Frozen shoulder is one of the more unusual and debilitating conditions in musculoskeletal physiotherapy and is defined as progressive and equal loss of active (patient moving shoulder) and passive range of motion (physiotherapist moving joint for patient) in the shoulder joint with associated pain and stiffness. Often individuals with FS lose the ability to lift their arm to the front and side, as well as the ability to reach behind their back and can greatly impact their ability to complete day to day tasks.
It is believed to be caused by local inflammation in the shoulder causing ongoing pain and stiffness. Common findings in patients with the condition include thickening of the shoulder joint capsule with associated elevated inflammatory markers within the joint. This inflammatory process is thought to initiate the onset of frozen shoulder and begin the process of pain and stiffness. Therefore, thickening of the joint capsule, local inflammation and associated muscle spasm in the joint are all believed to play a role in both pain and range of motion loss. The good news is while FS is an extremely painful and limiting condition, the vast majority of people with the condition make a full recovery with physiotherapy and rehabilitation. Frozen shoulder can last anywhere from 6 to 36 months.
Frozen shoulder can be classified into 1) Primary frozen shoulder and 2) secondary frozen shoulder. Primary frozen shoulder entails FS without a significant causative event or injury prior to the onset of symptoms (comes on out of the blue), while secondary FS or post traumatic FS can be attributed to a specific event or injury to the shoulder. Risk factors that may increase a persons risk of developing a FS include being diabetic, high BMI, thyroid issues and conditions that increase systemic inflammation.
FS can also be attributed to systemic factors such as diabetes or low thyroid hormone levels, it is thought that the elevated systemic inflammation associated with these conditions may increase the risk of developing FS.
Progression of condition?
The condition has been classified into four stages: 1. Painful, 2. Freezing, 3. Frozen and 4. Thawing – however there may be some overlap between stages. It was previously thought that FS was a self-limiting condition that would neatly progress through these phases over an 6-36 month period without need for intensive rehabilitation. However, it is now known that many people experience ongoing reduced range of motion and pain many years after the onset of symptoms, with research showing that up to 50% of individuals with FS were experiencing related symptoms seven years after initial onset.
There is however also evidence that if we can intervene early and optimise patients strength and range of motion throughout the progression of disease, it can reduce the duration of symptoms and optimise long term shoulder function, achieving superior outcomes. Addressing general health factors such as nutrition, sleep and stress management are also important in the treatment of frozen shoulder.
How can we treat Frozen Shoulder?
The first line treatment of FS is physiotherapy, which entails exercises targeted at improving shoulder strength and range of motion, education to assist patients in understanding the condition and manual therapy techniques targeted at improving joint range of motion and reducing pain levels.
Patients may also be given the option for a referral to their Doctor for a cortisone injection into the joint which may be helpful in reducing pain in the early stages. Additionally, shockwave can be a viable treatment option alongside rehabilitation.
If you are experiencing ongoing shoulder pain and stiffness it is best to seek advice from your Physiotherapist.