Shoulder pain is one of the most common musculoskeletal conditions accounting for between 7 -26% of G.P consultations in the UK & a Frozen shoulder, (adhesive capsulitis) affects up to 5% of the population and in the diabetic population, this increases to 10-20%! (Page & Labbe 2010).
What is Frozen shoulder?
Way back in 1934 was when the term ‘frozen shoulder’ was first coined and it was originally described as follows:
“It comes on slowly with pain usually felt near the insertion of the deltoid muscle on the side of the shoulder. There is an inability to sleep on that side and it is painful and restricted in shoulder elevation and external rotation. There is a restriction of both spasmodic and mildly adherent types, atrophy and little local tenderness. X-rays are negative except for bone atrophy”.
This has definitely got some key points but doesn’t mention the joint capsule and this was mentioned some years later by Neviaser (1945), they found that the shoulder capsule was thicker than normal and contracted and reported that it was abnormally adherent to the humerus. This is where the term ‘adhesive capsulitis’ came in.
Strictly speaking, a Frozen shoulder isn’t really an injury, nobody knows exactly what it is but the most common thinking is that it is more of an autoimmune response than anything else. This response gets triggered and this creates extreme sensitivity of your shoulder. This hypersensitivity then makes it painful to move your shoulder and this lack of movement causes the tissues to change. The joint capsule has been shown to become tough and thickened so the ability to stretch and distend is affected. It has been seen the joint capsules volume may shrink to as little as 3–4 ml, which is tiny! Another change that has been observed is the formation of new blood vessels in the synovial membrane and these vessels eventually become embedded in thick scar tissue (Bunker et al 2009).
Frozen shoulder comes on gradually and takes between 18 to 35 months to resolve!
It has long been considered to have 3 phases but this is difficult because the condition is fluid. Below are these phase descriptions of a Frozen shoulder but now we think it is best to describe the condition as either pain predominant or stiffness predominant. It gradually moves from pain predominant to stiffness predominant very slowly so the phases may be too rigid but here they are anyway:
This is where the pain is the predominant factor. Essentially pain limits the movement. If you were unconscious then you would have good movement. However, because the pain is so high the joint starts to stiffen up. This phase can last for 6 months to a year.
This is when the acute pain begins to reduce and leaves a severely restricted shoulder joint. This phase can remain up until 1 year to 18 months from the onset and is becoming less pain predominant and more stiffness predominant.
This is the final phase and is basically the gradual restoration of the movement in the joint to the normal range of movement and is very much stiffness predominant.
What are the signs and symptoms of a Frozen shoulder?
According to Boyle-Walker et al (1997), pain occurs first in 90% of frozen shoulder sufferers. After this initial pain, there is a phase of intensifying pain and increasing stiffness. This is still very much pain predominant at this point. The pain continues to rise and may then be present even at rest, sleep is commonly affected and you can’t lie on the problem side at all. The location of the pain is localised to the shoulder area usually on the deltoid muscle but the pain can begin to radiate down the arm (Cyriax 1982).
There is usually an extreme limitation of movement, which usually follows the capsular pattern, which is the order of most restricted to least restricted movement. External rotation is classically the worst range and is considered the cardinal sign of a frozen shoulder. Abduction is less restricted than external rotation and internal rotation less still, with a ratio of loss at 3:2:1. Another important element is that the limitation of movement is the same actively and passively, unlike something like a rotator cuff tear, which can move well passively in most cases (Cyriax 1982).
How do you diagnose Frozen shoulder?
Diagnosis is based on signs and symptoms so it is a clinical diagnosis, this is because there is no agreed diagnostic reference standard (Harryman & Lazarus 2004). So as we have mentioned above in the signs and symptoms section, this is the best and most accurate way to diagnose a frozen shoulder and this is exactly what we do in a physiotherapy assessment.
Often x-rays and scans can be used to rule out and screen for substantial trauma or other serious diseases so the absence of findings and the signs and symptoms will lead to a diagnosis of a frozen shoulder.
So what causes a frozen shoulder?
No cause has been found but you are at higher risk with the following:
After surgery or injury.
Most often in people 50 to 60 years old.
Slightly more often in women, especially post-menopause.
Most often in people with chronic diseases, especially diabetes, thyroid issues and stroke.
(Lowe et al 2019).
How Many People Fully Recover From A Frozen Shoulder And How Long Does It Take?
Hand et al (2008) found that 38% of patients still had persistent mild symptoms on average 4.4 years from the onset of symptoms. The lowest here was found to be 2 years and the maximum time was 20 years! 3% of patients had persistent severe symptoms with poor function and pain it was also noted that those with the worst symptoms at the start of the condition had the worst chance of recovery.
How do you treat a Frozen shoulder?
Treatments for frozen shoulder are generally split into 3 categories:
There is advice, support and empathy while just allowing it to take it’s a natural course, effectively wait and see.
Advice, support and time
It is important to explain the usual timescale of frozen shoulder, which can be hard to accept for patients. But explaining that it will spontaneously resolve over time with the reduction of pain and stiffness in most cases is vital.
Advice on avoidance of movements which aggravate the pain in the early, painful phase (e.g. overhead activities, vigorous stretching), but advise the person to try to continue a regular range of movement as best they can within their limits with pacing and activity management (Hanchard et al 2011).
This area is huge and there is very little consensus opinion or evidence to give much absolute definitive guidance on this.
Heat and cold
Both hot and cold treatments can lower pain and so either could be viable. Everybody is different so give both a try as they will do you no harm. Over 40% of Physiotherapists use either heat or cold treatment in the stiffness-predominant stage of a frozen shoulder but interestingly from an evidence standpoint, it was found to be unlikely to help frozen shoulder when added to outpatient physiotherapy & home exercises (Leung and Cheing 2008).
