What is Frozen Shoulder?
Frozen shoulder, also known as, Adhesive Capsulitis is an inflammatory and debilitating condition that causes severe stiffness and pain within the shoulder joint. During the course of this condition, the capsule that covers the shoulder and the shoulder ligament become inflamed and eventually causes fibrosis of the capsule, which leads to the significant loss of range of motion in the shoulder. There are two classifications of frozen shoulder, which are called primary and secondary.
Primary adhesive capsulitis is when the condition comes out of nowhere and there is no known cause. Secondary is when it appears after a predisposing factor or surgery. Examples of predisposing include post-shoulder injury or post-stroke.
Who gets Frozen Shoulder?
Women are more likely than men to get frozen shoulder as 70%, who present with this condition are female. In addition, persons who have medical conditions such as diabetes, hypothyroidism, and/or metabolic syndrome are more susceptible to frozen shoulder. 10-22% of people with diabetes get frozen shoulder compared to 2-4% of the general population. Also, the outcomes are not as good for patients with diabetes as they do not respond as well to treatment compared to healthy individuals. The average age of a person with frozen shoulder is 55 years old.
What are the common symptoms of Frozen Shoulder?
The common symptoms of frozen shoulder include increasing shoulder pain that came out of nowhere, gradual decrease of shoulder range of motion, and difficulty sleeping due to the pain. You will usually find that there are two or more planes of motion are severely decreased in the shoulder. The most affected motion is usually external rotation and that is followed by abduction, internal rotation, and forward flexion.
Due to the decrease in range of the motion in the shoulder, people will have difficulty combing their hair, washing their back, putting on their jacket, and other normal activities that require reaching and good shoulder ROM to perform.
What is the common course of Frozen Shoulder?
The common course of frozen shoulder consists of three phase.
Phase 1: Acute/freezing/painful
At this phase, the shoulder pain is at its highest level. There is sharp pain at extreme ranges of motion and the person will usually have difficulty sleeping during this stage. In addition, the affected shoulder gradually starts to lose ROM. This stage can last from 2-9 months.
Phase 2: Frozen/adhesive
Pain starts to improve, but the loss of ROM in the shoulder is at its most significant. The person will feel pain only at the end of the ROM. This stage can last for 12 months.
Phase 3: Thawing/regression
This is the recovery phase, where the shoulder ROM gradually starts to improve. It can take from 12-24 months to recover the affected shoulder’s full ROM.
How is Frozen Shoulder Diagnosed?
Frozen shoulder is primarily diagnosed through clinical examination. Imaging is not usually indicated to determine if the person has this condition. During the clinical examination, the physical therapist will first interview you about how the shoulder pain came about, your past medical history, and what activities you have been struggling with due to the shoulder pain.
Once the interview is completed, the physical therapist will test the strength and the range of motion of the affected shoulder. A person with frozen shoulder will somewhat maintain their shoulder strength, but still will have weakness compared to the unaffected shoulder. The cardinal symptom of frozen shoulder is severe loss of range of motion. A person with frozen shoulder will have a significant decrease in active and passive range of motion in two or more planes compared to the unaffected shoulder. Through this clinical examination, the physical therapist can also determine what stage of adhesive capsulitis you are in.
What conditions can mimic Frozen Shoulder?
Arthritis in the shoulder can limit your active shoulder range of motion into abduction, external rotation, and flexion. However, the difference is your passive range of motion will not be affected. In addition, forward flexion is the most limited motion in arthritis, whereas it is the least limited in frozen shoulder.
Bursitis is inflammation of the bursa, which is small fluid sac between the muscles, tendon, and bones to help reduce friction. With bursitis, you may have similar symptoms of frozen shoulder, especially in the early stages such as severe pain in most motions. However, you will also be able to achieve larger passive range of motion in the shoulder.
