Frozen Shoulder Pain

Understanding Frozen Shoulder – A Painful Condition Part-1

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Adhesive Capsulitis or more commonly known by Frozen Shoulder (FS), is considered a musculoskeletal condition, with 3-5% being affected in the general population. It has a significant impact on the daily activities of the patient’s life.

Anatomy of Frozen Shoulder

Duplay in 1879 first described the frozen shoulder as “humeroscapular periarthritis”. In 1934 the term “frozen shoulder” was introduced by Codman and still widely in use. He described the condition as “difficult to define, difficult to treat and difficult to explain,” and this remains true to this day (Ryan, Victoria et al. 2016). In 1945 Adhesive capsulitis was termed by Neviaser when he described the texture of the joint capsule as “adhesive” due to inflammatory and fibrotic changes observed in the capsule or bursa.

Classification of Frozen shoulder

Primary/ Idiopathic FS: usually associated with other diseases and conditions like diabetes and thyroid diseases or Parkinson’s disease etc. It is often an insidious onset.

Secondary FS:  can occur following a trauma (fracture, dislocation, or soft tissue injury) and immobilization following rotator cuff tendon tear, Impingement, biceps tenosynovitis and calcific tendonitis.

Studies have shown that the increased pain from the shoulder pathology is said to cause reduced movement in the shoulder leading to a frozen shoulder. The pain can increase the reluctance to move to cause neurological inhibition leading to a frozen state. It can explain why FS common after a shoulder injury.

Risk factors associated with Frozen Shoulder

– Diabetes Mellitus – Frozen shoulder is known to commonly occur in patients with specific comorbidities, of which more common being diabetes. Several studies reported an increased incidence in patients with diabetes, from 10-40% (Su, Yu-De et al.,2019). The study also noted that diabetic FS patient’s symptoms were found to be more persistent and were difficult to treat with the decreased functional outcome than nondiabetic FS (Le, HV et al., 2017)

– Thyroid, adrenal, cardiopulmonary disease and hyperlipidemia are also known to be related to FS

–  The incidence between the ages of 40 and 60

–  is slightly more common in women. 

– possible underlying psychosocial issues like depression and anxiety. A study noted that while there is no definitive relationship however increased pain and disability is more in patients who suffer from depression or anxiety (Ebrahimzadeh MH et al. 2019)

–  About 10% of people with rotator cuff injury develop a frozen shoulder.

Frozen Shoulder Symptoms:

Frozen Shoulder Vs Normal Shoulder
Normal Vs Frozen Shoulder

– localized pain

– pain with movement

– night pain with inability to sleep on the affected side

– A significant limitation of both active and passive range of motion, especially (external rotation and elevation) the outward movement of the arm.

Evaluation of Frozen Shoulder:

The X-Ray results with no significant findings in the history of the patient’s condition or radiographic evaluation where osteopenia or calcific tendonitis were not present. (Abrassart S. et al. 2020) to explain the movement loss or pain.

The absence of definitive diagnostic criteria brings a challenge for diagnosing and managing. Other problems like rotator cuff tendinopathy, calcific tendonitis, early glenohumeral arthritis can also resemble closely to frozen shoulder in the early stages and challenge the diagnosis.

A recent study suggested that thickening of the joint capsule, coracohumeral ligament and synovium to be a feature of frozen shoulder. However, there is not enough data from imaging studies to specify the articular changes associated with this condition. (Ryan, Victoria et al. 2016).

MRI with IV contrast injection can be helpful for the diagnosis of FS under challenging cases. The intensity of enhanced signals in the rotator cuff interval seems to be related to the early stage of frozen shoulder (Pessis E et al. 2020).

Phases of Frozen Shoulder:

Frozen shoulder is usually reported as a self-limiting condition and is described into three phases:

Freezing (painful inflamatory): this phase usually lasts about 2–9 months, with gradual onset of diffuse to severe shoulder pain that worsens at night.

Frozen (adhesive): The pain usually will subside during this phase with progressive loss of shoulder movement, both active and passive. This stage can last for 4–12 months.

Thawing phases: There is a gradual return of range of movement and takes anywhere between 5–26 months to complete resolution of symptoms.

This long recovery period affects patients their routine life, occupational performance, and recreational activities.

A recent study noted that the description of the disease in ‘three-phase or self-limiting condition’ to be avoided. It helps to reduce distress, and potential harm as most of the population affected by FS does not follow the described phase of resolution nor the time frame even with appropriate treatment. The recommendation is based on available evidence and natural history of the condition as “which often sees short-term improvement, but which bears a high chance of ongoing low-level restriction and pain.” (Abrassart S. et al. 2020)

Frozen Shoulder

Management for Frozen Shoulder:

Most of the patients experience resolution with a conservative management approach, and thus it has been the first line of management. The initial conservative management is known to be successful in up to 90% of patients. Appropriate treatment is usually required for return to their life and function. However, definitive treatment strategies have not been established, and several management strategies are in use.

