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Physio Penrith Frozen Shoulder Treatment

Treatment of Frozen Shoulder at Sydney Muscle & Joint Physio Penrith

What is frozen shoulder?

Frozen shoulder, also known as adhesive capsulitis, is a condition characterised by shoulder pain and significant loss of both active and passive range of motion of the shoulder. Frozen shoulder is most commonly classified as either primary or secondary. Primary frozen shoulder is idiopathic (unknown cause) in nature, and radiographs will appear normal. Secondary frozen shoulder develops due to some disease process, which can further be classified as systemic, extrinsic, or intrinsic. Systemic secondary frozen shoulder develops due to underlying disease processes, examples include diabetes mellitus and thyroid conditions. Extrinsic secondary frozen shoulder occurs from pathology not related to the shoulder, such as cardiopulmonary disease and cervical disc pathology. Intrinsic secondary frozen shoulder results from known shoulder pathology, including but not limited to rotator cuff tendinopathy, glenohumeral arthropathy, and acromioclavicular joint arthropathy.

 

Frozen shoulder usually affects patients aged 40-70 years, with females affected more than males. Frozen shoulder typically lasts 12 to 18 months with a cycle of 3 clinical stages, the freezing, frozen and thawing stages. The freezing stage is also known as the painful inflammatory phase. Patients present with constant shoulder pain and range of motion limitations in a capsular pattern- external rotation > abduction > flexion > and internal rotation. In the second phase, the frozen or stiff phase, the pain progressively decreases as does shoulder motion and individuals commonly experience increased restrictions in function. In the last phase, the thawing phase, patients gradually regain shoulder movement and experience progressively less discomfort.

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At Sydney Muscle & Joint Physio Penrith our treatment approach is in line with guideline-based practice, unfortunately recent evidence has not been able to conclude which treatment technique, whether physical therapy, home exercise program, cortisone injection, manipulation, or surgery, is most effective. Evidence regarding the use of intra-articular cortisone injections is conflicting, though some studies do indicate they provide better short-term (4-6 week) pain reduction than other forms of treatment. Our belief is that patients begin physical therapy and if they do not demonstrate progress within 3-6 weeks, referral for evaluation for an injection should be considered.

What are the symptoms of frozen shoulder?

Frozen shoulder will generally present with symptoms primarily of irritable shoulder pain and decreased range of motion. Most patinets will complain of impaired performance of activities of daily living, with these including difficultly drying the back of their head, brushing their hair or placing hands on their head. As frozen shoulder progress individuals will see decreased shoulder strength and impaired function.

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Cadaver studies demonstrate the restricting influence of the subscapularis and selected capsuloligamentous complex portions. Further, the rotator cuff interval forms a triangular-shaped tissue bridge between the anterior supraspinatus tendon edge and the upper subscapularis border, with the apex located on the biceps sulcus lateral ridge at the margin of the transverse humeral ligament.

 

The clinical course of frozen shoulder includes:

  • Stage 1- may last up to 3 months, and during this stage patients describe sharp pain at end ranges of motion, achy pain at rest, and sleep disturbance. Subacromial shoulder impingement is often the suspected clinical diagnosis early in this stage because there are minimal to no ROM restrictions. Early loss of external rotation motion with an intact rotator cuff is a hallmark sign of adhesive capsulitis and may be seen in this stage.

  • Stage 2- may last from 3 to 9 months, and is known as the “painful” or “freezing” stage, presents with a gradual loss of motion in all directions due to pain. Arthroscopic examination reveals aggressive synovitis/angiogenesis.

  • Stage 3- lasts from 9 to 15 months, and is known as the “frozen” stage, is characterised by pain and loss of motion. The synovitis/angiogenesis lessens but the progressive capsuloligamentous fibrosis results in loss of the axillary fold and range of motion when tested under anesthesia.

  • Stage 4- significant stiffness persists from 15 to 24 months after onsets of symptoms, and is known as the “thawing” stage, is characterised by pain that begins to resolve. This stage often progresses to pain resolution, but motion restrictions may persist. Although adhesive capsulitis was initially considered a 12- to 18-month self-limited process, mild symptoms may persist for years.

Treatment of highly irritability frozen shoulder

At Sydney Muscle & Joint Physio Penrith our physiotherapists follow guidelines from "Kelley M, et al. Shoulder Pain and Mobility Deficits: Adhesive Capsulitis Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 2013; 43(5): A1-A3". 

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Individuals with high irritability frozen shoulder are characterised by high levels of pain (≥7/10), consistent night or resting pain, high levels of reported disability on standardised self-report outcome tools, pain occurs before end ranges of active or passive movements and active range of motion is significantly less than passive range of motion due to pain.

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Intervention strategies for shoulder pain and mobility deficits related to high irritability frozen shoulder:

  • Modalities: heat for pain modulation, electrical stimulation for pain modulation

  • Self-care/home management training: patient education on positions of comfort and activity modifications to limit tissue inflammation and pain

  • Manual therapy: low-intensity joint mobilisation procedures in the pain-free accessory ranges and glenohumeral positions

  • Mobility exercises: pain-free passive range of motion exercises, pain-free active assisted range of motion exercises

Treatment of moderate irritability frozen shoulder

At Sydney Muscle & Joint Physio Penrith our physiotherapists follow guidelines from "Kelley M, et al. Shoulder Pain and Mobility Deficits: Adhesive Capsulitis Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 2013; 43(5): A1-A3". 

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Individuals with moderate irritability frozen shoulder are characterised by moderate levels of pain (4-6/10), intermittent night or resting pain, moderate levels of reported disability on standardised self-report outcome tools, pain occurs at end ranges of active or passive movements, active range of motion similar to passive range of motion.

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Intervention strategies for shoulder pain and mobility deficits related to moderate irritability frozen shoulder:

  • Modalities: heat for pain modulation as needed, electrical stimulation for pain modulation as needed

  • Self-care/home management training: patient education on progressing activities to gain motion and function without producing tissue inflammation and pain

  • Manual therapy: moderate-intensity joint mobilisation procedures, progressing amplitude and duration of procedures into tissue resistance without producing post-treatment tissue inflammation and associated pain

  • Stretching exercises: gentle to moderate stretching exercises, progressing the intensity and duration of the stretches into tissue resistance without producing post-treatment tissue inflammation and associated pain

  • Neuromuscular re-education: procedures to integrate gains in mobility into normal scapulohumeral movement while performing reaching activities

Treatment of low irritability frozen shoulder

At Sydney Muscle & Joint Physio Penrith our physiotherapists follow guidelines from "Kelley M, et al. Shoulder Pain and Mobility Deficits: Adhesive Capsulitis Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 2013; 43(5): A1-A3". 

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Individuals with low irritability frozen shoulder are characterised by minimal levels of pain (≤3/10), no night or resting pain, minimal levels of reported disability on standardised self-report outcome tools, pain occurs with overpressures into end ranges of passive movements, active range of motion same as passive range of motion.

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Intervention strategies for shoulder pain and mobility deficits related to low irritability frozen shoulder:

  • Self-care/home management training: patient education on progression to performing high-demand functional and/or recreational activities

  • Manual therapy: end-range joint mobilisation procedures, high amplitude and long duration of procedures into tissue resistance

  • Stretching exercises: stretching exercises, progressing the duration of the stretches into tissue resistance without producing post-treatment tissue inflammation and associated pain

  • Neuromuscular re-education: procedures to integrate gains in mobility into normal scapulohumeral movement during performance of the activities performed by the patient during his/her functional and/or recreational activities

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