How to Treat Frozen Shoulder: A Physical Therapist’s Guide

How to be sure of the diagnosis of adhesive capsulitis: symptoms

Three elements are considered to diagnose adhesive capsulitis:

1. Your medical history, current symptoms, family history, personal and professional lifestyle habits.
2. A clinical examination conducted by a healthcare professional.
3. One or more imaging tests (X-ray, MRI, ultrasound, CT scan): primarily to rule out other issues that could be causing the pain rather than to confirm adhesive capsulitis.

No single specific test (laboratory or imaging) can definitively confirm the diagnosis of adhesive capsulitis.

The symptoms of adhesive capsulitis can resemble those of other shoulder pathologies such as cervical radiculopathy, shoulder osteoarthritis (osteoarthritis of the shoulder), or shoulder tendonitis/tendinopathy.

That is why these three elements should be considered, along with the clinical experience of your doctor or physiotherapist, who is accustomed to seeing and treating various shoulder problems.

Here are the main symptoms:

• Pain in the front of one shoulder, without an identifiable cause (not due to a specific movement, impact, or accident).
• Reduced shoulder mobility compared to the other side, initially in rotation and then in abduction (when you move your arm sideways). Both in active (when YOU perform the movement) and passive (when your physiotherapist or doctor mobilizes your shoulder and you do not assist) movements.
• Difficulties in daily activities, particularly in hanging clothes, fastening a belt, reaching for things overhead, dressing, and brushing hair.
• Associated neck pain.

Source: Mezian 2023

What are the causes of frozen shoulder?

While experts may not always agree, the most commonly accepted cause of frozen shoulder is inflammation of the tissues around the shoulder joint.

What happens in your body

This inflammation is triggered by chemicals called cytokines and involves excessive growth of fibrous cells, making the tissues stiffer.

In addition to this, adhesions can form around the shoulder joint, making movements more difficult.

Initially, it is often a ligament called the coracohumeral ligament that is affected, limiting arm rotation. In advanced stages, the capsule around the shoulder joint thickens and contracts further, further limiting movement.

Why in some people more than others

It is not yet well understood why some people develop frozen shoulder and others do not.

However, here are the factors more commonly found in people with frozen shoulder compared to the general population:

• Type 2 diabetes: 1 in 5 people with frozen shoulder also have this type of diabetes;
• Stroke
• Thyroid disorder
• Shoulder injury
• Dupuytren’s disease
• Parkinson’s disease
• Cancer
• Complex regional pain syndrome

Women are 4 times more affected than men. And it’s more often the non-dominant side (left if you are right-handed, and vice versa) that is affected.

Source: Mezian 2023

How does frozen shoulder naturally progress?

There are studies that track the progression of individuals diagnosed with frozen shoulder, including those who decide not to pursue any medical or physiotherapy treatment.

What do these studies say?

• After 1 to 4 years of follow-up, shoulder range of motion improves but does not fully return to normal in most people.
• Symptoms improve relatively quickly (within the first few weeks or months) rather than later.
• In a group of 83 people, recovery was declared on average 15 months after the onset of symptoms. More than half of the people no longer felt any pain during activity, at rest, or at night, and 9 out of 10 had resting pain rated below 3/10.

Source: Wong 2017, Vastamäki 2012

Another study synthesis indicates recovery (with or without treatment) on average within 30 months (2.5 years), and as early as one year (Mezian 2023).

What to remember: in the case of frozen shoulder, even without specific treatment, shoulder pain can decrease, and range of motion can improve. Let’s stay optimistic!

What are the possible treatments?

Depending on the medical and paramedical team you encounter, various approaches may be proposed.

Although there is no universally agreed protocol, most recommendations suggest conservative treatment in most cases:

• Allowing time to heal
• Utilizing physiotherapy
• Taking medications (or using non-medication approaches) to manage pain

Much more rarely, in cases of persistent and severe symptoms with failed conservative treatments, arthroscopic surgery may be suggested.

Source: Mezian 2023

A South Korean team 🇰🇷 [Cho 2020] surveyed over 70 orthopedic shoulder surgeons specializing in adhesive capsulitis. Here are some insights from this publication:

• 97 out of 100 specialists recommended therapeutic education (providing information about the condition, its progression, and self-management) and stretching exercises.
• 9 out of 10 recommended anti-inflammatory medication.
• 8 out of 10 suggested corticosteroid injections into the shoulder.
• 2 out of 10 responded that more than 1 in 10 individuals did not respond to this type of conservative treatment.

Physical Therapy, Rehabilitation

Physical therapy sessions are often prescribed for frozen shoulder. After an initial assessment, your physical therapist will define a treatment plan with you.

The proposed treatment plan depends on several factors:

• Your symptoms and preferences
• What you have already tried
• Your physiotherapist’s treatment approach

Generally, physiotherapy treatment focuses on these 4 aspects:

1. Maintaining or restoring shoulder mobility: by adapting stretching exercises, muscle strengthening, and mobilization to your pain level
2. Alleviating your pain: by discussing the best strategies such as positioning, activity modification, physiotherapy, massage, etc.
3. Providing reassurance and answering your questions
4. Gradually reintroducing movements and activities that are important for you in your daily life

The number of physical therapy sessions varies case by case.

Medical treatments: medications, injections

The treatments offered will vary even more depending on the professionals encountered, as these approaches have even less consensus than physiotherapy.

• Prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen to relieve pain, and occasionally opioids.
• Intra-articular injection of corticosteroids under ultrasound or fluoroscopic guidance.
• Suprascapular nerve or interscalene brachial plexus block. A doctor injects an anesthetic or corticosteroid near the suprascapular nerve or brachial plexus (a group of nerves in the neck).
• Arthrographic distension: a doctor injects a large amount of fluid (usually saline solution) into the shoulder joint under pressure.

Surgery

If pain and discomfort persist for many months, some doctors or physiotherapists may recommend consulting an orthopedic surgeon who may perform:

• “Forced” mobilizations under general anesthesia (similar to knee mobilization under GA).
• Capsular release under arthroscopy.