Conservative management can include:

  • NSAIDs: are usually prescribed to relieve pain but have not shown to have a substantial effect on recovery.
  • Oral steroids: are given for rapid pain relief and ROM recovery in the short term.
  • Corticosteroid injections:  can be beneficial in the early phases of the condition, especially in the first six weeks for early improvement of movement in frozen shoulder and capsular distension; however, it is not associated with significant changes in the long term (Wu et al. 2017). A Study reported that single intra-articular steroid injection used as a conservative treatment for diabetic FS and is said to be less effective than for idiopathic FS. Corticosteroid injection is an invasive procedure and ha some associated risks such as septic arthritis. Ultrasound-guided intraarticular injections shown to be beneficial for pain relief over regular injection technique in the initial two weeks but no differences beyond the 3rd week (Lee et al. 2009)
  • Suprascapular nerve block:  A study with a randomized trial of 30 patients comparing single suprascapular nerve block with a course of intra-articular injections, suggests that suprascapular nerve block is a safe and effective treatment for frozen shoulder

Surgical interventions for Frozen Shoulder:

Patients who are regressing or not making improvements despite appropriate therapy are likely to require surgical intervention. Surgical intervention for FS at 2.67 procedures per 10,000 general population in a year. Surgical management of FS varies substantially and is highly based on personal experience and training rather than evidence (Cho CH et al. 2019)

  • Manipulation under anesthesia (MUA) has been used extensively with satisfactory outcomes, which involves passive tearing of the thickened inflamed capsule and contracted ligaments. However, there are risks and iatrogenic complications with the possibility of recurrence in patients, especially with diabetes. Complications and risks may include labral tear, humeral shaft fracture, glenoid fracture, rotator cuff tear, shoulder dislocation, and traction injury to the axillary nerve.
  • Arthroscopic capsular release (ACR) is a treatment method most frequently used, with a lower complication, for restoring function and improvement in pain with patients; however, this also remains controversial. The most potential clinically relevant complication of ACR is axillary nerve damage. It is considered in the decision-making process if ACR release is required, and some are very cautious about the inferior release.
  • Hydrodistension (HD)  first described in 1965 to treat FS by the expansion of the capsule. It can be useful in providing short-term benefits to pain, ROM, and function in FS. But there is not enough evidence to suggest any superiority to other treatments (Uppal et al. 2015).

Physiotherapy treatment for Frozen Shoulder:

Physiotherapy is widely accepted in the conservative management of Frozen Shoulder. Several studies have demonstrated physiotherapy as an adjunctive intervention in providing excellent results.

NSAIDs were more effective when used combined with physiotherapy compared to NSAIDs alone. Steroid injection, in conjunction with physiotherapy, provided better outcomes compared to intraarticular injection alone.

Physiotherapy and home exercises are provided as a first-line treatment for frozen shoulder.

Frozen Shoulder Physiotherapy
Frozen Shoulder Physiotherapy

In the freezing phase (2-9 months), pain is quite predominant, and steroid injection provides rapid pain relief in the short-term period with an Active assisted range of movement as tolerated.

During the frozen phase (4–12 months), physiotherapy focused on increasing ROM, such as mobilization techniques (limited evidence).

 In the thawing phase (12–42 months), progressive improvement in ROM, strength and functional retraining or rehabilitation. As pain with muscular inhibition usually results in compensatory movements, the adaptation of scapular motion is essential in managing rehabilitation in FS.

Mobilization, Progressive Therapeutic exercises, and functional neuromuscular training are strongly recommended for improving pain, range of motion and function during the 2nd and 3rd phases of the frozen shoulder.

Therapeutic Modalities for Frozen Shoulder:

  • Studies have noted that Low-level laser therapy was effective for pain relief, but moderately suggested for improving function and was not recommended for improving ROM.
  • Acupuncture with therapeutic exercises – moderately recommended for pain relief, ROM, and function.
  • Continuous passive motion recommended for short-term pain relief but did not improve ROM or function.
  • Deep heat may be used for pain relief and improving ROM.
  • Therapeutic Ultrasound for pain relief, improving ROM or function is not recommended and delayed the improvement (Jain TK et al. 2014). The study also noted that adding an ultrasound treatment modality did not provide any additional benefits for the treatment of the frozen shoulder.
  • Extracorporeal shockwave therapy (ESWT) – few studies have found some decrease in pain and slight functionality improvements (forward ROM) through the administration of ESWT with Fascial manipulation (Yuan X et al. 2018). However, to determine the recovery is enhanced by a supervised exercise program or on its own or combined with ESWT-FM, additional research and prospective randomized, blinded controlled clinical trials must be conducted and are still lacking at this time.
  • High-intensity Laser Therapy (HILT): Study noted that HILT (non-invasive procedure) provided significant pain relief at 3 and 8 weeks, but not at later stages. Further study is still required.

Studies and literature review have shown that most patients with frozen shoulder experience resolution of symptoms with conservative management. It is, however, essential to be able to tell a patient with some confidence that an idiopathic frozen shoulder generally recovers well without any restriction in range of motion or pain (Vastamiki Heidi et al. 2012)

If you think you have a frozen shoulder or are developing one, see your physician or your physiotherapist for a physical exam and exercise program to manage and help the condition. Call Opal Physiotherapy in Langley B.C, to book a physiotherapy if need further information or to book an appointment.

Self-management approaches to help Frozen Shoulder – Coming Soon – Part-2

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