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Treatment and Management of Frozen Shoulder

This is Part 2 of a series on Frozen Shoulder or Adhesive Capsulitis. Part 1 covers anatomy, signs & symptoms, and assessment of frozen shoulder. Check it out here.

As previously mentioned in Part 1, treatment and management of adhesive capsulitis varies greatly from other common shoulder injuries such as shoulder impingement or bursitis. Therefore, clinicians must understand best practices for treating adhesive capsulitis.

In this article, we will cover:

  • Medical management of frozen shoulder
  • Invasive & noninvasive procedures
  • Therapeutic & Physiotherapy treatment approaches and techniques

Medical Management of Frozen Shoulder

As mentioned in Part 1, Frozen Shoulder is a self-limiting condition that can take up to 24-36 months for symptoms to resolve; with some patients never regaining full ROM [1]. As a result, it is important for patients to receive treatment for pain, range of motion, and loss of function. Various interventions exist to treat frozen shoulder from corticosteroid injections, physical rehabilitation (PT/OT), manipulations (MUA), and even surgical interventions. All of these interventions show significant benefits and improvements when compared to no intervention at all, however there is little evidence to confirm a definitive treatment method. As a result, physical rehabilitation and anti-inflammatory treatments are suggested as the primary treatment strategies, though these outcomes may not always be superior to other intervention strategies [2][3]. We will review some of the most common medical & surgical interventions for frozen shoulder below:

Steroid Injections

Surgeons and physicians often use corticosteroid injections to manage inflammation in the early stages of frozen shoulder since inflammation appears to be a key factor in progression of the disease. This aims to limit the formation of fibrosis and adhesions within the glenohumeral (GH) joint capsule by reducing the synovitis (inflammation) occurring within the joint [3][4][5]. This may reduce the overall length of the disease process. Given that inflammation appears to play a key role in the formation of fibrous adhesions, these injections are though to be more effective in the early stages of frozen shoulder [3][5].

Injection for Frozen Shoulder

Corticosteroid Injection

Effectiveness of Injections

Many studies have been completed comparing the effectiveness of corticosteroid injections to physical rehabilitation, however results are unclear as to which is superior. Many studies show that corticosteroid injections provide the best short-term benefits (4-6 weeks), but outcomes show no difference at 12 weeks compared to physical rehabilitation [2][3][4]. The evidence suggests that the effectiveness of corticosteroid injections appears to be dependent on dosage, stage of the disease, and the duration of the patient’s symptoms [1][5].

It appears that the earlier a patient receives the injections, the shorter the disease process may be. Corticosteroids are contraindicated for individuals with a history of infection, uncontrolled diabetes, or cuagulopathy [1]. They appear to have a success rate ranging from 44-80% [3]. Though they may be effective in the early stages, corticosteroid treatment should take place in conjunction with physical rehabilitation [1][4].

Clinical Takeaways
  • Injections can be offered to reduce disability and pain in conjunction with physical rehabilitation during the acute “freezing” stage [2][5].
  • If a patient pursues only physical rehabilitation initially and does not experience any gains in 3-6 weeks —or if their symptoms increase— a corticosteroid injection should be offered [2].

Manipulation Under Anesthesia (MUA)

A manipulation under anesthesia (MUA) is exactly what it sounds like. The patient is sedated, a nerve block placed to the brachial plexus, and a clinician (generally an orthopedic surgeon) applies a controlled force at the patient’s end range position of the humerus. The force is typically applied in flexion, abduction, and rotation. The nerve block allows the muscle of the shoulder to completely relax so that the force applied by the surgeon directly affects the capsule and ligamentous structures of the GH joint [2].

Success rates for MUA are very high, at 75-100% [2]. Despite the high success rates, these procedures should be seen as a last resort and are not indicated unless the patient has failed to show improvement with conservative treatments (injections and therapy) for at least 6 months [2][3][5]. This is due to the risks associated with MUA such as: nerve injuries, fractures, rotator cuff tears, labral tears, and forced dislocation of the GH joint.

