Frozen shoulder: Not just giving you the cold shoulder!

Shoulder pain is one of the most common musculoskeletal conditions accounting for between 7 -26% of G.P consultations in the UK & a Frozen shoulder, (adhesive capsulitis) affects  up to 5% of the population (Page & Labbe 2010). In the diabetic population this increases to 10-20%!

What is a Frozen shoulder?

Strictly speaking a Frozen shoulder isn’t an injury, it is more of an autoimmune response. That response causes the tissues around the joint to stiffen, scar tissue forms, and shoulder movements become difficult and painful. Frozen shoulder comes on gradually and takes between 18 to 35 months to resolve.

It is considered to have 3 phases:

Phase 1:

This is where pain is the predominant factor. Essentially pain limits the movement. If you were unconscious then you would have good movement. However because the pain is so high the joint starts to stiffen up. This phase can last for 6 months to a year.

Phase 2: 

This is when the acute pain begins to reduce and leaves a severely restricted shoulder joint. This phase can remain up until 1 year to 18 months from onset.

Phase 3: 

This is the final phase and is basically the gradual restoration of the movement in the joint to normal range of movement.

What are the symptoms?

Pain is localised to the shoulder area usually on the deltoid muscle. There is usually very limited movement, which usually follows the capsular pattern (see below). Pain is both at rest and during movement, the limitation of movement is the same actively and passively and it is also painful to lie on the affected shoulder.

Is Frozen shoulder Complex Regional Pain Syndrome (CRPS)?

Complex regional pain syndrome (CRPS) is an autoimmune condition in which a person develops a persistent pain, usually after a minor injury. The pain is out of all proportion to what you would normally expect. The skin of the affected body part can become extremely sensitive, even the slightest touch or change in temperature can cause intense pain. This is not unlike a frozen shoulder in onset, cause and sensitivity.

On a Physiological point of view there are definite established links. These are as follows:

Central sensitisation.

Trigger points bilaterally.

Pain pressure threshold is decreased.

Spinal-altered afferent (conducting inwards) input.

Thermal pain threshold is reduced.

Increased synaptic efficacy and development of a pain neurosigniture.

Cortical disinhibition.

Sensory motor mismatch.

Primary somatosensory cortex : distance between adjacent representative body areas becomes reduced.

All very complicated but it does show that like CRPS, it is an auto immune response and it is driven by pain for the sake of pain.

So what causes a frozen shoulder?

There is no cause that has been found but you are at higher risk with the following:

After surgery or injury.

Most often in people 40 to 70 years old.

More often in women, especially post menopause.

Most often in people with chronic diseases, especially diabetes and stroke.

How do you diagnose a Frozen shoulder?

There is no single, agreed diagnostic reference standard for a frozen shoulder. However, a positive passive lateral rotation test is useful but needs to be backed up by a thorough history taking. Due to the fact that a frozen shoulder is usually absent of other conditions it is important to screen for substantial trauma or other serious disease.  Palpation to check for gross crepitus, which is suggestive of osteoarthritis and ideally X-ray should be clear.

The movement loss follows the capsular pattern:

External rotation is the most limited, abduction is the next most limited and internal rotation after that. The ratio of loss is 3:2:1.

How do you treat a Frozen shoulder?

Here is what the evidence says:

Overall there are lots of treatments (conservative & surgical) that help Frozen shoulder in the short term but nothing works very well in the long term (Favejee et al 2011).

Exercise & Mobilisations: (Yes to both)

Out-patient physiotherapy (with passive mobilisations) and home exercises works better than a subacromial steroid injection (Hanchard et al 2012).

Mobilisations done according to the stage of frozen shoulder with home exercises are more beneficial than exercises alone (Ryans et al 2005).

Low grade mobilisations are more beneficial than high grade mobilisations for pain at rest (Vermeulen et al 2006).

High grade mobilisations are more beneficial than low grade mobilisations for pain on movement in frozen shoulder (Vermeulen et al 2006).

