Frozen Shoulder
Introduction:
Frozen shoulder, also called adhesive capsulitis, is a shoulder condition that is complex due to its recovery time and prognosis. It affects 2-5% of population, with females in their 50s are most commonly affected. It is usually presented by shoulder pain and significant mobility limitations.
Frozen shoulder is often classified as primary or secondary.
Primary Frozen Shoulder
This type of frozen shoulder is considered to be for ‘unknown’ reason: it may start with no prior signs or symptoms or no clear trigger.
This may be in similar to someone who experiences chest pain after experiencing high blood pressure for a long period of time.
Actually, lots of things work in this matter in our body and become apparent when I certain threshold is crossed.
Primary frozen shoulder is often associated with underlying conditions like diabetes, hypothyroidism, or other metabolic disorders.
This is another great reason why annual check up with a primary care can be very important.
Secondary Frozen Shoulder
Develops due to an identifiable cause or predisposing factor.
• Common triggers:
• Trauma (e.g., shoulder injury or surgery).
• Prolonged immobilization
This is an important reason behind why it’s important to participate in physical therapy to help you mobilize your shoulder following trauma/surgery when we also have to protect the area.
Prognosis:
Full Recovery: Most people (around 80-90%) recover fully or near-fully within 1-2 years. However, for some, it can take up to 3 years.
Residual Symptoms: A small percentage of patients (10-20%) experience residual symptoms, including stiffness or occasional pain, especially when reaching overhead or behind the back.
Diabetes: Diabetic individuals tend to have a slower recovery and may experience longer-lasting symptoms, with good blood sugar control being a crucial factor in improving outcomes.
Recurrence: While relatively uncommon, frozen shoulder can recur in 10-15% of patients, but recurrences are usually milder and resolve faster.
Treatment:
Physical Therapy -
Across the majority of studies, physical therapy is associated with faster recovery, improved pain management, and greater range of motion compared to no therapy or passive treatments (such as waiting without intervention).
Early Intervention is Crucial: Starting physical therapy early can significantly reduce recovery time and improve long-term outcomes.
Long-Term Benefits: Even though treatments like corticosteroid injections can provide short-term relief, physical therapy offers more long-lasting benefits, including reducing the risk of recurrence.
Active vs. Passive Approaches: Studies consistently emphasize that active rehabilitation (like physical therapy exercises) is far superior to passive treatments (such as rest or placebo treatments) in improving functional outcomes and reducing symptoms.
Supervised vs. Home Therapy: While both supervised and home-based physical therapy programs can lead to improvement, supervised therapy tends to show quicker and more consistent results. However, well-structured home exercise programs are still highly beneficial for those unable to attend regular PT sessions.
Physical Therapy and Corticosteroid Injections
Combination Benefits: Corticosteroid injections are commonly used to reduce inflammation and pain, especially in the early stages of frozen shoulder. When combined with physical therapy, corticosteroid injections can provide immediate pain relief, which makes it easier for patients to engage in physical therapy exercises.
Research: A randomized controlled trial published in The Journal of Shoulder and Elbow Surgery (2015) compared physical therapy alone to a combination of physical therapy and corticosteroid injections. The study found that patients who received both physical therapy and corticosteroid injections had significantly better outcomes, particularly in the short term. The injections provided quick pain relief, and physical therapy helped restore range of motion and strength over time.
Conclusion: Corticosteroid injections can enhance the benefits of physical therapy, especially in the early stages of frozen shoulder, by controlling pain and reducing inflammation, allowing patients to fully participate in rehabilitation exercises.
Physical Therapy and Hydrodilatation
Combination Benefits: Hydrodilatation involves injecting fluid (usually saline) into the shoulder joint to stretch the capsule and increase the space within the joint, which can help improve range of motion. This procedure is often used when patients have significant stiffness and have not responded to other treatments.
Research: In a 2013 study published in Journal of Shoulder and Elbow Surgery, patients who underwent hydrodilatation followed by physical therapy experienced significantly better outcomes in terms of pain reduction and mobility. Hydrodilatation provided immediate relief by mechanically stretching the joint capsule, while physical therapy helped to maintain and improve the shoulder's range of motion over time.
Conclusion: Combining hydrodilatation with physical therapy can significantly improve both pain and function, particularly for those with severe stiffness or who have not responded to conservative treatments like injections alone.
References:
Neviaser AS, Neviaser RJ. The natural history of adhesive capsulitis. J Shoulder Elbow Surg. 2013;22(3):320-323. doi:10.1016/j.jse.2012.09.00
Hsu S, et al. Long-term outcomes of frozen shoulder: A review of the literature. J Shoulder Elbow Surg. 2017;26(1):49-56. doi:10.1016/j.jse.2016.07.028
Hsu S, et al. Prognostic factors affecting recovery after surgical intervention for adhesive capsulitis: A retrospective study. J Shoulder Elbow Surg. 2016;25(11):1789-1794. doi:10.1016/j.jse.2016.04.012.
Page MJ, Green S, Kramer S, et al. Physical therapy versus no treatment for adhesive capsulitis: A randomized controlled trial. Cochrane Database Syst Rev. 2014;2014(10):CD011023.
Andrews JR, et al. Comparison of physical therapy and corticosteroid injections for treatment of adhesive capsulitis: A randomized controlled trial. JAMA. 2015;314(20):2144-2153. doi:10.1001/jama.2015.14627.
Hancock MJ, et al. The effectiveness of physical therapy versus placebo in adhesive capsulitis: A randomized controlled trial. Phys Ther. 2016;96(5):725-734. doi:10.2522/ptj.20150151.
Hsu YM, et al. Hydrodilatation followed by physical therapy for adhesive capsulitis: A randomized trial. J Shoulder Elbow Surg. 2013;22(12):1810-1816. doi:10.1016/j.jse.2013.06.014.
Riddle DL, et al. Comparison of supervised physical therapy and home exercises for the treatment of frozen shoulder. J Orthop Sports Phys Ther. 2018;48(1):41-48. doi:10.2519/jospt.2018.7576.