Watch this video showing a surgeon completing a MUA on a female patient with adhesive capsulitis:

Treatment following MUA

Post-manipulation therapy programs begin immediately following a MUA. Patients are generally prescribed range of motion exercises which should be completed every 2 hours for the initial 24 hours following the procedure. They are also instructed to apply ice to their shoulders every two hours as well. These programs are intended to maintain the gains achieved by the manipulation, though care should be taken to ensure that each patient’s specific impairments are addressed with the range of motion exercises given [2][6].

Though these procedures can be very effective in regaining range of motion and function, there are contraindications that should be accounted for. For example, history of dislocation, fractures, bone loss/osteoporosis, or inability to adhere to post-treatment care plan are included in the list of contraindications for MUA.

Clinical Takeaways
  • Manipulation under anesthesia (MUA) should be considered a last resort if a patient has failed to show improvement with conservative treatment methods for at least 6 months.
  • Patients should be educated and counseled on possible risks, complications, and contraindications for MUA.

Arthroscopic Capsular Release

Capsular Release Frozen Shoulder

Capsular Release

If a patient is not a candidate for manipulation under anesthesia, arthroscopic capsular release procedures offer an alternative options. As with MUA, these procedures are indicated only when a patient has failed to make any gains or has experienced and increase in symptoms after attempting conservative treatment for at least 6 months. Evidence suggests that it is a reliable treatment for improving range of motion, particularly with patients diagnosed with diabetes or secondary adhesive capsulitis following surgery or fracture [3]. Since it allows more control over which tissues are being released, and may decrease some of the risks associated with MUA, arthroscopic capsular release has become a very popular treatment method for frozen shoulder [2][5][7].

Post-surgical rehabilitation programs vary between physicians and facilities, however they typically follow an outline similar to post-manipulation rehabilitation. Frequent and regular range of motion exercises are completed to maintain the relative gains resulting from the procedure.

Clinical Takeaways
  • Arthroscopic capsular release has been shown to be an effective treatment to improve range of motion in patients diagnosed with frozen shoulder and who have not experienced gains after 6 months of conservative treatment options [3][7].
  • Because it limits the risks associated with MUA, arthroscopic capsular release is recommended for patients who are not candidates for MUA, those diagnosed with diabetes, or those who are diagnosed with secondary adhesive capsulitis following fracture or surgery [3].

Physical Rehabilitation for Frozen Shoulder

As mentioned previously, there is no definitive treatment for frozen shoulder indicated by current evidence. Typically, patients diagnosed with adhesive capsulitis are referred to physical rehabilitations (PT/OT), perhaps in conjunctions with corticosteroid injections, in an attempt to conservatively treat the disease. Common therapeutic interventions include: patient education,, physical agent modalities (PAMs), & manual therapy/stretching [2][8]. Evidence suggests that patients with adhesive capsulitis benefit rom therapy and reduced symptoms, increased range of motion, and improved functional status or ability [8].

Patient Education

Taking into account the biopsychosocial effects of frozen shoulder, clinicians must ensure that patient education plays a large and important role in the rehabilitation process. Appropriately educating patient about the disease process, average prognosis, and course of treatment helps improve patient compliance and outlook for recovery. Taking the time to explain the basics of pain to patients also improves compliance, outlook, and clinical outcomes.

It is important to provide realistic expectations to patient about recovery time, prognosis, and typical outcomes. Explain that, though it is possible that full recovery of motion does not happen, frozen shoulder will spontaneously resolve and the stiffness and pain will be reduced significantly. Along with this information, a home exercise program that is easy for the patient to complete is important as daily movement and exercise is a critical component for recovery and relieving symptoms [2].

Physical Agent Modalities (PAMs)

Ultrasound for Frozen Shoulder

Ultrasound for Frozen Shoulder

Physical agent modalities (PAMs) such as heat, ice, electrical stimulation, and therapeutic ultrasound provide clinicians tools to aid with pain control and improving clinical outcomes. While there remains uncertainty in the literature regarding the measurable effects of PAMs specifically on adhesive capsulitis there is general consensus that  they may offer positive benefits when combined with other therapeutic interventions.

For example, heat application in conjunction with manual stretches may help improve range of motion and increase soft tissue extensibility [2]. A Cochrane review published in 2014 indicated that there is uncertainty whether manual therapy, exercises, and electrotherapy such as ultrasound is an effective short-term adjunct to corticosteroid injections, though patients did report perceived improvement and benefit from such treatment [9].