Passive external rotation mobilisations: Favour high grade mobilisations in the medium & long term (Vermeulen et al 2006).

So you need to work on low grade mobilisations and light stretches in Phase 1 and as Phase 2 and 3 progress the grade and stretch intensity need to become higher and more intense.

Acupuncture: (Maybe for short term relief)

Acupuncture may improve pain and function over the short term in people with shoulder pain but there is no long term benefit (Green et al 2008).

A combination of acupuncture with shoulder exercise may offer effective treatment for frozen shoulder in the short term (Sun et al 2001).

Injection: (Maybe, yes)

In the long term, evidence is unclear about the effects & clinical importance of injection for Frozen shoulder (van der Windt et al 1998).

Severe shoulder pain: Exercise & steroid injection by a physio was found to be more cost-effective than exercise alone (Jowett et al 2013).

Steroid injections: Better in short term compared with physiotherapy, decreasing to a small effect in the long term (Blanchard et al 2010).

Medication: (Yes)

Oral steroids provide significant short-term benefits in pain, range of movement & function in Frozen shoulder (Buchbinder et al 2009).

Heat treatment: (no, but will do no harm)

Hot packs: Unlikely to help frozen shoulder when added to outpatient physiotherapy & home exercises (Leung and Cheing 2008).

Surgery: (Maybe, no)

Manipulation under anaesthetic doesn't add effectiveness to an exercise program in Frozen shoulder (Kivimaki et al 2007).

So if that’s what the evidence says what do the N.I.C.E. Guidelines recommend for the management of a frozen shoulder?

Here they are:

Education& Advice:

Explain the usual timescale of frozen shoulder: it will spontaneously resolve with reduction of stiffness (although the full range of motion may not be fully recovered), but this will usually take months to years.

Advise avoidance of movements which aggravate the pain in the early, painful phase (e.g. overhead activities, vigorous stretching), but advise the person to try to continue a regular range of movement.

Medication:

Offer analgesia, particularly in the early, painful phase: paracetamol with or without codeine, or an oral nonsteroidal anti-inflammatory drug (NSAID, e.g. ibuprofen).

Consider which drug has a more favourable balance of benefits and risks for the person.

If an oral NSAID is indicated, consider gastroprotection with a proton pump inhibitor if the person is:

At increased risk of gastrointestinal adverse effects.

Subject to dyspepsia from oral NSAIDs.

In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line options.

If there is no early benefit from the oral NSAID, discontinue its use.

Physiotherapy:

Refer to physiotherapy if the person is able to tolerate movement of the affected shoulder. Ensure adequate analgesia is provided.

Injection:

Consider an intra-articular (glenohumeral) corticosteroid injection early in the course of frozen shoulder if there is no, or slow, progress with conservative treatment.

This can be done in primary care if the expertise is available, otherwise refer.

Discuss potential adverse effects when obtaining informed consent.

Although a number of steroid preparations are available, triamcinolone or methylprednisolone are the preferred option for many specialists.

Local anaesthetic (e.g. lidocaine) is frequently used in addition to corticosteroid.

If a corticosteroid injection does not produce the expected benefit, the diagnosis should be reviewed.

Monitor people with diabetes following steroid injection, as transient hyperglycaemia may occur for 24–48 hours.

Do not give a corticosteroid injection if:

The person has previously had an intra-articular corticosteroid injection from an experienced healthcare practitioner, with minimal or no benefit.

The person has previously had three or more injections in the same shoulder in the course of a year.

The pain has settled and stiffness is the predominant feature.

Corticosteroid injection is contraindicated (e.g. infection, sensitivity to local anaesthetic, adjacent osteomyelitis).

So there it is everything that you need to know about Frozen shoulder.

It is important to note that frozen shoulder is hugely misdiagnosed so it is important to get an accurate diagnosis. The amount of people that I have seen with the “tag” Frozen shoulder that actually were something else entirely.

If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914

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