diagnosis of frozen shoulder (adhesive capsulitis) starts with a detailed consultation and review of the patient's medical history, followed by a thorough physical examination to evaluate shoulder movement and pain. Because symptoms frequently appear gradually and may initially mimic other shoulder issues, early detection can be difficult. An orthopedic specialist or physiotherapist considers the following before selecting the appropriate tests to diagnose frozen shoulder: 

• Taking medical history 
• Performing a physical examination
  
  

Taking medical history 

The following questions help an orthopedic specialist or physiotherapist assess the onset, severity, functional impact, and contributing factors of a patient’s shoulder problem. They guide a focused medical history for patients suspected of having frozen shoulder (adhesive capsulitis).

• What is the main problem you’re experiencing with your shoulder?
• When did the pain or stiffness first begin? Does pain worsen with movement or at night?
• Was the onset of your symptoms sudden or gradual?
• Can you describe the type of pain you feel (for example, dull, sharp, aching, or burning)?
• On a scale of 0 to 10, how severe is your pain?
• Have you noticed stiffness or restriction in your shoulder movement?
• Which movements are most difficult—reaching overhead, behind your back, or across your chest?
• How has this shoulder problem affected your daily activities, such as dressing, combing your hair, reaching for objects, or sleeping?
• Have you had any previous shoulder injury, surgery, or a period of immobilization?
• Do you have any medical conditions such as diabetes, thyroid disease, or other metabolic disorders?
  
  

Performing a physical examination 

• A thorough visual assessment helps identify obvious abnormalities and compensatory mechanisms. The examiner should observe for asymmetry, swelling, or muscle wasting, especially in the deltoid or supraspinatus, and note any altered posture or loss of natural arm swing during walking.
• Palpation identifies tenderness and helps differentiate frozen shoulder from other conditions. Diffuse tenderness is typically present around the shoulder joint, particularly over the anterior and lateral aspects. The absence of localized bony tenderness helps rule out fracture or arthritis.
• Evaluating both active and passive movements is crucial, as the Range of Motion(ROM) is markedly reduced in adhesive capsulitis. Flexion and abduction are limited and painful, external rotation is usually the first and most restricted movement, and internal rotation becomes limited in later stages. Comparing ROM with the contralateral shoulder helps determine the severity of the restriction.
• Special tests help identify secondary involvement of surrounding structures. Neer's test may be positive due to associated impingement; the Hawkins-Kennedy test may elicit pain, suggesting impingement; and Speed's test may be positive, indicating biceps tendon involvement. Positive results often reflect secondary pain rather than the primary pathology.
• A neurological examination rules out nerve involvement or cervical radiculopathy. Sensation, reflexes, and muscle strength in the arm and hand are typically normal in frozen shoulder.
• Functional testing evaluates the impact of stiffness on daily activities. The patient may be asked to touch the opposite shoulder, reach behind the back for internal rotation, and reach overhead for flexion or abduction. Compensatory scapular movements or limitations in motion should be noted during these tasks.

✅Diagnostic evaluation

Based on the above information, an orthopedic specialist advises diagnostic tests to detect frozen shoulder. The following are the tests that might be recommended to diagnose frozen shoulder:

• Laboratory tests
• Blood Glucose Tests
• Thyroid Function Tests
• Inflammatory Markers (ESR, CRP)
• Imaging tests
• X-ray (Radiography)
• Magnetic Resonance Imaging (MRI)
• Ultrasound (USG)
• Arthrography (Shoulder Arthrogram)

Laboratory tests

• Blood Glucose Tests: It measures the level of glucose (sugar) in the blood to check for diabetes or abnormal blood sugar levels, which can affect overall health. It helps diagnose and monitor metabolic disorders.
• Thyroid Function Tests: It evaluates how well the thyroid gland is working by measuring hormones like T3, T4, and TSH. It helps detect hypothyroidism, hyperthyroidism, or other thyroid-related issues.
• Inflammatory Markers: Tests such as CRP (C-reactive protein) and ESR (Erythrocyte Sedimentation Rate) detect inflammation in the body. High levels may indicate infection, autoimmune disorders, or chronic inflammatory conditions.
  
  

Imaging tests

• X-ray (Radiography): It uses low-dose radiation to produce images of bones and internal structures, helping doctors identify fractures, joint issues, and abnormalities in organs.
• Magnetic Resonance Imaging (MRI): It uses strong magnets and radio waves to create detailed images of soft tissues, bones, and organs. It is useful for detecting joint injuries, tumors, or spinal issues.
• Ultrasound (USG): It uses high-frequency sound waves to create images of internal organs and also soft tissues. It is safe, non-invasive, and commonly used for abdominal, pelvic, and fetal examinations.
  
  

Arthrography (Shoulder Arthrogram): A specialized imaging technique where contrast dye is injected into the shoulder joint before X-ray, CT, or MRI. It produces detailed images of joint structures—including ligaments, cartilage, and tendons—to help detect tears or other injuries.

✅Frozen Shoulder Stages

Frozen shoulder (adhesive capsulitis) usually progresses through three stages, characterized by changes in pain and shoulder mobility: The 3 stages of frozen shoulder include:

• Stage 1: Freezing Stage 
• Stage 2: Frozen Stage
• Stage 3: Thawing Stage
  
  

Stage 1: Freezing Stage (Painful Stage)

The freezing stage is the early phase of frozen shoulder, typically lasting 6 weeks to 9 months. During this stage, the shoulder slowly becomes painful, often worsening at night and limiting sleep. Along with pain, the range of motion starts to decrease, making it uncomfortable to lift the arm, reach overhead, or move it behind the back. Pain is the predominant symptom in this stage, and stiffness begins to develop slowly.