This is key in the early, pain predominant phase: Paracetamol with or without codeine, or an oral nonsteroidal anti-inflammatory drug (NSAID, e.g. ibuprofen) can be used with gastro-protective medication. However, consider which drug has a more favourable balance of benefits and risks for the person and if there is no early benefit from the oral NSAID then stop using them.
Oral steroids may provide significant short-term benefits in pain, range of movement & function in Frozen shoulder according to Buchbinder et al (2004).
The key to medication is to lower pain to enable better function so you need to work out if this is what it actually does or not.
There are short-term benefits for physiotherapy for frozen shoulder, these are the prescription of exercise and mobilisation techniques, for example. It is generally considered the usual practice to refer to physiotherapy if you can tolerate movement of the affected shoulder as you may be able to progress range and function. Exercise for patients who have had a frozen shoulder for less than 6 months alongside mobilisation techniques can be useful. They can be used alongside a corticosteroid injection to maximise the effect of the injection, as a window of opportunity. It is recommended that 8–10 sessions of physio over 4 weeks may be useful post-injection (Lowe et al 2019). This too was highlighted by Hanchard et al (2011), where it was found that out-patient physiotherapy (with passive mobilisations) and home exercises worked better than a subacromial steroid injection.
Here are some shoulder mobility exercises:
When it comes to passive mobilisation techniques they can be of help in some patients and should be used alongside other modalities. More specifically, mobilisations done according to the stage of frozen shoulder with home exercises are more beneficial than exercises alone (Ryans et al 2005). Both high grade and low-grade techniques have their place depending on your needs, for example, low-grade mobilisations were found to be more beneficial than high-grade mobilisations for pain at rest but high-grade mobilisations were better for pain on movement (Vermeulen et al 2006).
Due to passive external rotation being the most limited movement in a frozen shoulder then this should be a direction to mobilise and Vermeulen et al (2006) found that high-grade mobilisations were better in the medium & long term.
As usually, acupuncture is always a contentious issue but interestingly, as I write this draft NICE guidelines are being drawn up recommending acupuncture and exercise for chronic pain and they actually do not recommend pain killers at all, so there is evidence now at a level to support acupunctures inclusion into the draft guidelines and even the final guidelines for chronic pain, which frozen shoulder is classified as. Green et al (2008), found that acupuncture may improve pain and function over the short term in people with shoulder pain but there is no long term benefit and Sun et al (2001), found that a combination of acupuncture with shoulder exercise may offer an effective treatment for frozen shoulder in the short term (Sun et al 2001). So depending on effectiveness for pain and function for you acupuncture could be a treatment for short term regular relief.
In a study of acupuncture used for Frozen shoulder by Physiotherapists, it was found that 68% would use or recommend acupuncture for the pain-predominant (Hanchard et al 2011).
Now a corticosteroid injection isn’t without its risks and as with all conservative treatment for frozen shoulder it is unclear especially in the long term. If pain is very severe in the pain predominant phase then it can be useful. (Jowett et al 2013) found that exercise & steroid injection was more cost-effective than exercise alone in severe pain cases. So if in the early stages, there is no, or slow, progress with conservative treatment then injection can enable some progress.
The steroid injections can be triamcinolone or methylprednisolone and there is a local anaesthetic (e.g. lidocaine) often used in addition to corticosteroid. It is important to monitor people with diabetes following a steroid injection, as transient hyperglycemia, may occur for 24–48 hours. It is advised to not have a corticosteroid injection if you have previously had an intra-articular corticosteroid injection with minimal or no benefit, you have previously had three or more injections in the same shoulder in 1 year. If the pain predominant stage is passing and the frozen shoulder is more stiffness predominant then also don’t’ inject it.
Not all injections are steroid-based!
Distension therapy (hydrodilation)
This involves injecting large volumes of fluid (saline or local anaesthetic, into the shoulder joint. The aim is to stretch and distend and in some cases rupture the joint capsule to increase the range of movement. I have seen this work well with some of my patients in our clinics in Stoke-on-Trent and it is effective for the stiffness predominant phase, especially for predominant external rotation limitation, early distension in the stiffness phase could be considered the primary choice of treatment (Lin et al 2017).
Massage has been shown to reduce pain and spasm and as seen below can improve the range of movement especially in the short term. So it could be an option in a frozen shoulder for pain and movement.
There are a couple of different surgical techniques for treating a frozen shoulder.
Manipulation under anaesthetic
This is a forceful technique, whereby you are put under anaesthetic and the shoulder is forced to move. More commonly now this tends to be done with an arthroscopic capsular release to reduce the potential harms by allowing it to be done with less force.
Arthroscopic Capsular Release
This is a surgical release technique done using a ‘keyhole’ technique, the capsule is divided and cut at the front and lower part of the joint but if there is still a lack of external rotation in abduction, then capsule can also be released at the back of the joint. In addition to a due to the trauma then not only is a general anaesthetic required but it is normal for a regional nerve block to be given to.
This is usually done in patients that do not improve with an adequate course of physiotherapy but intense physiotherapy should follow on afterwards asap.
So frozen shoulder is rather an unknown quantity and little is known about what it is and even how to treat it best. One thing is that it will take a long time to recover from and certainly everybody is different. I have seen people respond well to exercise, mobilisations, injections and surgical techniques, so the key is to assess you to firstly diagnose you and then try some approaches that may help the pain and movement and function. Certainly, there is always something that can help a Frozen shoulder.
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