Treating Frozen shoulder

Paddy Dowling

February 21, 2024

How to treat frozen shoulder and how physio can help frozen shoulder symptoms:

Historically patients have been told to wait for shoulder pain to resolve over 2 years following a diagnosis of frozen shoulder. Research suggests on the contrary this reasoning is outdated and an early diagnosis combined with early treatment intervention will lead to best outcomes.

What is Frozen Shoulder?

Adhesive Capsulitis more commonly known as frozen shoulder is a condition that causes shoulder stiffness and can be defined as an equal restriction of both active (when you lift your arm) and passive (when someone else lifts your arm) range of movement. Xray imaging is usually normal and in the initial stages of the condition pain is often severe. There may often be concurrent injuries to the shoulder contributing to pain including rotator cuff injuries. The shoulder joint is made of a ball and socket to enable large degrees of movement. A strong connective tissue called the shoulder capsule is what surrounds the joint. In Frozen shoulder the capsule becomes thickened and adhesions develop, and there is less lubrication in the joint.


https://orthoinfo.aaos.org/en/diseases–conditions/frozen-shoulder

Who gets frozen shoulder?

Frozen shoulder is most common between the ages of 40 and 65 and is more common in women than men.

What causes frozen shoulder?

The cause of frozen shoulder is not completely understood, however it is often associated with diabetes and other metabolic conditions as listed below. It may also occur after an acute injury or surgery where the shoulder is immobilised for a long period of time, therefore this is why some form of gentle movement is important in initial stages after injury to prevent too much stiffness.

Diabetes:

Within the general population the prevalence of frozen shoulder is estimated at 5%, however in diabetic populations the prevalence increases to 46% (Juel et al. 2017). If we look further into this population group, those with long term type 1 diabetes have an astounding 76% prevalence for frozen shoulder (Juel et al. 2017). This stark contrast between populations is often crucial to an early diagnosis of frozen shoulder (Dyer et al. 2023). Diabetes is also linked with more significant symptoms from frozen shoulder including

  • increased need for surgery
  • longer duration of symptoms and a more significant loss of range of movement than the general population.

Obesity:

Obesity can be a predictive factor to developing frozen shoulder with 82% of frozen shoulder patients being classified as overweight/obese (Kingston et al. 2018) – this may suggest a metabolic syndrome impact on the condition.

Genetics:

Genetics may also play a role in the development of frozen shoulder, with 30% of those diagnosed having a 1st degree relative who has also had a frozen shoulder.

How long until Frozen Shoulder gets better?

Studies examining the long-term outcomes of individuals with frozen shoulder would suggest that frozen shoulder completely resolving within 2 years is not always the case, with 41% of individuals in one study still having mild to moderate symptoms at 4 years (Hand et al., 2008). For individuals that may be active such as swimming, mild to moderate symptoms would not be acceptable at 4 years, hence why treatment may be invaluable.

A more recent high level research review found that the claim that frozen shoulder fully resolves without treatment was not supported (Wong et al. 2017), with a 30% loss of function after one year. Due to the long lasting and significant effect on quality of life, it is important frozen shoulder is diagnosed within a reasonable timeframe and treated appropriately. Physiotherapy is thought of as the best treatment option to treat deficits and maintain function.

How to treat Frozen Shoulder?

There are several physiotherapy treatment options for frozen shoulder which have been shown to be more effective than a ‘wait and see’ approach and the main goal of treatment is to control pain, improve range of motion, increase strength and improve function.

With regards to physiotherapy, resistance strengthening, stretching and mobility exercises have all be shown to be more effective compared to control groups. These exercises need to be individualised and tailored to the stage of frozen shoulder. After the initial painful inflammatory stages in the first four months, shoulder mobilisations and mobility treatment are effective at regaining range of movement as well as decreasing pain.

Exercises prescribed may include mobility exercises to maintain mobility from treatment and increase it at home, scapula stability exercises to improve the base on which the shoulder moves and appropriate shoulder strengthening exercises to assist in improving function. Exercises may also look at the rest of the body for a strong core and legs for the shoulder to work from.

What about injections?

In order to have a greater effect, evidence suggests an intra-articular steroid injection followed by an exercise program is the best treatment option for frozen shoulder. Therefore a steroid injection may improve pain and provide a window for interventions such as mobility and strengthening exercises to build mobility and shoulder strength.

Frozen Shoulder Summary:

In summary, ongoing research suggests that the idea that frozen shoulders are a condition that resolves independent and to a pre-injury level is outdated. A combination of intra articular steroid injection is currently the most evidence based management strategy for frozen shoulder combined with an exercise program. It is therefore important a clinical diagnosis can be made early in order for patients to have the best opportunity for a positive long term outcome.

About the Author:

Paddy graduated from Monash University in 2017 with a Bachelor of Physiotherapy with Honours and has been working in private practice since. Paddy has a keen interest in knee injuries, sporting complaints as well as post-surgical rehabilitation.

Paddy has completed further studies in dry needling and has incorporated this into his physiotherapy treatment as well as manual therapy and tailored exercise programs to improve outcomes. Paddy is a certified Early Intervention Physiotherapist with Workcover and TAC. Paddy treats at our Belmont Clinic. To book an appointment with Paddy click here.

References:

Juel, N. G., Brox, J. I., Brunborg, C., Holte, K. B., & Berg, T. J. (2017). Very high prevalence of frozen shoulder in patients with type 1 diabetes of≥ 45 years’ duration: the dialong shoulder study. Archives of physical medicine and rehabilitation, 98(8), 1551-1559.

Kingston, K., Curry, E. J., Galvin, J. W., & Li, X. (2018). Shoulder adhesive capsulitis: epidemiology and predictors of surgery. Journal of shoulder and elbow surgery, 27(8), 1437-1443.

Dyer, B. P., Rathod-Mistry, T., Burton, C., van der Windt, D., & Bucknall, M. (2023). Diabetes as a risk factor for the onset of frozen shoulder: a systematic review and meta-analysis. BMJ open, 13(1), e062377.

Wong, C. K., Levine, W. N., Deo, K., Kesting, R. S., Mercer, E. A., Schram, G. A., & Strang, B. L. (2017). Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy, 103(1), 40-47.

Hand, C., Clipsham, K., Rees, J. L., & Carr, A. J. (2008). Long-term outcome of frozen shoulder. Journal of shoulder and elbow surgery, 17(2), 231-236.