Frozen shoulder syndrome, clinically known as adhesive capsulitis, is a painful and debilitating condition affecting up to 5% of the population. Adhesive capsulitis is considered to be fibrosis of the glenohumeral joint capsule with a chronic inflammatory response. Patients experience pain, limited range of motion, and disability generally lasting anywhere from 1 to 24 months (Page & Labbe, 2010). At Blackberry Clinic we treat this condition using a multi disciplinary approach with treatments available including hydrodilatation injections and steroid injections followed by physiotherapy, chiropractic or osteopathic manual therapy and exercises to mobilise and strengthen the shoulder. See what our patients say about treatment at Blackberry Clinic for this condition. Click here.
The presentation of this disorder varies greatly depending on the stage at which the patient presents for examination, however it usually affects patients over 40 years of age. There are three main stages of adhesive capsulitis:
Freezing: In the “freezing” stage, pain slowly increases and shoulder range of motion decreases. Freezing typically lasts from 6 weeks to 9 months in the absence of treatment.
Frozen: During the “frozen” stage, pain reduces but stiffness remains and daily activities become more difficult due to restricted movement.
This stage typically lasts 4-6 months.
Thawing: Shoulder motion slowly improves during the “thawing” stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.
Cause
The pathophysiology behind adhesive capsulitis is still not fully understood. There is no clear connection to either arm-dominance or occupation. Generally, adhesive capsulitis is more common in women than men. It can affect either shoulder, although it most commonly affects the non-dominant shoulder. A fall onto an outstretched hand up to 6 months prior to the onset of shoulder pain is thought to be a possible contributor to the onset of adhesive capsulitis.
Although the aetiology of this disorder is still unclear, a capsular pattern has consistently been found of most limited motion in external rotation, followed by glenohumeral abduction and internal rotation.
A few of the following factors may put you more at risk for developing frozen shoulder:
- Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.
- Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson’s disease, and cardiac disease.
- Immobilisation. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.
Treatment
The aim of treatment for adhesive capsulitis is pain relief and restoration of normal shoulder movement. It should consist of one or more of the following:
- Education: the natural history of the condition and support with the use of analgesics
- Manual therapy: Chiropractic, Physiotherapy or Osteopathy using gentle mobilisation techniques with active exercise and/or other modalities (Jewel et al, 2009)
- Injection therapy: Corticosteroid injections are commonly used in the early stages for pain relief. Hydrodilatation injections can be used to reduce the adhesions formed within the capsule, which contribute to the restriction of movement.
- Manipulation under anaesthesia
The treatment given depends on the severity and stage of the condition. In the initial stage, the ‘freezing stage’, high pain levels means that manual therapy is likely to increase pain and so injection therapy is more often considered at this point. In the ‘frozen’ and ‘thawing’ stages, lower pain levels allow a more manual approach to be taken to increase range of motion without increasing pain levels.
In conclusion, adhesive capsulitis is a challenging condition for both the physical therapist and patient. It is important for clinicians to make an accurate diagnosis and assessment in order to best choose their interventions. By understanding the published evidence related to the rehabilitation of patients with adhesive capsulitis, both therapist and patient will benefit from an integrated, multi-faceted, evidence-based approach to intervention (Page & Lebbe, 2010).
References
DePalma, A. F. (1983) Surgery of the Shoudler. Lippincott, Philadelphia.
Harris,J. D., Griesser, M. J., Copelan, A., Jones, G. Treatment of adhesive capsulitis with intra-articular hyaluronate: A systematic review. International Journal of Shoulder Surgery. 2011 Apr-Jun; 5(2): 31–37.
Jewell, D. V., Riddle, D. L. & Thacker, L. R. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Journal of Physical Therapy. 2009;89:419-429.
Nice Guidelines for Shoulder Pain (July 2017) https://cks.nice.org.uk/shoulder-pain#!scenario:1
McLoughlin, H. L. (1961) The Frozen Shoulder. Clinical Orthopaedics, 20, 126.
McNab, I. (1973) Rotator Cuff Tendonitis. Annals of the Royal College of Surgeons of England, 52, 271.
Neviaser, J.S. (1945) Adhesive Capsulitis of the Shoulder: Study of Pathological Findings in Peri-arthritis of the Shoulder. Journal of Bone and Joint Surgery 27, 211.
Page, P., Labbe, A. Adhesive Capsulitis: Use The Evidence to Integrate Your Interventions. North American Journal of Sports Physical Therapy. 2010;5(4);266-273
Simmonds, F. A. (1949) Shoulder Pain with Particular Reference to the Frozen Shoulder. Journal of Bone and Joint Surgery, 31B, 426.