Clinicians should take into account patient preference, clinical experience, and the available evidence to make a clinical judgement on whether a patient would benefit from the use of PAMs in their specific situation.

Manual Therapy Techniques

Manual Therapy Frozen Shoulder

Manual therapy for Frozen Shoulder

Manual therapy has been included in physical rehabilitation treatment programs for adhesive capsulitis for both its mechanical and neuromuscular effects on the tissues of the shoulder. These mechanical effects include: adhesion break-up, collagen realignment, and improving arthrokinematic movements (ex: roll, glide, spin) of the GH joint. In fact, joint mobilizations have been shown to improve range of motion in patients with frozen shoulder for at least 3 months [10].

In this study by Vermeulen et al., clinicians completed posterior, anterior, and inferior glides as well as distraction to the GH joint. Subjects were divided into two groups, one receiving low grade joint mobilizations (Grade I-II) and the other receiving high grade mobilizations (Grade III-IV). At 3 and 12 months after treatment, subjects in the high grade group demonstrated statistically significant improvement in range of motion [10]. Evidence also suggests that end range mobilizations provides better outcomes that mid-range joint mobilizations for patients with frozen shoulder [11].

Overall, evidence indicates that significant positive effects can be attained by including joint mobilizations and manual therapy into treatment plans of patients with frozen shoulder [12].

Stretching

When applying manual stretches to patients with adhesive capsulitis (or when instructing home stretching programs), clinicians must understand the three important findings of clinical research:

  1. High intensity, low duration stretching improves the elastic response of tissues. Low intensity, high duration stretches improve plastic response of tissue.
  2. Plastic deformation —or permanent elongation— of tissues is directly correlated with the duration of a stretch.
  3. The intensity of a stretch is directly correlated with the degree of trauma or weakening of the stretched tissues. [13]

Each individual will tolerate stretching differently based on their age, gender, occupation, and this may affect progression of stretching.

Phase 1: Acute or Freezing Stage

Acute Frozen Shoulder

Acute, Painful Stage: Frozen Shoulder

Given that each individual will experience symptoms differently and will have unique biopsychosocial facts affecting their situation, physical rehabilitation programs must be customized to each individual based on their current stage or progression of frozen shoulder.

During the initial —or painful, freezing— stage of frozen shoulder, clinicians focus on pain relief and patient education.  The patient should be instructed to avoid any activities which cause pain. Evidence shows that patients experience better results when completing pain-free activities or exercises rather than intensive physical rehabilitation during the early stages of frozen shoulder [5].

Exercises

During the initial painful stage of frozen shoulder, exercises should be pain free, low intensity, and short duration. Completing exercises in this manner can alter joint receptor input, decrease muscle guarding, and reduce pain. Here is a list of “core” exercises that can be included in this stage:

  • Pendulum exercises
  • Passive forward flexion/elevation while supine
  • Active assisted range of motion in horizontal adduction, extension, and internal rotation.

Once range of motion begins to return, evidence suggests that isometric deltoid exercises may be initiated, progressing to theraband exercises, scapular stabilization exercises, and finally advanced shoulder strengthening exercises utilizing weights [4].

Phase 2: Frozen or Stiffening Stage

Low Load Stretches Frozen Shoulder

Manual Low Load Stretches for Frozen Shoulder

Once in the frozen or stiffening stage, rehabilitation treatment should focus on stretching to improve range of motion. It is important that the patient and clinician understand that stretches should be low load and prolonged in order to produce a plastic elongation at the tissues. High load, brief stretching produces high tensile resistance and should be avoided [4].

Stretching programs for the shoulder seem to produce good outcomes for patients in this stage [3]. Patients also benefit from movement with mobilization and end-range mobilizations. These manual techniques can help correct scapulohumeral rhythm, restore range of motion, and decrease pain during movement [11].

Patients may continue to complete pain-free stretching programs at home during this phase of frozen shoulder.

