Frozen shoulder (FS), medically known as adhesive capsulitis, is a self-limiting condition characterised by an insidious, progressive onset of symptoms. The main symptoms typically being pain and significantly reduced range of motion. Although the onset of frozen shoulder is not fully understood, these symptoms are thought to occur due to a progressive inflammation and thickening of the shoulder joint capsule.

Certain populations are more prone to the development of FS, specifically individuals aged 40-60 years, women, individuals in sedentary jobs, and people with diabetes mellitus (1). For further reading on the understanding and aetiology of frozen shoulder refer here.

There is no gold-standard treatment for FS, but there are many ways your physiotherapist can assist you. So, how do we manage frozen shoulder?

Education & Monitoring

When patients present with FS, often there is a lack of understanding around what the condition is and how long the healing process may take. A key role of your physiotherapist will be to educate you on your condition and the stages of healing.

Monitoring your condition will be essential in order to track changes in range of motion, pain, strength and function over time. Methods your physiotherapist may use to monitor changes include:

Function, pain and quality of life: questionnaires such as the Disabilities of Arm, Shoulder and Hand (DASH) questionnaire.

Range of motion: with FS there are significant losses in all key ranges of motion in the shoulder joint. This may be tracked in a variety of ways, including photographs (at the patient’s request), or goniometry (measuring joint angles).

Strength: strength testing will be measured in key positions regularly and can be done quickly and efficiently. Your therapist can grade your strength using manual muscle testing.

Exercise

Exercise will be a key component of all management plans for individuals with frozen shoulder. Many different types of exercise will be used in order to gain most benefit (2). Passive and active range of motion drills will be key initially. Passive means your muscles are fully relaxed when the shoulder is moving. Your therapist will perform passive exercises with you. Active exercises involve you using your muscles to bring your joint through specific ranges of motion.

Muscle strengthening will be utilised as a key component of your program. When range of motion begins to improve, it will be essential for you to regain strength throughout the available range, which will allow you to maintain that range moving forward and hopefully reduce the likelihood of you experiencing pain in the future.

Cardiovascular exercise is crucial during injured periods, to help maintain and increase your health and general well-being. Your therapist will advise you on ways you can adapt activities that you enjoy in order to keep fit and active. This will not only be important from a physical point of view, but it will also be crucial for psychological health, as you may feel very limited in doing meaningful activities.

Manual Therapy

Throughout the course of our treatment sessions your therapist may use a variety of manual therapy treatment techniques in order to aid you along your healing pathway. These may include passive and active mobilisations, mobilisations with movement, muscle energy techniques and/or proprioceptive neuromuscular facilitation (PNF) work. Each individual patient may get different benefits from different techniques, so communication between therapist and patient will be key in finding the most beneficial treatment plan.

The Reality Of Frozen Treatment

FS is not a condition where you will be able to attend physio for 1-2 sessions and get a quick fix. The rehabilitation process can be arduous. Timeframes for healing and resolution of symptoms typically last anywhere from 12-18 months, although some individuals may observe symptoms up to 3 years later. Early assessment and diagnosis, as well as high-quality evidence-based management will be key for you to get the best results possible (3).

Key Take Home Messages

FS is a self-limiting condition which can last for upwards of 1 year, sometimes lasting up to 3 years.
The causes of FS are not fully understood, but there are certain populations at a higher risk, most notably individuals with diabetes mellitus.
Many individuals diagnosed with FS do not fully understand the condition or the treatment process. Proper education and communication with a qualified health care practitioner is crucial.
There is no gold-standard treatment for the management of FS. Treatment incorporates a combination of education, symptom and disease monitoring, exercise therapy, and manual therapy.
If you think you may have FS, make a physiotherapy appointment to get an official diagnosis and treatment plan.

References

Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. JBJS. 1992 Jun;74(5):738–46.
Mertens MG, Meert L, Struyf F, Schwank A, Meeus M. Exercise Therapy is Effective for Improvement in Range of Motion, Function, and Pain in Patients With Frozen Shoulder: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil [Internet]. 2021 Aug 21 [cited 2022 Mar 20]; Available from: https://www.sciencedirect.com/science/article/pii/S0003999321013666
Challoumas D, Biddle M, McLean M, Millar NL. Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020 Dec 16;3(12):e2029581.