Frozen Shoulder - Understanding the Condition and Exploring Treatment Options
September 9, 2018
Time and again in our practice at BodyLab, Osteopathy and Physiotherapy | Rehabilitation and Training in Zurich, we see patients with a painful shoulder and limited mobility. Often waiting, patients only saw a doctor after a few months, once a significant restriction of movement had developed.
In this blog, we explore the development and causes of a so-called Frozen Shoulder, with the aim to educate and inform patients, potentially enabling an earlier diagnosis. Additionally, we will discuss treatment options and attempt to evaluate their effectiveness based on various studies.
Understanding a Frozen Shoulder
A Frozen Shoulder, or colloquially known as painful shoulder stiffness, is a usually painful limitation of both passive and active shoulder movement, especially at the start.
General orthopedic literature describes three stages of the disease:
Phase I: An initial inflammatory phase, often characterized by severe pain, especially at night.
Phase II: A second stiffening phase where motion restrictions progressively accompany the pain. Everyday movements, such as dressing or fastening a seatbelt in the car, become increasingly difficult; pulling often sharp pains mostly occur in the anterior shoulder area.
Phase III: A third phase where normal mobility is gradually restored with the help of manual mobilization techniques in physiotherapy, and the pain disappears.
Causes of Development
A Frozen Shoulder often develops idiopathically (meaning the cause is unknown). However, studies suggest that diabetes, shoulder trauma (such as rotator cuff injuries, long biceps tendon injuries, impingement problems), thyroid diseases, increased body weight, and cervical spondylosis are associated with a significantly increased risk [1]. Factors like professional and athletic activity seem to have no impact. The influence of psychological issues and stress is discussed in the literature but is not clearly proven. Interestingly, many people develop a second Frozen Shoulder in the other shoulder after having one.
What Happens in the Body
The pathophysiology of a Frozen Shoulder remains largely unclear. Studies show that a capsule inflammation is characterized by both synovitis and a capsular fibrosis. Cytokines and increased immune system activity appear to be precursors to subsequent fibrosis of the shoulder joint, caused by increased fibroblast activity.
Braus, Hermann, Braus 1921 148, marked as public domain, details on Wikimedia Commons
Recognizing Early Signs of a Frozen Shoulder
Many patients do not recognize the early signs of a Frozen Shoulder and see a doctor late. This is because the complex and automatic shoulder movement is often unnoticed, with more attention given to hand movement. Initial evasive movements are often spotted too late, resulting in advanced fibrotic processes and frequently a prolonged therapy course. If you experience burning or pulling pains, initially often occurring at night in your shoulder, don't wait too long and consult a specialist.
The shoulder joint is very complex. The joint must balance good mobility with stability. Even minor changes or overuse can lead to shoulder joint issues.
The variety of symptoms is vast, the diagnosis often complex, and should, as mentioned, be left to a professional.
Effective Therapies
Several studies show a high short-term effectiveness of corticosteroid injections for pain and inflammation control, especially during the inflammatory phase [4,7]. From our perspective, especially for those already experiencing a second Frozen Shoulder, this can be beneficial in the early stages, but only accompanied by passive manual therapy!
Laser therapy is strongly indicated for early and short-term pain reduction but does not improve function or range of motion [4,7].
Active movement therapy, passive physiotherapeutic or osteopathic mobilization are strongly indicated for pain and movement improvement in stages 2 and 3 of a Frozen Shoulder [4,5].
Electrotherapy, ultrasound, and heat therapy can be used short-term to reduce pain. Long-term studies show little effect [7].
The effectiveness of acupuncture could not be proven [7].
As a last resort, arthroscopic capsular release (arthrolysis) proves effective. This procedure partially or fully removes the inflamed joint lining and capsular adhesions. However, this method is the last resort for reducing complaints and is typically applied only after months or years of ineffective conservative therapy [6,7].
In summary, a quick diagnosis is helpful. Early medical evaluation using MRI is recommended so that infiltrations can be administered if needed to control the inflammatory phase. After or towards the end of the first phase, a rapid start to conservative therapy should occur. Active movement therapy and learning specific home exercises are essential for future progress. Nonetheless, the most important factor is perseverance. The course can last several months or even years despite intensive conservative therapy.
If you feel similar symptoms, don't take it lightly shoulder it off! Contact us or your doctor.
If you need us, we are here for you!
Your BodyLab Team – Your Shoulder Specialists
Osteopathy and Physiotherapy | Rehabilitation and Training
Zurich Altstetten
References
[1] Case-control study of risk factors for frozen shoulder in China.
Li W, Lu N, Xu H, Wang H, Huang J.
Int J Rheum Dis. 2015 Jun;18(5):508-13. doi: 10.1111/1756-185X.12246. Epub 2014 Jan 18.
[2] Primary frozen shoulder: brief review of pathology and imaging abnormalities
Kazuya Tamai, Miwa Akutsu, and Yuichiro Yano.
J Orthop Sci. 2014; 19(1): 1–5. Published online 2013 Dec 4. doi: 10.1007/s00776-013-0495-x
[3] The pathology of frozen shoulder.
Hand GC, Athanasou NA, Matthews T, Carr AJ.
J Bone Joint Surg Br. 2007 Jul;89(7):928-32.
Jain TK, Sharma NK.
J Back Musculoskelet Rehabil. 2014;27(3):247-73. doi: 10.3233/BMR-130443.
Yang JL, Chang CW, Chen SY, Wang SF, Lin JJ.
Phys Ther. 2007 Oct;87(10):1307-15. Epub 2007 Aug 7.
Smith CD, Hamer P, Bunker TD.
Ann R Coll Surg Engl. 2014 Jan;96(1):55-60. doi: 10.1308/003588414X13824511650452.
[7] Frozen shoulder: the effectiveness of conservative and surgical interventions–systematic review.
Favejee MM1, Huisstede BM, Koes BW.
Br J Sports Med. 2011 Jan;45(1):49-56. doi: 10.1136/bjsm.2010.071431. Epub 2010 Jul 20.
