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Frozen shoulder, also known as adhesive capsulitis, is a common presentation in the primary care setting and can be significantly painful and disabling. The condition progresses in three stages: freezing (painful), frozen (adhesive) and thawing, and is often self-.limiting. Common conservative treatments include nonsteroidal anti-.inflammatory drugs, oral glucocorticoids, intra-.articular glucocorticoid injections and/or physical therapy. However, many physicians may find themselves limited to prescribing medications for treatment. This article elaborates on physical therapy exercises targeted at adhesive capsulitis, which can be used in combination with common analgesics.
Lucy, a 53-year-old woman, visited you several times in the past year. She had an aching pain on her shoulder and, lately, had increasing difficulty lifting her arm or reaching behind her back. You previously gave her painkillers as treatment. However, due to her history of gastric problems, you were keen to explore physical therapy as part of management.
WHAT IS FROZEN SHOULDER?
Frozen shoulder, also known as adhesive capsulitis, is defined as “a condition of uncertain aetiology, characterised by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder”.(1) Patients with frozen shoulder typically experience insidious shoulder stiffness, severe pain that usually worsens at night, and near-complete loss of passive and active external rotation of the shoulder.(2) There are typically no significant findings in the patient’s history, clinical examination or radiographic evaluation to explain the loss of motion or pain.
Frozen shoulder can be classified as primary or secondary. Primary idiopathic frozen shoulder is often associated with other diseases and conditions, such as diabetes mellitus, and may be the first presentation of a diabetic patient.(3) Patients with systemic diseases such as thyroid diseases(4,5) and Parkinson’s disease(6) are at higher risk. Secondary adhesive capsulitis can occur after shoulder injuries or immobilisation (e.g. rotator cuff tendon tear, subacromial impingement, biceps tenosynovitis and calcific tendonitis). These patients develop pain from the shoulder pathology, leading to reduced movement in that shoulder and thus developing frozen shoulder.
Frozen shoulder often progresses in three stages: the freezing (painful), frozen (adhesive) and thawing phases (
Chart shows the clinical presentation of frozen shoulder. Icons with facial expressions represent the level of pain of the patient.
HOW COMMON IS THIS IN MY PRACTICE?
Frozen shoulder is estimated to affect 2%–5% of the general population,(12) and can be significantly painful and disabling. It most commonly affects those in their fourth to sixth decades of life, and more often occurs in women than in men.(8,13)
The term ‘frozen shoulder’ is often loosely used and wrongly attributed to other shoulder limitations such as a rotator cuff tear or osteoarthritis. Subacromial pathology (e.g. rotator cuff tendinopathy, subacromial bursitis and impingement syndrome) can closely resemble frozen shoulder in the early stages as well.(7) For appropriate management, it is important for physicians to ascertain the diagnosis. As the physical therapy described in this article is specifically targeted at adhesive capsulitis, techniques for other shoulder conditions require further customisation.
WHAT CAN I DO IN MY PRACTICE?
Most frozen shoulder cases can be managed in the primary care setting. Clinicians are encouraged to start the treatment with patient education. Explaining the natural history of the condition often helps to reduce frustration, increase compliance and allay fears for the patient. It is also advisable to acknowledge that full range of motion may never be restored. Common conservative treatments for frozen shoulder include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids given orally or as intra-articular injections, and/or physical therapy.(14) Many practitioners, however, find themselves limited to prescribing medications to relieve pain and inflammation.
Many physical therapy and home exercises can be used as a first-line treatment for adhesive capsulitis.(12) Physical therapy has been shown to bring about pain relief and return of functional motion.(15) When used in combination with physical therapy, NSAIDs were proven to be more effective as compared to using NSAIDs alone.(16) Similarly, various studies on intra-articular corticosteroids used in combination with physiotherapy resulted in better outcomes compared to intra-articular corticosteroids alone.(17,18)
The physical therapy for primary idiopathic frozen shoulder described herein can be useful for prescribing home exercises to increase shoulder mobility. Nevertheless, it is imperative to consider the patient’s symptoms and stage of the condition when selecting a physical treatment method for frozen shoulder.