Stage 2: Frozen Stage (Stiffness Stage)

The frozen stage usually lasts 4 to 12 months. Pain may start to reduce, but the shoulder becomes significantly stiff, restricting movement in almost all directions. Daily activities, like dressing, reaching, or lifting objects, become challenging due to the loss of mobility. The stiffness is the main problem during this stage, and patients frequently observe the difficulty in performing even simple tasks.

Stage 3: Thawing Stage (Recovery Stage)

This is the final phase and can last 6 months to 2 years. During this period, the shoulder gradually regains its range of motion, and pain continues to decrease. Function slowly returns, allowing patients to perform daily activities more comfortably. Recovery may be slow, but with proper physiotherapy and care, most individuals eventually regain normal or near-normal shoulder movement.

✅Frozen Shoulder Differential Diagnosis

Several shoulder conditions can resemble Frozen Shoulder (Adhesive Capsulitis). Correct frozen shoulder diagnosis requires careful clinical assessment and imaging to distinguish it from other causes of shoulder pain and stiffness. The following conditions need to be considered as possible differential diagnoses:

• Shoulder Osteoarthritis (OA)
• Acromioclavicular (AC) Joint Dysfunction
• Bursitis
• Parsonage-Turner Syndrome (PTS)
• Rotator Cuff (RC) Pathologies
• Posterior Shoulder Dislocation
• Active Muscle Guarding (Motor Control Dysfunction)
  
  

Shoulder Osteoarthritis (OA)

Degeneration of joint cartilage results in pain and stiffness. Both Active Range of Motion (AROM) and Passive Range of Motion (PROM) may be painful, but PROM is usually less limited than in frozen shoulder. Flexion is most restricted in OA, unlike frozen shoulder.

Acromioclavicular (AC) Joint Dysfunction

Pain occurs at the top of the shoulder, mainly during cross-body adduction (Scarf Test). Localized tenderness over the AC joint helps to differentiate it from other shoulder conditions.

Bursitis

Inflammation of the subacromial bursa causes severe, diffuse shoulder pain and tenderness. PROM is more preserved than in adhesive capsulitis, helping differentiate it.

Parsonage-Turner Syndrome (PTS)

An inflammatory condition of the brachial plexus causing sudden, severe shoulder pain without trauma. Pain subsides quickly, followed by muscle weakness or atrophy after a few weeks.

Rotator Cuff (RC) Pathologies

Tears or tendinopathy of the rotator cuff muscles typically result in pain and weakness, usually without a capsular pattern of restriction. Imaging methods such as MRI and ultrasound help confirm soft tissue involvement.

Posterior Shoulder Dislocation

It occurs after trauma; the shoulder is painful and has limited motion. Inability to supinate the arm during flexion suggests a posterior dislocation rather than frozen shoulder.

Active Muscle Guarding (Motor Control Dysfunction)

Protective muscle tightness limits movement without structural damage. Under anesthesia, ROM increases significantly, showing that restriction may be due to muscle guarding, not capsular stiffness.

✅Goals of treatment for frozen shoulder

The goals of treatment for frozen shoulder (adhesive capsulitis) are to restore shoulder function and reduce pain. Key goals include:

• Analgesics and corticosteroid injections may be used to relieve pain, particularly during the early freezing phase.
• To maintain and gradually restore the shoulder range of motion (ROM) throughout all phases by structured physiotherapy involving stretching and mobilization exercises.
• To improve shoulder function and enable a return to daily activities as pain diminishes and range of motion (ROM) improves.
• To prevent muscle weakness by incorporating strengthening exercises in the frozen and thawing stages.
• To reserve surgical interventions like manipulation under anesthesia or arthroscopic capsular release only for patients who do not respond to 6–9 months of conservative treatment.
• To educate patients about the natural history, expected timeline, and realistic outcomes of frozen shoulder.

Frozen Shoulders Exercises

Frozen shoulder causes pain and stiffness due to the tightening of the shoulder joint capsule. Gentle, regular stretching helps reduce stiffness, improve movement, and restore function when done slowly within pain limits, ideally under physiotherapy guidance. The following are the exercises performed to relieve frozen shoulder:

• Pendulum stretch: This stretch helps to relax the shoulders by reduce pain and stiffness in frozen shoulder by allowing gentle, gravity-assisted movement of the shoulder joint. This exercise improves joint lubrication, relaxes surrounding muscles, and prevents further tightening of the shoulder capsule without placing stress on the joint. 
• Towel stretch: The towel stretch increases shoulder flexibility by gently stretching the stiff joint capsule and muscles, especially those engaged in internal rotation. While progressively expanding the range of motion, using the unaffected arm to aid minimises violent movement.
• Finger walk: The finger walk exercise helps restore forward and upward arm movement by encouraging controlled, active shoulder motion. Walking the fingers up a wall allows gradual stretching of the stiff capsule while limiting pain. 
• Cross-body reach: The cross-body reach targets the back portion of the shoulder capsule, which commonly becomes tight in frozen shoulder. Gently pulling the arm across the chest improves flexibility and reduces stiffness during reaching activities. 
• Armpit stretch: The armpit stretch helps lengthen the lower part of the shoulder capsule, improving the ability to lift the arm sideways and overhead. By gently raising the arm with support, this exercise reduces stiffness and improves shoulder flexibility. 
• Outward rotation: Outward rotation exercises improve the ability of the shoulder to rotate externally, a movement often severely limited in frozen shoulder. Gentle assisted rotation stretches the front of the joint capsule and improves functional activities like dressing or grooming. 
• Inward rotation: Inward rotation exercises help stretch the back and inner structures of the shoulder joint, improving movements such as reaching behind the waist or back. This exercise gradually reduces capsule tightness and improves coordination.

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