Parsonage-Turner syndrome is inflammation of the brachial plexus which is a network nerves found in the upper extremities. In this condition, you will likely present with pain and restriction in all shoulder motions, but the course of this syndrome is much shorter compared to frozen shoulder. In addition, neurological symptoms may arise such as atrophy of muscles or weakness.
Rotator Cuff pathologies
This is a common condition among shoulder pain patients and presents quite similarly to frozen shoulder as you will likely have shoulder range of motion restrictions in all or most motions. However, the difference is it does not follow the same pattern as the frozen shoulder. As mentioned before, in frozen shoulder, external rotation is most affected followed by abduction, internal rotation, and forward flexion.
Posterior shoulder dislocation
Like frozen shoulder, you will present with shoulder pain and limited range of motion, but this condition occurs after a traumatic incident. Meanwhile, in most frozen shoulder cases, the onset of pain occurs gradually and without a specific incident.
How is Frozen Shoulder treated in physical therapy?
Treatment for frozen shoulder is customized to your needs and deficits as well as to the phase of the condition that you are currently in. Here are the types of treatments you may see in each phase of frozen shoulder.
Phase 1: Acute/freezing/painful
The main objective in treating frozen shoulder in the freezing phase is to give the patient as much pain relief as possible. Any activity that causes the pain should be avoided in this phase. Stretching can be prescribed at this phase, but patients tend to respond better when it is done within their pain-free range. Other treatment options that could be applied are more focused on pain relief such as heat, massage, joint mobilization, dry needling, and electric stimulation.
In addition, corticosteroid injection can be an option for pain relief and has been shown to be effective when used in combination with physical therapy, especially in the early stage of frozen shoulder.
Phase 2: Frozen/adhesive
As pain starts to decrease, exercises will be progressed in order to further increase the affected shoulder’s range of motion and to start strengthening the muscles around the shoulder. Active assisted range of motion exercises will be utilized, such as using a cane, broom, or wand to improve movements such as forward flexion, external rotation, abduction, and internal rotation. Strengthening exercises may start as shoulder isometrics and will be then progressed to isotonic. A strengthening program for frozen shoulder will focus on strengthening the muscles that support the shoulder such as rotator cuff muscles and the scapular musculature.
Mobilization with movement or Mulligan technique may also be used to help improve the range of motion of the shoulder. This technique is done with a licensed physical therapist. The physical therapist will perform a shoulder joint mobilization while the patient performs a movement of the shoulder, such as forward flexion.
Phase 3: Thawing/regression
In this phase, the exercises are further progressed to help restore normal shoulder range of motion, if possible, and to continue to strengthen the shoulder musculature. Physical therapy is even more effective at this stage as the patient is able to better tolerate the treatment and perform the exercises at a higher intensity and for a longer duration.
What other treatment options are there for Frozen Shoulder?
If conservative measures do not work, patients can opt for surgery to treat frozen shoulder. Two common surgical techniques include manipulation under anesthesia and arthroscopic capsular release.
Arthroscopic capsular release has become the most popular surgical method to treat frozen shoulder as it shown to be quite effective and to have less complications compared to manipulation under anesthesia. It is also especially recommended for those with diabetes and in post-operative or post-fracture frozen shoulder folks. In this technique, they cut and remove the thickened, swollen, and inflamed capsule in order to restore the range of motion of the affected shoulder.
Manipulation under anesthesia involves passive tearing of the thickened, inflamed capsule as well as the contracted ligaments. There are more risks of complications with this method, which include humeral shaft fracture, glenoid fracture, rotator cuff tear, dislocation of shoulder, and traction injury to nerve.
A person should start to consider surgery if their frozen shoulder has not responded to conservative treatment after at least 6 months.
To be frank, frozen shoulder is a tough condition to deal with and to treat. Frozen shoulder is a condition that takes time to get better as course of this condition can take from 1 to 3.5 years. Despite it being a difficult condition, physical therapy is still a great option to help relieve your symptoms and get back to the activities you want to do.