Frozen Shoulder
Frozen shoulder is a disorder where the shoulder capsule and connective tissues surrounding the shoulder joint becomes stiff and thickened. This restricts motion and often causes chronic pain. It mainly affects people ages 40 – 60. It is also more commonly found in women than men, people with diabetes and may be associated with thyroid disorder, heart and Parkinson’s disease.
The cause of frozen shoulder is unknown.
The onset is most commonly idiopathic or post-trauma or shoulder surgery.
Frozen shoulder can be a disabling condition as people with it often report that activities, such as dressing, washing or drying their hair, become almost impossible.
In addition, the condition may affect the ability to work and causes severe interruptions to sleep.
How To Diagnose Frozen Shoulder
Given the similarity in its presentation to other shoulder disorders, early diagnosis for frozen shoulder is difficult. There is no definitive gold standard diagnostic test. Its a diagnosis based on clinical progress over time, exclusion of other pathologies and normal imaging findings.
Signs & Symptoms
- Progressive loss of global shoulder movement
- Pain in the shoulder at rest
- Pain when lying on the shoulder
- Night pain
- Pain aggravated easily by movement
Recovery From Frozen Shoulder
The prognosis varies across individuals. The disorder can last for 12 months up to a few years with the average duration standing at 30.1 months.
Around 50% of people continue to experience pain and stiffness at an average of 7 years post-onset although the symptoms are usually mild.
Lastly, people without diabetes are found to respond better to treatment.
Stages Of Frozen Shoulder
A frozen shoulder typically progresses through 3 stages.
1. Freezing Stage
- Developing pain and progressive stiffness in the shoulders
- Painful when lying on shoulders
- Night pain
2. Frozen Stage
- Improving pain levels
- Stiffness gets worst
3. Thawing Stage
- Pain settles
- Range of motion returns
Non-Operative Treatment Options
The amount of high-quality studies in the management of frozen shoulder is limited.
While some studies reported frozen shoulder as a self-limiting condition that self-resolves over time, there are also reports of patients who do not regain full range of motion. Despite this, it is not uncommon for people suffering from frozen shoulder to be advised that the condition improves without treatment.
Considering that the average recovery period of 30.1 months (2.5 years!) it’s sensible that most people would prefer a resolution.
The good news is current studies have found multi-modal treatment approaches that combine physiotherapy and other adjunctive treatments to provide early improvement of function and pain.
These treatment options are illustrated by the table below.
| Phase | Treatment | Outcome |
| Freezing – more pain than stiff | Corticosteroid injection + range of motion exercises + stretching. | At 12 weeks, improved function, range of motion and decreased pain* |
| Frozen – more stiff than pain | Manual therapy + strengthening + stretching | At 1 year, significant improvement in function and passive range of motion* |
| Heat + manual therapy + movement-based exercise + progressive static stretch | At 1 year, significant improvement in function, pain and passive & passive range of motion* |
*Studies were conducted on non-diabetic population.
Other supplementary treatments that may be useful when used as part of a multimodal treatment regiment includes the following
- Shortwave diathermy
- Laser therapy
- Hydrodistension
Operative Procedures
Manipulation under anaesthesia (MUA) and Arthroscopic capsular release (ASR) are 2 common operative options for the treatment of frozen shoulder.
While there are studies that found improvement in pain, function or range of motion with either of the procedure, there are also studies that proved otherwise.
One study of MUA, for instance, found no difference in outcome between MUA compared to other non-operative options. In addition, MUA is found to be associated with joint damage.
At present, the benefits of operative procedures are unclear. Such procedures also carry inherent risk should only be considered if active rehabilitation fails to improve symptoms
Window Of Opportunity For Treatment
Most studies have found standalone treatment options to be of limited benefit compared to a multimodal treatment approach.
During the feezing/painful phase, it is suggested that the pain relief provided by corticosteroid injection provides a window for early engagement in movement therapy that is otherwise limited by pain. Whereas, during the frozen phase, where the shoulder develops stiffness, heat and manual therapy may help reduce the degree of joint restriction and similarly allow better engagement in movement therapy.
The road to recovery for frozen shoulder is a long one. What would I do if I developed Frozen Shoulder? I’d want to get a thorough assessment from a skilled physiotherapist and get started on my multimodal plan ASAP.
If you’re looking to start making progress with your stiff and sore shoulder pop in to see our physio team in Pascoe Vale.
References
Shaffer, B., Tibone, J. E., & Kerlan, R. K. (1992). Frozen shoulder. A long-term follow-up. The Journal of bone and joint surgery. American volume, 74(5), 738-746.
Rangan, A., Gibson, J., Brownson, P., Thomas, M., Rees, J., & Kulkarni, R. (2015). Frozen shoulder. Shoulder & elbow, 7(4), 299-307.
Yoon, S. H., Lee, H. Y., Lee, H. J., & Kwack, K. S. (2013). Optimal dose of intra-articular corticosteroids for adhesive capsulitis: a randomized, triple-blind, placebo-controlled trial. The American journal of sports medicine, 41(5), 1133-1139.
Ibrahim, M., Donatelli, R., Hellman, M., & Echternach, J. (2014). Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study. Physiotherapy, 100(3), 228-234.
Lewis, J. (2015). Frozen shoulder contracture syndrome–Aetiology, diagnosis and management. Manual therapy, 20(1), 2-9.
Çelik, D., & Kaya Mutlu, E. (2016). Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial. Clinical rehabilitation, 30(8), 786-794.
Mun, S. W., & Baek, C. H. (2016). Clinical efficacy of hydrodistention with joint manipulation under interscalene block compared with intra-articular corticosteroid injection for frozen shoulder: a prospective randomized controlled study. Journal of shoulder and elbow surgery, 25(12), 1937-1943.
Wu, W. T., Chang, K. V., Han, D. S., Chang, C. H., Yang, F. S., & Lin, C. P. (2017). Effectiveness of glenohumeral joint dilatation for treatment of frozen shoulder: a systematic review and meta-analysis of randomized controlled trials. Scientific reports, 7(1), 10507.
Saltychev, M., Laimi, K., Virolainen, P., & Fredericson, M. (2018). Effectiveness of hydrodilatation in adhesive capsulitis of shoulder: a systematic review and meta-analysis. Scandinavian Journal of Surgery, 107(4), 285-293.
