If I’ve heard it once, I’ve heard it 1000 times in my career (okay this is an exaggeration, it’s probably only a few dozen times), “I think my frozen shoulder is acting up!”
Meanwhile, the patient is moving their arm all over and wincing with a bit of pain.
The very name is enough to strike long term fear into a patient.
“Frozen Shoulder” it just sounds like something utterly debilitating, no wonder patients catastrophize over the diagnosis.
Part of the problem with this diagnosis is that all too often as soon as someone has an issue with their shoulder, it gets labeled, labeled with a damning diagnosis, and usually an improper one.
So, how do we convince someone their shoulder is probably okay and just needs to be de-sensitized, or actually realize frozen shoulder is the issue? Well, there are several ways, and while we can’t “diagnose” there are certainly some signs and symptoms we can look at which will help us recognize the difference and refer out when necessary.
Getting To Know Frozen Shoulder
Most of the time a detailed intake form, case history, and clinical examination should be enough to manage those who are coming in with shoulder pain, however, there are things we need to look for during this to determine the severity of a shoulder issue.
Frozen shoulder’s clinical name is “adhesive capsulitis” and is characterized by patients experiencing pain along with limited range of motion and disability of the glenohumeral joint which lasts anywhere from 1-24 months. There are two types of adhesive capsulitis:
- Idiopathic (primary): occurs spontaneously from a chronic inflammatory response (possibly an abnormal immune system response).
- Secondary adhesive capsulitis: happens after a shoulder injury or surgery and can be associated with conditions like diabetes, rotator cuff injury, cerebrovascular accident, or cardiovascular disease.
It seems those with diabetes (10-36% of diabetic patients) are quite prone to dealing with frozen shoulder as both types I and type II diabetics are susceptible and have worse outcomes compared to non-diabetics. They also experience more severe symptoms and are more resistant to treatment. Those who have had a stroke are also quite susceptible as it happens to 25% of stroke patients within 6 months, which is likely due to some muscle spasticity on the affected side. Some studies have also shown an association with Dupuytren’s disease, hypothyroidism, and Parkinson’s disease (however these last few are much rarer).
Mostly this affects people in their 50’s with the peak age being 56, but rarely happening to people under 40, and more commonly affects women than men (sorry ladies). However, some research suggests a high prevalence of shoulder issues among the elderly, who aren’t seeking medical attention for the issue.
One study tried to develop a new clinical sign to help diagnose a frozen shoulder with something called the “Coracoid Pain Test”. This is essentially putting digital pressure on the coracoid process, which creates more intense pain compared to the unaffected shoulder. In the study, 96.4% of patients with this condition complained of pain when the test was done, which they argue shows a high specificity rating, but I don’t know if this is widely accepted yet.
If we have a patient come in who is experiencing shoulder pain, trying to get a differential diagnosis is important (even though we can’t diagnose), but if we look at the above instances, these are all things which could be on our intake form that could help us narrow down and understand that maybe our patient is dealing with frozen shoulder as opposed to just some simple shoulder pain. One other thing that stands out as being consistent with a frozen shoulder is the complete loss of external rotation.
Once we understand this, it is also important to understand the “phases” this condition goes through.
There are 3 phases with varying degrees of length:
- The painful phase:
- Pain with AROM & PROM.
- Reduced flexion, abduction, and rotation.
- Pain worse at night.
- Duration lasting 10-36 weeks.
- Adhesive “frozen” phase:
- Pain starts to subside (still bad at full range) but still stiff.
- Almost no external rotation.
- Rigid “end feel”.
- Duration 9-15 months.
- Resolution “thawing” phase:
- Spontaneous improvement in ROM.
- Minimal pain.
- Happens during 15-24 months since issues started.
While it is quite common for the symptoms to resolve themselves, it does take a considerable amount of time for that to happen and of course, this depends on whether things like diabetes are influencing the healing process. There are studies showing that 39% of people had a full recovery, the remaining 61% had some issues with pain and or range of motion.
However, there are things we can do to help move this along and education with movement looks like the primary treatment.
Of course, the treatment we are giving must be tailored not only to the patient but also the phase of the condition.
During the painful phase, the main thing we are looking for is pain relief and movement within pain-free tolerances and using graded exposure to get to the edges of painful movement. We did an article a couple of weeks ago where you can see how to do this by clicking HERE. While much of the literature points to the use of NSAIDs, there isn’t a lot to confirm its effectiveness for frozen shoulder.
One study on Idiopathic Adhesive Capsulitis showed good success with an exercise program that involved a four-direction shoulder stretching program that included passive forward flexion, passive external rotation, passive horizontal adduction, and passive internal rotation. With this program they had 64% of patients report a satisfactory outcome, 7% not satisfied, and 5% who went for surgery.
Treatments during the adhesive phase should be more aggressive toward longer stretches and a low load to push toward an increase in range of motion.
When these exercise interventions don’t work, the patient is often referred for surgery or for manipulation under anesthesia and have relatively good outcomes. There is also well-documented use of injected steroids, which when combined with manual therapy have some good outcomes as well. Although, in reading over Paul Ingraham’s post on frozen shoulder, there is also a risk of causing shoulder issues with various types of injections, so this should be considered as well.
Much of this is going to be left up to your clinical decision making, but having a good understanding of the timelines and what is happening, along with feedback from your patient should give you a good idea of how to manage this, should someone come in for treatment.
Educating
As mentioned in this post, education is a major part of helping someone with this condition.
Unfortunately, this probably isn’t done as much as it should be. While most patients are probably looking for a “quick fix”, the reality is, this is just going to take some time and effort on their part and yours.
There is a normal course the condition takes and at the 12-24 month period it falls into a resolution phase and there is a greater improvement in range of motion. While any patient would look for complete resolution one study showed at the 5-10 year follow up of 41 patients:
- 39% had full recovery.
- 54% had some limitation without functional disability.
- 7% had functional limitations.
And still another study showed 50% of their patients had some degree of pain and stiffness seven years after the condition started.
However, the above studies did show that the longer the person was in the stiffness stage, the longer the recovery stage, there was a direct correlation. So, perhaps proper education and movement in the painful phase could, in turn, shorten the stiffness and recovery stage?
Interestingly one of the previously mentioned studies showed that prior “physical therapy treatment and a workman’s compensation claim or pending litigation were the only variables that were associated with the eventual need for manipulation or capsular release”.
This is a fact I find really interesting. While some argue that the biopsychosocial approach to pain isn’t in our scope, how can we look at that study and say these other factors are not a contributing factor to a persons pain and disability? In my old job I was told by a compensation representative that their studies had shown if someone was off work for 18 months on an injury claim, chances are they were never going back to that job. And here we have studies showing us that a compensation claim is one of the contributing factors to needing more aggressive treatment for this condition. While we cannot counsel a patient on this, it is something we should be cognizant of when treating them (if a compensation claim is part of their issue).
While we would never want to tell a patient there is only a 50% chance that after seven years they would be pain-free, we do want to try to educate, encourage, and build resilience with them through each phase of this condition, giving them hope for the most positive outcome possible. Reassuring them that there is a bit of a longer recovery process compared to other shoulder issues, but that full recovery is possible will probably bring a better chance of shortening the stiffness, and recovery stages.
