Frozen Shoulder – James Clayton
This Blog will explain what frozen shoulder is, how we diagnose it and how the evidence states we should treat our patients.
What is frozen shoulder?
Previously coined as ‘peri-arthritis’ by Duplay in 1872(Reeves, 1975), frozen Shoulder was a term that was first used in 1934 by Codman (Rizk and Pinals, 1982), where he described a painful shoulder condition of insidious onset, which is painful to sleep on at night. Colman also stated that the condition clinically presented as reduction in shoulder flexion and external rotation. In 1945, the term which we now often refer to frozen shoulder as, adhesive capsulitis (AC), was first introduced by Naviesar (Shaffer, Tibone and Kerlan, 1992). However, the poor evidence for capsular adhesions is often refuted and therefore the term adhesive capsulitis should be used with caution(Lewis, 2015).
We now know that frozen shoulder, is a painful inflammatory disorder with progressive fibrosis of the shoulder capsule but it’s pathogenesis is still unknown (Bak and Isaaksson, 2019).
Due to the variety and conflicting evidence over the years stemming from the varying definitions of frozen shoulder, Lewis (2015), compiled a summary of abnormalities which were regularly seen in patients with frozen shoulder from 1952 through to 2009 yet there was still some uncertainty regarding the inflammatory changes. These were;
- Thickening and fibrosis of the rotator interval
- Scaring of the subscapular recess (between biceps and subscapularis tendons)
- Neovascularity
- Increased cytokine concentrations
- Contraction and fibrosis of the coracohumeral ligament
- Proliferation of fibroblasts and myofibroblasts
- Presence of contractile proteins
Who does it affect?
Despite the lack of literature, frozen shoulder is thought to affect around 2-5% of the population. Normally, it is found in people aged between 40-60 with it being rare in people aged younger than 40. To add to this, it tends to affect women slightly more than men. 20% of patients will also experience frozen shoulder in the opposite shoulder. (Robinson et al., 2012)
Both obesity and diabetes are significantly associated with frozen shoulder and are therefore considered as modifiable risk factors. (Kingston et al., 2018)
How do we diagnose it?
The diagnosis of frozen shoulder is often clinical with the main findings being progressive loss of range of motion combined with pain. External rotation at the glenohumeral joint often sees the biggest reduction in range. Frozen shoulder is then split up into three stages which can be diagnosed;
- Freezing phase (10- 36 weeks) – main symptom is pain with little response to anti- inflammatories.
- ‘Frozen’ phase (4-12+ months)- pain decreases but stiffness increases with almost complete loss of external rotation
- ‘Thawing’ phase (12-42 months)- stiffness gradually decreases as range of motion increases
In less severe cases imaging may be useful where frozen shoulder may be misdiagnosed as other shoulder pathologies. Imaging such as plain radiography, conventional arthography, ultrasound or MRI may be used to identify abnormalities that indicate a diagnosis of frozen shoulder. These might include thickening of the coracohumeral ligament, reduced capsular distension, synovial hypertrophy and tissue scarring. (Zappia et al., 2016)
How do we treat it?
STAGE 1
Patients want a definitive diagnosis and a clear treatment pathway along with the relevant advice and education in the very early stages of the disease. (Jones et al., 2013) The goals of therapy in stage 1 are to disrupt inflammation and reduce pain. An intra-articular injection of 80 mg of methylprednisolone acetate mixed with lidocaine can be a very useful technique- it can also help to distinguish between stage 1 and 2. (Yoon et al., 2016) Corticosteroid injections are also recommended by the NICE guidelines (Cks.nice.org.uk, 2019)
STAGE 2+3
Several studies have also demonstrated the importance and effectiveness of joint mobilisation in adhesive capsulitis patients. (Çelik and Kaya Mutlu, 2016) (Jewell, Riddle and Thacker, 2009) And therefore following, a systematic review in 2014, therapeutic exercises and mobilisation are strongly recommended for improving ROM and function in patients with stage 2 and 3 frozen shoulder (Jain and Sharma, 2014).
