Musculoskeletal Physiotherapy Consultants

Frozen Shoulder

By on July 11, 2016 in General with 0 Comments

frozen shoulder

We are often asked about frozen shoulder (aka adhesive capsulitis) and in particular what is the best treatment for this fairly common condition, regularly referred for physiotherapy. In the community it affects 3% – 5% and up to 20% of diabetics.

First it is important to recognise that there are essentially two types of frozen shoulder, primary or ‘idiopathic’, which means there is no known reason for it, and secondary frozen shoulder which appears to be associated with some other condition or occurrence e.g. trauma, surgery, underlying diabetes or cardiac surgery. While we know there is an association it is still unknown how these other conditions actually lead to frozen shoulder starting. Unfortunately, there is evidence that secondary frozen shoulder often has a poorer outcome.

So what is this condition?

Firstly, it is important to make the distinction between true frozen shoulder and a shoulder that is just stiff. We know that frozen shoulder is characterised by a lot of inflammation (hence a lot of pain) in the early stages followed by progressive tightening of the shoulder capsule which limits movement in a particular pattern and then gradual ‘thawing’ as movement begins to return. It has always been believed to be a self-limiting condition that will eventually go away over a couple of years but research has shown that a good number (60%-70%) will still have some loss of movement in 7 years’ time.

How is it treated?

There have been many treatments for frozen shoulder over the more than 100 years since it was first recognised, these include; manipulation under anaesthetic, physiotherapy (manual mobilisation and exercise) corticosteroid injection, surgery to release the capsule and hydrodilatation (pumping saline into the joint to stretch out the tight capsule).

What actually works?

While there are a number of published studies showing some benefit from any or all of these treatments the larger systematic reviews that look more deeply at many studies tell us that;

  1. Corticosteroid injection gives short term pain relief
  2. Manipulation under anaesthesia (and presumably strong mobilisation) can cause damage to the tissues and result in more inflammation and slower recovery
  3. Both manual therapy and exercise are equally effective
  4. Hydrodilatation may give short term pain relief if administered with corticosteroid injection

Recently the Australian Physiotherapy Association released its position through the ‘Choosing wisely’ initiative in which, following broad consultation and evaluation of the research base, they conclude that for frozen shoulder there were “….no worthwhile clinical benefits for ongoing physiotherapy beyond the benefits of a simple home exercise program” https://www.physiotherapy.asn.au/APAWCM/Advocacy/Campaigns/Choosing_Wisely.aspx

However, it must be acknowledged that every case is different and what works for some does not work for others and these, albeit large, studies report the overall effect and averages not individual variations.

So perhaps it would be wise not to throw the baby out with the bath water and place the burden of proof on the practitioner. If any treatment can demonstrate ongoing clinically meaningful changes in appropriate validated outcomes (see previous blog) at a rate faster than nature would heal, then it can be justified but, that progress must be real (not just perceived), continuous and measureable.

If it is not clear whether treatment is having such an effect over and above the natural progression of the condition, then it might be prudent to refer for independent specialist physiotherapy opinion sooner rather than later to ensure the most efficient and effective management is being undertaken.

  • Buchbinder R, Youd JM, Green S, et al. Efficacy and cost-effectiveness of physiotherapy following glenohumeral joint distension for adhesive capsulitis: a randomized trial. Arthritis & Rheumatism 2007; 57:1027-37.
  • Carette, S., H. Moffet, et al.. “Intra-articular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial.” Arthritis & Rheumatism 2003; 48: 829-838.
  • Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R. Manual therapy and exercise for adhesive capsulitis (frozen shoulder), Cochrane Database Syst Rev 2014; 8: CD011275.
  • Robinson CM, Seah KT, Chee YH, Hindle P, Murray IR. Frozen Shoulder.
    J Bone Joint Surg Br. 2012 Jan; 94(1):1-9.

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