Frozen shoulder, clinically known as adhesive capsulitis, is a debilitating condition that causes stiffness and pain in the shoulder joint. The condition, which typically develops gradually, can significantly impair daily function and quality of life. In this blog post, we will explore the current understanding of frozen shoulder, its diagnosis, and evidence-based management strategies.
What is Frozen Shoulder?
Frozen shoulder occurs when the connective tissue surrounding the shoulder joint (the shoulder capsule) becomes inflamed, thickened, and stiff. Over time, this leads to a restriction in the range of motion in the shoulder, which can cause both pain and significant functional limitations. The exact cause of adhesive capsulitis is not fully understood, but it is commonly associated with risk factors such as:
- Diabetes (especially poorly controlled)
- Immobilisation or lack of shoulder movement (e.g., after surgery or injury)
- Age and gender (more common in people aged 40-60, and slightly more common in women)
- Other conditions like cardiovascular disease, thyroid disorders, and Parkinson's disease
Frozen shoulder typically develops in three phases:
1. Freezing phase (painful phase): Characterised by increasing pain and decreasing range of motion.
2. Frozen phase (adhesive phase): The pain may decrease, but significant stiffness and limited mobility persist.
3. Thawing phase (recovery phase): Gradual improvement in range of motion and function.
Although the condition usually self-resolves - typically lasting between 1 and 3 years (although sometimes persisting much longer) - it can cause substantial impairment in daily activities and quality of life, particularly for individuals involved in overhead movements, such as reaching or lifting.
Diagnosis of Frozen Shoulder
The diagnosis of frozen shoulder is primarily clinical, based on a patient's history, symptoms, and physical examination findings. A thorough assessment involves evaluating the patient's range of motion, the onset of pain, and any history of trauma, surgery, or systemic diseases like diabetes.
To confirm the diagnosis, imaging techniques may be used to rule out other pathologies, such as rotator cuff tears or arthritis. The following are commonly used diagnostic tools:
- X-ray: Typically used to rule out other causes of shoulder pain, as frozen shoulder itself doesn't typically show up on X-rays.
- MRI: Can show thickening of the shoulder capsule, though it's not always necessary for diagnosis.
- Arthrography: In some cases, contrast dye may be injected into the shoulder joint to evaluate the tightness and inflammation of the capsule.
The hallmark of adhesive capsulitis is a gradual reduction in both active and passive range of motion, particularly in external rotation, which is often the most restricted movement.
Evidence-Based Management of Frozen Shoulder
Management of frozen shoulder involves a combination of pain management, improving shoulder mobility, and restoring function. Recent evidence, particularly from renowned experts like Jeremy Lewis and Jarred Powell, has highlighted the importance of a tailored, multimodal approach to treatment. Here's an overview of the evidence-based interventions currently recommended:
1. Physical Therapy
Jeremy Lewis, a leading researcher in shoulder rehabilitation, emphasises the importance of active rehabilitation for frozen shoulder. A structured program of graded exercise therapy, including stretching and strengthening exercises, is crucial in the management of adhesive capsulitis. The goal is to restore the range of motion and gradually reduce stiffness.
Lewis’ research suggests that manual therapy, including joint mobilisations, can be particularly effective in the early stages of the condition. However, it's important to avoid overloading the joint during the early inflammatory phase, as this may worsen pain and stiffness.
A systematic review by Powell et al. (2015) highlighted the efficacy of stretching exercises to improve range of motion and function in patients with frozen shoulder. Active stretching and shoulder mobilisations that work to stretch the tight capsule are a cornerstone of rehabilitation.
2. Pain Management
Managing pain is an essential aspect of treatment, especially during the freezing phase. Several approaches have been shown to be effective:
- Non-steroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation.
- Corticosteroid injections have been shown in numerous studies to provide significant short-term relief from pain and stiffness, particularly in the early phases of the condition. A randomised controlled trial by Bunker et al. (2007) found that steroid injections were more effective than placebo in improving range of motion and reducing pain.
- Cryotherapy and other modalities like ultrasound therapy may also help alleviate pain and reduce inflammation, although evidence supporting their long-term effectiveness is limited.
3. Corticosteroid Injections vs. Surgery
While corticosteroid injections are a common intervention, their role in long-term management remains debated. Some studies suggest that steroid injections can provide short-term relief, particularly for patients with significant pain during the freezing phase. However, the benefit may not persist long-term, and some patients experience a return of symptoms after several months.
For those who do not respond to conservative measures, surgical options may be considered. A manipulation under anaesthesia (MUA) or arthroscopic capsular release is typically reserved for patients who do not improve with physiotherapy and other interventions. These procedures aim to release the contracted capsule and restore mobility to the joint. However, surgery carries risks and is often seen as a last resort.
4. Multidisciplinary Approach
Frozen shoulder management benefits from a multidisciplinary approach, where physiotherapists, general practitioners, and orthopaedic specialists work together. Physiotherapy is often the backbone of treatment, but adjunct therapies such as pain management and psychosocial support can play a significant role in improving outcomes, especially in cases where pain and dysfunction are persistent.
Prognosis and Recovery
The prognosis for frozen shoulder is generally positive, with most individuals experiencing a full recovery or significant improvement in range of motion and pain resolution. However, recovery can take time, often well over a year. The 'thawing phase', where movement gradually improves, is often slow and gradual, but the condition typically resolves without the need for surgery in the majority of cases.
Conclusion
Frozen shoulder, while challenging and frustrating, is a condition that can be managed effectively with a combination of physiotherapy, pain management, corticosteroid injections and, in some cases, surgery. Contemporary research underscores the importance of early, active rehabilitation and individualised care. With the right approach, most patients can expect a positive outcome and return to normal function.
If you or someone you know is suffering from frozen shoulder, it's important to seek advice from a healthcare professional experienced in musculoskeletal rehabilitation. Early intervention can significantly improve outcomes and help you return to a pain-free, fully functioning shoulder.
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References:
1. Lewis, J. (2017). *Shoulder Pain and Frozen Shoulder: Mechanisms and Management*. Churchill Livingstone.
2. Powell, J., et al. (2015). *Exercise therapy for the treatment of frozen shoulder: A systematic review*. Physiotherapy Theory and Practice.
3. Bunker, T. D., et al. (2007). *Corticosteroid injection versus placebo for the treatment of adhesive capsulitis: A randomized controlled trial*. Journal of Shoulder and Elbow Surgery.
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