A summary of the three phases of frozen shoulder.
Pain is often most severe during the freezing phase and patients in this phase would benefit from learning pain-relieving techniques. These exercises include gentle shoulder mobilisation exercises within the tolerated range (e.g. pendulum exercise, passive supine forward elevation, passive external rotation, and active assisted range of motion in extension, horizontal adduction, and internal rotation). A heat or ice pack can be applied as a modality to relieve pain before the start of these exercises. The application of moist heat in conjunction with stretching has been shown to improve muscle extensibility.(19) Certain patients might also find it useful to take analgesics before physical therapy.
Patients should begin with short-duration (1–5 seconds) range of motion exercises, which should be in a relatively pain-free range.(20)
Photographs show examples of stretching exercises: (a) active assisted shoulder forward flexion with wand; (b) active assisted shoulder external rotation with wand; and (c & d) pendulum exercise.
Similar to the freezing phase, a heat or ice pack can be applied during the frozen phase to relieve pain before commencing exercises. Home exercises such as those in
Photographs show examples of strengthening exercises: (a) scapular retraction; (b) posterior capsule stretch; and (c) isometric shoulder external rotation. In scapular retraction, the scapulae are pulled towards each other (arrows in a).
In the thawing phase, the patient experiences a gradual return of range of motion. It is crucial to get the shoulder back to normal as quickly as possible by regaining full movement and strength. Strengthening exercises are important, as the shoulder is considerably weakened after a few months of little movement. Compared to the frozen phase, the patient can perform more mobility exercises and stretches (e.g. Figs.
Referral to a physiotherapist can be made when the physician thinks that the patient’s condition needs more guidance and can benefit from a physiotherapist review, or when the patient’s condition fails to improve after trialling exercises such as the above. Referral to an orthopaedics specialist may be necessary if some investigations are needed, such as radiography of the shoulder (to look for calcific tendonitis or acromial bone spur, i.e. a Type 3 Bigliani spur) and magnetic resonance imaging of the shoulder to rule out cuff tear.
Manipulation of the frozen shoulder under regional anaesthesia together with intra-articular glenohumeral joint cortisone injection is an effective form of treatment in frozen shoulder without cuff tear. This is especially so if the patient would like a rapid improvement in symptoms and avoid the expected natural history of pain, stiffness and slow gradual thawing of the stiff shoulder.
TAKE HOME MESSAGES
Patients with frozen shoulder typically experience insidious shoulder stiffness and near-complete loss of passive and active external rotation of the shoulder.
Frozen shoulder occurs in three phases: freezing (painful), frozen (adhesive) and thawing, and is often self-limiting.
Common conservative treatments for frozen shoulder include NSAIDs, glucocorticoids given orally or as intra-articular injections, and/or physical therapy.
Physical therapy and home exercises can be a first-line treatment for frozen shoulder, with consideration of the patient’s symptoms and stage of the condition.
In the freezing (painful) stage, gentle stretching exercises can be done but should be kept within a short duration (1–5 seconds) and not go beyond the patient’s pain threshold.
In the frozen (adhesive) stage, strengthening exercises such as scapular retraction, posterior capsule stretch and isometric shoulder external rotation can be added to the patient’s exercises for maintenance of muscle strength.
In the thawing stage, the patient experiences a gradual return of range of motion; both stretching and strengthening exercises can increase in intensity, with a longer holding duration.
Lucy started on strengthening exercises at home, following your instructions. On her next visit to your clinic, she was happy to report that these exercises had relieved some of her pain and improved her shoulder movement. You assured her that her condition usually takes time to recover and instructed her to progress to resistance-based exercises. You noted that she was on track to recovery and did not refer her to a physiotherapist.
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