Important Considerations for Frozen Shoulder

Frozen shoulder. Did you shudder as well? When I see it on an intake form I know I’m always in for a challenging case. 

Early in my career I had a lady with a diagnosis of frozen shoulder come into my office. She had seen many other practitioners, without resolve, and was seeing me as a last resort. After one treatment her symptoms went away and did not return. I thought at the time that I was the frozen shoulder guru. I was going to help all of the frozen shoulders on planet earth (that was naive). It turns out that helping someone with frozen shoulder is about as difficult as finding an Elsa doll the day before Christmas. 

Frozen shoulder is a painful, stiff shoulder and can be divided into two categories; primary frozen shoulder and secondary frozen shoulder. Primary frozen shoulder is a stiff, painful shoulder, without any specific trauma or disease. Secondary frozen shoulder is described when stiffness is thought to have been caused  by underlying trauma, infection, inflammation or disease². An increased prevalence of frozen shoulder has been seen in those individuals with diabetes⁵ and thyroid dysfunction⁶. This condition affects 2-5% of the population⁸, is more common in men⁹ and is observed most commonly between 40-60 years of age¹⁰. Frozen shoulder is often described in 3 stages: freezing (8 weeks – 3 months), frozen (16 weeks – 1 year) and thawing (16 weeks – 3 years)³. Often these stages can overlap making it difficult to understand where a person is at during their journey. While clinicians struggle to often agree on inclusion criteria and accurate diagnosis, several authors have defined frozen shoulder as a pathology by the presence of inflammatory mediators (interleukins, cytokines, B- and T-lymphocytes, growth factors, matrix metalloproteinases, tumor necrosis factors and fibroblast activation markers) as well as a change in local collagen structure of the shoulder capsule¹¹.

There are several commonly accepted treatment strategies for frozen shoulder . It should be noted that due to the level and quality of evidence available, superiority of one treatment over another cannot be concluded³. 

Pain relief, advice, and education

Pain relief may come by way of exercise, manual therapy or medications. Medications most commonly used are both steroidal and non-steroidal anti-inflammatory medications. Medications are often suggested at night to improve sleep quality¹. An integral part of education is also understanding the potential central mechanisms which may present in longer-standing shoulder pain¹⁴. Furthermore, the often self-limiting nature of frozen shoulder can have a profound effect on a person’s ability to cope with normal daily activities³.  

Physical therapy, activity, exercise

This is often used alongside medications or injection therapy. Activities are typically based around pain relief/modulation, regaining/maintaining motion and strengthening. While most programs are discussed as person-specific, there has been suggestion of avoiding passive range of motion of the shoulder during the freezing stage¹.

Intra-articular (IA) injections

Corticosteroid injections are often use in attempt to break the pain and inflammation cycle. Research may suggest that doses of less than 10mg may be less effective at managing pain¹². It also appears that single injections often yield similar outcomes to multiple IA injections¹³. 

Manipulation under anesthesia

The capsule of the shoulder is forcibly broken under general anesthesia by manoeuvring the shoulder across its restricted range of motion². 

Arthroscopic capsular release

Surgical release of the shoulder capture with the goal of restoring range of motion and reducing pain³. It should be noted that less than 10% of people require surgical interventions for frozen shoulder¹. Of those that receive surgery, 17% of patients fail to maintain range of motion and between 5-10% of procedures are consider unsuccessful (having made no significant improvements in clinical outcomes)^15,16. 

Hydrodilation

In the early stage of injury, saline along with anesthesia is injected into the shoulder capsule. The premise of the procedure is an attempt to break the early fibrotic cycle of inflammation within the shoulder. Hydrodilation while often discussed, is not currently standard practice in the management of frozen shoulder¹. 

My perspective

I don’t know how else to put this but it’s very difficult to help people with frozen shoulder. What I’ve found has helped me over the years is as follows:

First, I don’t make promises. This is generally true for most things I see, but particularly for frozen shoulder. I don’t know when it well get better. I don’t know what will improve first. I will also clarify there are no magic pill treatments. Frozen shoulder appears to be one of those things that many practitioners have the “secret” to and will market themselves that way. Unfortunately, there is no secret, it’s simply a complicated condition that takes an unpredictable amount of time to resolve.

Second, I tell people to try to stay active with the arm by their side. The arm by side position is one of my favourites when people are scared, or too sore, to move the shoulder. Most people can carry some weight with the arm by their side (farmers or suitcase carries). It may be uncomfortable at times, but it is often manageable. If people are have difficultly walking with a weight, they can stand and hold a weight for repetitions. This allows you to continue to work in a way that may be meaningful for the person you are helping.

Third, as the therapist do your best to stay grounded in the face of your client’s hard feelings. You have to meet people where they are at because you have no other choice. If a person is having a bad day, shifting treatment away from the shoulder may be the best thing. Helping a person relax and feel good, may indirectly reduce the person’s discomfort that day. Sometimes the best treatment for the shoulder may be a low back massage.

Fourth, cardiovascular exercise and/or lower body exercise should always be used when possible. I think we can often forget about the positive systemic effects of exercise. Whether it’s cardiovascular training or lower body resistance training, the body will release adrenaline and neurotransmitters which may reduce sensations of pain.

Fifth, you can only control what you can control. Try and work on things that improve general health parameters. Diet, sleep, exercise and stress when made a priority often yield positive results over time. In circumstances where they do not directly affect frozen shoulder, they may still positively impact other aspects of life.

Sixth, consider co-managing frozen shoulder with a physician. This is what I usually do. Frozen shoulder can be incredibly painful. It is fairly frequent that the person I am seeing will be compliant with all my clinical advice, and they will still have no change in symptoms or pain. At times medications or procedures are needed. To have someone already in that care funnel is beneficial. It’s also great to have the opinion of a trusted physician, or therapist, to work alongside you.

While frozen shoulder is a very frustrating thing to experience the good news is there is often light at the end of the tunnel, no matter how long. The vast majority of people make a full recovery. As with most things, doing nothing is seldom the answer. Start slow, establish trust and try and move a little bit more in a better direction each day.