Exercises focusing on shoulder ROM as well as cervical and thoracic ROM statistically improved ROM, pain and quality of life between 6 weeks- 12 months. These exercises were further enhanced when done in a group or combined with manual therapy as they statistically improved pain, function and anxiety compared with a home exercise plan alone. (Russell et al., 2014)
In terms of joint mobilisations, the Maitland mobilisation techniques is often seen throughout the recent literature as an effective method to improve ROM and decrease pain in patients with frozen shoulder. (Do Moon et al., 2015) (Goyal, Bhattacharjee and Goyal, 2013)
Summary
In conclusion, frozen shoulder is painful and debilitating condition that can last between 12-48 months. Because of this, as clinicians, it is important that we diagnose the condition early with a clear pathway for our patients to maximise the prognosis. Physiotherapy including a variety of treatment techniques from injections to manual therapy combined with exercise can help maintain and increase range of motion to improve patient’s function in their day to day life.
References
Bak, K. and Isaaksson, F. (2019). Frozen Shoulder. Ugeskrift for Laeger.
Çelik, D. and Kaya Mutlu, E. (2016). Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial. Clinical Rehabilitation, 30(8), pp.786-794.
Cks.nice.org.uk. (2019). Shoulder pain – NICE CKS. [online] Available at: https://cks.nice.org.uk/shoulder-pain#!scenario:1 [Accessed 17 Dec. 2019].
Do Moon, G., Lim, J., Kim, D. and Kim, T. (2015). Comparison of Maitland and Kaltenborn mobilization techniques for improving shoulder pain and range of motion in frozen shoulders. Journal of Physical Therapy Science, 27(5), pp.1391-1395.
Goyal, M., Bhattacharjee, S. and Goyal, K. (2013). Combined Effect of End Range Mobilization (ERM) and Mobilization with Movement (MWM) Techniques on Range of Motion and Disability in Frozen Shoulder Patients: A Randomized Clinical Trial. Journal of Exercise Science and Physiotherapy, 9(2), p.74.
Jain, T. and Sharma, N. (2014). The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: A systematic review. Journal of Back and Musculoskeletal Rehabilitation, 27(3), pp.247-273.
Jewell, D., Riddle, D. and Thacker, L. (2009). Interventions Associated With an Increased or Decreased Likelihood of Pain Reduction and Improved Function in Patients With Adhesive Capsulitis: A Retrospective Cohort Study. Physical Therapy, 89(5), pp.419-429.
Jones, S., Hanchard, N., Hamilton, S. and Rangan, A. (2013). A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder. BMJ Open, 3(9), p.e003452.
Kingston, K., Curry, E., Galvin, J. and Li, X. (2018). Shoulder adhesive capsulitis: epidemiology and predictors of surgery. Journal of Shoulder and Elbow Surgery, 27(8), pp.1437-1443.
Lewis, J. (2015). Frozen shoulder contracture syndrome – Aetiology, diagnosis and management. Manual Therapy, 20(1), pp.2-9.
Reeves, B. (1975). The Natural History of the Frozen Shoulder Syndrome. Scandinavian Journal of Rheumatology, 4(4), pp.193-196.
Rizk, T. and Pinals, R. (1982). Frozen shoulder. Seminars in Arthritis and Rheumatism, 11(4), pp.440-452.
Robinson, C., Seah, K., Chee, Y., Hindle, P. and Murray, I. (2012). Frozen shoulder. The Journal of Bone and Joint Surgery. British volume, 94-B(1), pp.1-9.
Russell, S., Jariwala, A., Conlon, R., Selfe, J., Richards, J. and Walton, M. (2014). A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder. Journal of Shoulder and Elbow Surgery, 23(4), pp.500-507.
Shaffer, B., Tibone, J. and Kerlan, R. (1992). Frozen shoulder. A long-term follow-up. The Journal of Bone & Joint Surgery, 74(5), pp.738-746.
Yoon, J., Chung, S., Kim, J., Kim, H., Lee, H., Jeong, W., Oh, K., Lee, D., Seo, A. and Kim, Y. (2016). Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial. Journal of Shoulder and Elbow Surgery, 25(3), pp.376-383.
Zappia, M., Di Pietto, F., Aliprandi, A., Pozza, S., De Petro, P., Muda, A. and Sconfienza, L. (2016). Multi-modal imaging of adhesive capsulitis of the shoulder. Insights into Imaging, 7(3), pp.365-371.