Phase 3: Thawing or Resolution Stage

In the final phase of frozen shoulder, rehabilitation is progressed increasing the frequency and duration of stretches while maintaining the intensity of the stretch. This results in holding the stretches longer and completing stretches for more sessions during the day. As the patient’s pain and irritability decrease, inclusion of pulley exercises may be initiated [2].

Summary

When treating patients with adhesive capsulitis, clinicians must understand how to appropriately progress rehabilitations treatment to maximize the benefits to the patient. As a general rule, manual therapy and exercises should only be progressed as the patient’s pain and irritability decline.

Outcome measures should be based on pain reduction, functional improvement, and patient satisfaction rather than by range of motion gains. Once a patient has experienced a significant reduction in pain, ROM gains have plateaued, and functional improvement & patient satisfaction have been maximized, the patient is ready for discharge [2].

The reality is that our understanding of adhesive capsulitis, or frozen shoulder, is still lacking. No evidence or literature points to a clear and concise practice guideline for idiopathic frozen shoulder. At this point clinicians must rely on clinical experience, patient preference, and the available research (the three pillar of evidence-based practice).

Have you treated patients with frozen shoulder or adhesive capsulitis? Share any additional resources that you found helpful in the comments below!

For more informational reads, check out our Blog to see all the articles we’ve published to date. Click here to head over to our resources section and check out our variety of clinical and professional resources aimed at increasing your knowledge and skills. We have many free and inexpensive resources, like our report on Total Shoulder Replacements or our Core-4 Shoulder Exercise Program.

 

Rafael E. Salazar II, MHS, OTR/L is the president and CEO of Rehab U Practice Solutions. He has experience in a variety of rehab settings, working with patients recovering from a variety of injuries and surgeries. He worked as the lead clinician in an outpatient specialty clinic at his local VA Medical center. He also has experience as an adjunct faculty instructor at Augusta University’s Occupational Therapy Program, as a Licensed Board Member on the GA State OT Board, has served on several committees for the national OT Board (NBCOT), and as a consultant for the State of Georgia.

Read his full bio Here. Read about Rehab U Here.

 

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References

[1] Blanchard V, Barr S, Cerisola FL. The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitits: A systematic review. Physiotherapy 2010; 96: 95-107. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20420956

[2] Kelley M, Mcclure P, Leggin B. Frozen shoulder: Evidence and a proposed model guiding rehabilitation. J Orthop Sports Phys Ther 2009;39:135-148. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19194024

[3] Brue S et al. Idiopathic adhesive capsulitis of the shoulder: a review. Knee Surg Sports Traumatol Arthrosc. 2007. 15:1048-1054. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17333122

[4] Bal A, Eskioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clinical Rehabilitation 2008; 22:503-512. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18511530

[5] Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005; 331:1453-6. DOI: https://doi.org/10.1136/bmj.331.7530.1453

[6] Boyles RE, Flynn TW, Whitman JM. Manipulation following regional intrascalene anesthetic block for shoulder adhesive capsulitis: A case series. Man Ther 2005:10;164-171. Available from: https://www.sciencedirect.com/science/article/pii/S1356689X0400075X?via%3Dihub

[7] Neviaser AS, Hannafin JA. Adhesive Capsulitis: A Review of Current Treatment. The Am J Sports Med 2010;38:2346-56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20110457

[8] Cleland J, Durall CJ. Physical therapy for adhesive capsulitis: Systematic review. Physiotherapy 2002;88:450-457. Available at: https://doi.org/10.1016/S0031-9406(05)60847-4

[9] Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD011275. DOI: 10.1002/14651858.CD011275

[10] Vermeulen HM, Rozing PM, Obermann WR, Cessie S, Vlieland T. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: Randomized clinical trial. Phys Ther 2006;86:355-368. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16506872

[11] Yang JI, Chang C, Chen S, Wang S, Lin J. Mobilization techniques in subjects with frozen shoulder syndrome: Randomized multiple-treatment trial. Phys Ther 2007;87:1307-1315. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17684085

[12] Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: A retrospective cohort study. Phys Ther 2009;89:419-429. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19270045

[13] Ruiz J. Positional Stretching of the Coracohumeral Ligament on a Patient with Adhesive Capsulitis: A Case Report. The Journal of Manual and Manipulative Therapy Vol 17: Number 1: 58-63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704342/