Frozen Shoulder
Frozen shoulder is a difficult and mysterious condition which is often assumed when a middle-aged person gets a painful and stiff shoulder. However, there is a lot of confusion about the exact diagnosis, how long it lasts and what the best treatments are. Over the last few years research has identified much more closely what the diagnosis means and how this problem should be managed.
The Definition of a Frozen Shoulder
It is important to be clear exactly what frozen shoulder is.
1. Symptoms (what the person complains of)
True shoulder pain. Pain in the neck, shoulder and arm can have many different causes. True shoulder pain is usually indicated by the sufferer by placing their palm across the shoulder joint and just below on the upper arm.
Gradual onset of night pain. Often there is no sudden onset of pain, no injury or event to explain it, it just gradually appears and steadily increases. Sometimes it can develop as a progression of a shoulder issue such as rotator cuff tendonitis or tear. Some clinicians speculate that in many cases neck dysfunction is a causal factor to frozen shoulder.
2. Signs (what the examiner finds)
Restriction in the movements of the shoulder, both active (the person doing them themselves) and passive (the joint being moved by someone else). Upward motion is usually less than 100 degrees (i.e. not far above shoulder level) and the arm cannot be turned outward more than 30 degrees.
Other causes of shoulder problems should be excluded before frozen shoulder is diagnosed.
3. Investigations
Plain x-rays are normal in appearance
An arthrogram, an investigation where dye is injected into the joint, shows a tight and contracted joint space
The natural history of frozen shoulder
Frozen shoulder is typically thought to have three phases, with the whole course of the condition sometimes lasting several years.
Painful phase. This phase can last 10-36 months. The pain can be severe and unrelenting, leading to severe problems sleeping. Sufferers often appear unhappy, and may have lost some of their sense of humour due to the pain lasting so long.
Stiffening phase. This lasts 4-12 months, leading to a gradual loss of movement of the shoulder. The end result can be a very stiff joint at some point.
Recovery period. This lasts from 12-24 months. The shortest time for this condition to resolve is over two years, the longest up to seven years. Recovery is often not complete, with mild pain and stiffness/restriction being a common long term problem.
Treatment for frozen shoulder
Physiotherapy
Physiotherapy for frozen shoulder (depending on the phase) includes:
1) Manual therapy / Mobilization / Muscle Energy Techniques (the physiotherapist exerts gradual forces of varying intensity and frequency and hold time on the joint as tolerated by the patient),
2) Passive and Active exercises (i.e. stretching / pulleys) for the shoulder joint which are implemented as part of a home exercise program,
3) Deep Tissue Techniques such as active release therapy or stripping of tight tissue,
The above three options focus on stretching or rupturing restrictive, tight, and or fibrosed tissues that must be broken down in order for the shoulder to regain range of motion and function properly. These fibrosed tissues to be broken down are often referred to as adhesions.
4) Heat or cold : heat to improve pliability of the tissue; cold to stave off inflammatory concerns
5) Electrotherapy: Interferential currents / TENS : to increase patient’s tolerance for stretching by helping to control pain and inflammation
6) Ultrasound : to help control for inflammation and make the fibrotic tissue more pliable for stretching and manual therapy
7) Laser : to help control for inflammation, relieve pain and create a cellular environment more conducive to faster progression through the phases of frozen shoulder
8) Acupuncture : to help control for pain and inflammation, to utilize nerve pathways to release tight / contracted tissue, to increase the patient’s tolerance for physiotherapist’s manual therapy ,
Regardless of the combination or timing of treatment options noted above, frozen shoulder inevitably continues through its phases, but it is the intent of the physiotherapist to improve the comfort of the patient as they deal with the symptoms and sequellae of this dysfunction, reduce the duration of the phases of frozen shoulder and fashion an end result for the patient that leaves them in the end with greater range of motion, strength and function than they would have been able to achieve without physiotherapy intervention.
Steroid injections
Injections of corticosteroid are commonly given for shoulder problems, but the effectiveness of this treatment is not clear. Clinical experience may suggest that steroid injections for frozen shoulder are much more effective very early in the first phase if early identification is achieved and the option of injection is made available to the patient. Co-ordination between physiotherapy and steroid injection often leads to the most optimal effect as the injection is helpful at controlling pain and inflammation making the patient more tolerant of manual therapy and stretching. This creates a window in which treatment can be both more aggressive and more effective. The effect of the steroid injection is for a limited period of time. Too many repeat injections into the joint is not advisable.
Manipulation under anaesthetic (MUA)
Surgical opinion about manipulation has varied over the years, with many doctors feeling the risks outweighed the benefits. Modern work has shown there can be significant benefits to manipulation, in both range of motion and pain relief. However, diabetic people show less benefit and so may be less suitable for this procedure. The challenge with this technique is that the inflammatory reactions created (if not diligently addressed) by the aggressive nature of tearing the adhesions in this procedure may set up another inflammatory reaction that sets the frozen shoulder in motion all over again.
Open surgery
Ozaki described open (i.e. not keyhole) surgical release of frozen shoulder in 17 patients. Bunker showed later that if the coracohumeral ligament was cut then the shoulder would release immediately, with manipulation into outward rotation sometimes being required. Afterwards, physiotherapy is indicated to maintain the range of motion gained by the operation.
Arthroscopic surgery
Various surgeons have published work on this technique, and it seems to be useful for patients who do not respond to normal treatments or manipulation.