Frozen shoulder, adhesive capsulitis, ‘50 year old shoulder’, and frozen shoulder contracture syndrome. All names used to describe the same condition. The multiple nomenclature used to describe this condition shows a poor overall understanding on what is occurring. Is there a freezing and thawing stage as suggested by the word ‘frozen’, or is there formation of adhesions within the capsule itself? There are many theories out there about the pathoaetiology of the condition from chronic inflammation to, capsular shrinking, adhesions, an immune response, and trauma. So not only do we have a poor understanding of what is happening, we also have a poor understanding of why it is happening. This can make assessment and management of frozen shoulder difficult.
Signs and Symptoms
The most common symptoms of frozen shoulder are severe pain and stiffness. Night pain is often present making it difficult to sleep particularly on the affected side. There is also marked reduction in both passive and active range of motion, in particular into external rotation. These symptoms result in activity and participation restrictions. Overhead activities, reaching out, and putting your hand behind your back all become increasingly difficult. X-rays are generally normal in appearance but used to rule out more significant conditions such as fracture, avascular necrosis, locked dislocations, arthritis, or osteosarcomas.
Tradition dictates that we manage this condition based on what stage it is in ie freezing, frozen, or thawing. Whilst managing it in stages is a valid concept, I do believe our stages can improve. Personally, I manage these patients dependent upon if their pain is greater than their stiffness, or if their stiffness is greater than their pain.
Pain Greater Than Stiffness
During this stage, pain is the predominant factor, and thus needs to be the main consideration. Treatment during this stage aims to decrease and manage the pain, whilst promoting as much gentle movement as possible to maintain range of motion. Physiotherapy treatment options include soft tissue therapy, heat, education, load management, and exercise targeted at maintaining range of motion that are guided by pain. A cortisone injection may also be beneficial during this stage again to hep manage pain.
Stiffness Greater Than Pain
During this stage the pain has begun to settle, but overall shoulder stiffness has increased. Physiotherapy treatment options during this stage include shoulder and thoracic joint mobilisation, deep tissue massage, and more aggressive range of motion exercises. A hydrodilatation may be more appropriate during this stage to promote more range of motion within the shoulder capsule. If this procedure is done during the pain is greater than stiffness phase there will likely be a severe aggravation of the pain resulting in further range of motion loss.