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Frozen shoulder, also known as adhesive capsulitis, is a condition that affects the shoulder joint capsule. This blog will provide an in-depth look at what frozen shoulder is, its signs and symptoms, risk factors, treatment and management options, and the expected prognosis. I will also discuss the role of physiotherapy, the use of injection therapies, and their importance in the recovery process.
What is Frozen Shoulder?
Frozen shoulder is characterised by stiffness and pain in the shoulder joint, resulting from the thickening and tightening of the joint capsule, which encases the shoulder. We previously assumed the condition progresses through three stages: the freezing stage, the frozen stage, and the thawing stage, each lasting several months to years. Now we try to keep it simpler and refer to the painful phase and the stiffness phase. While the exact cause is not always known, it often occurs following an injury or surgery, or in association with other health conditions such as diabetes, thyroid issues, obesity and cardiovascular risk factors.
Signs and Symptoms
Frozen shoulder typically presents with:
Pain: A dull, aching pain that often worsens with movement and is most intense during the "freezing" stage. The pain can be particularly severe at night, disrupting sleep.
Stiffness: As the condition progresses, shoulder movements become increasingly restricted, making it difficult to perform daily tasks such as dressing, reaching overhead, out to the side, or lifting objects.
Limited Range of Motion: Over time, both active and passive range of motion in the shoulder decreases significantly, leading to substantial functional limitations.
Risk Factors
Several factors can increase the risk of developing frozen shoulder:
Age and Gender: Frozen shoulder most commonly affects individuals between the ages of 40 and 60, with a higher prevalence in women.
Diabetes: There is a strong association between frozen shoulder and diabetes, with diabetic patients being more likely to develop the condition and experiencing a more prolonged course. Particularly, when poorly controlled.
Immobilisation: Shoulder immobility, often following an injury, surgery, or stroke, can precipitate frozen shoulder.
Other Medical Conditions: Conditions such as thyroid disorders, Parkinson’s disease, and cardiovascular disease have also been linked to an increased risk of frozen shoulder.
Prognosis
The prognosis for frozen shoulder is generally favourable, and in most cases is a self-resolving condition, though recovery can be slow. Most individuals experience significant improvement within 1 to 3 years, although some may continue to have mild symptoms beyond this period. The "thawing" stage marks the gradual return of shoulder mobility, with most patients regaining nearly full function over time.
Factors that influence prognosis include the duration of symptoms before treatment, the patient’s adherence to physiotherapy, and the presence of underlying conditions such as diabetes and whether these are well controlled or not. Early intervention with physiotherapy and, when appropriate, injection therapy, can significantly enhance outcomes and shorten the recovery time.
Treatment and Management
Treatment for frozen shoulder aims to reduce pain, restore shoulder mobility, and improve function. The following sections will detail the most effective treatment strategies, including physiotherapy and injection therapies, as well as when these options are most appropriate.
Physiotherapy: The Cornerstone of Treatment
Physiotherapy is considered the gold standard for managing frozen shoulder, supported by the National Institute for Health and Care Excellence (NICE) guidelines. It involves a combination of manual therapy, exercise, and education to alleviate symptoms and restore function.
Manual Therapy: Techniques such as joint mobilisations, stretching, and soft tissue manipulation help reduce stiffness and improve the shoulder's range of motion. Manual therapy should be tailored to the individual's pain tolerance and stage of the condition, with a gradual progression to more intensive techniques as the shoulder improves. Manual therapy may be tolerated less during the ‘early phases’ as tends to be most painful and shoulder be administered with caution.
Exercise Therapy: A structured exercise program is essential for improving shoulder mobility and strength. Exercises should focus on gentle stretching to maintain or increase range of motion and strengthening exercises to support the shoulder joint. It's crucial to start with low-intensity exercises and gradually increase intensity as tolerated, always under the guidance of a physiotherapist. Again, in the early, painful stage exercise is also not tolerated that well.
Patient Education: Educating patients about the condition is very important. Managing expectations regarding time frames and reassuring them about pain levels, particularly in the early stages is vital. People with who have a frozen shoulder often feel there is something sinister going on in their shoulder as the pain can be severe in the early stages. Education regarding this is key. The importance of maintaining mobility, and the expected course of recovery can empower patients to actively participate in their treatment and set realistic expectations.
Injection Therapy: When to Consider Steroids and Hydrodilatation
Injection therapy can be a valuable adjunct to physiotherapy, particularly in cases where pain severely limits participation in rehabilitation. There are two primary types of injections used in the treatment of frozen shoulder:
Corticosteroid Injections:
When to Consider: Corticosteroid injections are most beneficial during the early "freezing/painful" stage of frozen shoulder when inflammation and pain are at their peak. They can provide significant pain relief and reduce inflammation, allowing patients to engage more effectively in physiotherapy.
Administration: Typically, a single injection is given into the joint capsule, and its effects can last several weeks to months. Repeated injections are generally not recommended due to the potential for adverse effects on the shoulder tissues. Administration can be completed either with or without ultrasound guidance and outcomes tend to be similar for both in terms of pain and function.
Hydrodilatation:
When to Consider: Hydrodilatation, also known as distension arthrography, involves injecting a saline solution (often combined with a corticosteroid) into the joint capsule to stretch and break up adhesions. This procedure is usually considered when a patient has moved from the painful phase to the stiff phase.
Benefits: Hydrodilatation can provide significant improvements in shoulder mobility and pain relief, facilitating more effective participation in physiotherapy.
Inflammation and adhesion in joint capsule during arthroscopic surgery
Importance of Physiotherapy Post-Injection
Regardless of the type of injection, physiotherapy plays a critical role in maximising the benefits of these interventions. Post-injection physiotherapy is crucial for maintaining and improving the range of motion achieved through the injection and preventing the recurrence of stiffness. A physiotherapist will guide patients through a tailored exercise program designed to optimise shoulder function and ensure a smooth recovery.
Conclusion
Frozen shoulder is a painful and debilitating condition, but with appropriate treatment, including physiotherapy and, when necessary, injection therapy, most individuals can achieve significant improvement in their symptoms and return to normal activities, gradually over a period of time. Physiotherapy remains the cornerstone of treatment, supported by manual therapy and exercise, while injection therapies offer valuable adjuncts to reduce pain and enhance rehabilitation efforts.
References
National Institute for Health and Care Excellence (NICE). (2019). "Frozen Shoulder." Available at: NICE Guidelines
Bunker, T.D. (2009). "Frozen shoulder: unravelling the enigma." Annals of the Royal College of Surgeons of England, 91(6), 447-452.
Cohen, C., & Ejnisman, B. (2021). "The role of corticosteroids and hydrodilatation in the management of frozen shoulder: a systematic review." Shoulder & Elbow, 13(1), 51-60.
Wong, C.K., & Levine, W.N. (2019). "Frozen Shoulder: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment." Orthopedic Clinics of North America, 50(4), 615-623.
Dias, R., Cutts, S., & Massoud, S. (2005). "Frozen shoulder." BMJ Clinical Evidence. Available at: BMJ
Hanchard, N.C., Goodchild, L., & Thompson, J. (2011). "Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder." Physiotherapy, 97(2), 143-155.
Robinson, C.M., Seah, K.T.M., Chee, Y.H., Hindle, P., & Murray, I.R. (2012). "Frozen shoulder." The Journal of Bone and Joint Surgery. British Volume, 94(1), 1-9.
Maund, E., Craig, D., Suekarran, S., Neilson, A.R., Wright, K., & Brealey, S. (2012). "Management of frozen shoulder: a systematic review and cost-effectiveness analysis." Health Technology Assessment, 16(11), 1-264.
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