A Review of Current Frozen Shoulder Treatment Options -with Lewis Craig

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In this blog post POGO physiotherapist Lewis Craig reviews the latest treatment evidence for frozen shoulder.

Frozen shoulder or adhesive capsulitis, is a common cause of shoulder pain, estimated to influence 3-5% of the general population and 10-15% of the population with diabetes (1). Despite being relatively common, it remains a medical enigma, difficult to understand and difficult to manage. For people with frozen shoulder it’s a real pain. Not only is it incredible painful, but also results in significant reduction in shoulder movements, impacts daily activities and has long duration (commonly 12-42 months). Here I have reviewed the latest evidence regarding management options for Frozen Shoulder.

What Is Frozen Shoulder?

Frozen shoulder is a condition of unknown aetiology (or causation), in which there is restriction of shoulder movements due to tightening of gleno-humeral (shoulder) joint capsule. More information about what Frozen Shoulder is can be found HERE.

Essentially the shoulder joint becomes increasingly stiff and painful, with the cause and mechanisms why largely unclear. It presents with reductions in all shoulder movements, with the same reduction in movement performed actively by yourself or passively by a physiotherapist or doctor whilst you are relaxed. Night pain and difficulty lying on the affected shoulder are also commonly reported. Peak incidence for frozen shoulder is in women aged 40-60 years. Frozen shoulder is grouped into either primary frozen shoulder with no underlying cause or secondary, which occurs due to precipitating factors such as recent shoulder injury, surgery, prolonged shoulder disuse, diabetes or thyroid disease (2). This is one of the most frustrating and strange things about frozen shoulder, something as simple as reaching behind you in the car could trigger it.

Treatment

Frozen shoulder is often described as progressing through three main stages.

• Painful/acute (“freezing”) stage: The first and most painful stage lasting 3 to 9 months sees gradual reduction in shoulder movement.
• Adhesive/chronic (“frozen”) stage: The shoulder becomes rigid in movement with reduced pain, mainly at the end point of movements. Commonly lasts 9 to 15 months.
• Recovery (“thawing”) stage: Minimal shoulder pain and gradual increase in shoulder movements, lasting 15 to 24 months.

Treatment options differ according to phases of frozen shoulder. It is often considered a self-limiting disorder, resolving without intervention. There is strong evidence showing a considerable number of untreated patients are left with long-term disability and pain (3). Additionally, of available treatments many can improve shoulder range of movement, increase function and decrease pain, however they cannot shorten the natural progression of frozen shoulder.

Currently there is no consensus on best treatment of frozen shoulder.  A recently published systematic review (1), has sought to provide better consensus on treatment options. It reviewed the evidence for Frozen shoulder treatment options including; physiotherapy, oral steroids, intra-articular steroid injection, hydrodilatation, manipulation under anaesthesia, and arthroscopic capsular release.  I have compiled the studies findings along with some other recent evidence on frozen shoulder below.

Let’s explore the findings of this  review.

Physiotherapy

Physiotherapy has been a mainstay in the assessment and management of frozen shoulder. As first contact practitioners Physiotherapists are routinely involved in the assessment of painful shoulder problems and can interpret clinical findings to confirm diagnosis of frozen shoulder.

Once the diagnosis is established the first stage of frozen shoulder management involves patient education. People typically want to know:

• what is the problem with my shoulder?
• what has caused the problem?
• how long will it last?
• what treatments are available?
• how effective are the available treatments?
• what are the expected outcomes?

This part of treatment  primarily involves diving deeper into the last three questions. Clinicians should describe what frozen shoulder is and the natural course of the disease, including the three stages outlined above. Understanding the condition can assist in reducing some of the fears and frustration that come with frozen shoulder. Education will also focus on activity modification to encourage functional, pain-free range of shoulder movement, and matching the intensity of stretching to patients pain levels (4).

Physiotherapist’s management of frozen shoulder utilizes various joint mobilisations, soft tissue massage, assisted movements, stretching and exercises. The aims of the techniques are to relieve pain, increase joint range and improve function (2). These are varied according to the stage of frozen shoulder and the sensitivity of the shoulder joint.

An extensive 2014 Cochrane review (5) highlighted the need of more high quality studies to examine the effects of physiotherapy. No trials compared manual techniques and exercise to a no intervention group. The study did find moderate quality evidence greater improvement was seen with glucocorticoid injection compared to physiotherapy for pain and range of movement. There is also short-term benefit of adding physiotherapy to a single intra-articular steroid injection (6). A single study has shown support for the added use of short wave diathermy to a home exercise program, whilst the benefit of acupuncture remains equivocal (6). Physiotherapy is also routinely used following surgical procedures such as manipulation under anaesthesia and arthroscopic capsular release.

Oral Medications (Steroids and NSAIDs)

Oral steroids are not commonly prescribed or used in the management of frozen shoulder. Recent evidence of oral steroids is limited. The majority of trials were reviewed in a systematic Cochrane review in 2006 (7). It found that there is a mild short-term (under 6 wk) benefit to oral steroid therapy but it does not alter long-term outcomes. The studies do not report the stage of disease at the time of treatment, however it is most commonly used in the first painful stage.

The short-term benefits of oral steroids must be weighed up against documented side effects and risks (eg dyslipidemia, hypertension, gastrointestinal upset and weight gain). No study of oral steroid treatment for adhesive capsulitis has been of sufficient duration to report long-term complications but the well-known side effects remain a possible concern (8). Non-steroidal anti-inflammatory drugs (NSAIDS) although of theoretical benefit, have yet to be proven effective in management of frozen shoulder. They are however commonly routinely used in any stage of disease for the analgesic effect and to facilitate both physiotherapy and sleep (8).

Intra-articular Steroid Injection

Intra- articular steroid injection is another conservative treatment option, most commonly utilised during stage 1 or 2 of frozen shoulder. It commonly involves an ultrasound-guided injection of steroids; methylprednisolone acetate or triamcinolone hexacetonide into the joint capsule. The injection is utilised to reduce pain and improve shoulder function (4).

The Uppal et al., 2015 study does not detail recent literature findings regarding steroid injections. It draws upon the 2003 review (9) to conclude that there is at best a small short term benefit to steroid injection alone for frozen shoulder, but that the evidence base is poor. A cost effectiveness analysis for frozen shoulder treatments has also identified that there may be short-term benefit for patients with frozen shoulder of adding a single intra-articular steroid injection to home exercise. There is also short-term benefit for the same population of adding physiotherapy to a single intra-articular steroid injection (6).

These findings suggest intra-articular injections may be more efficacious for pain relief in stage 1 (freezing) or early stage 2 (frozen) before development of a significant capsular contracture, and in combination with physiotherapy. The effects however appear short-lived and will not alter the long-term outcome or progression of the disease (8). Recommendations have also been made to consider re-injecting at 4weeks if pain is not under control, with no more than 3 injections in one year and at least one month between injections (2).

Hydrodilatation

Hydrodilatation or distension arthrography involves the injection of fluid (often saline and or steroids) into the joint capsule, under local anaesthetic. The injection occurs at a high pressure, which distends and stretches the joint capsule and resultantly improves glenohumeral movement. The procedure is non-operative unlike MUA or arthroscopic capsular release, which both require general anaesthesia.

The systematic review of Uppal and colleagues (1), concluded that hydrodilatation is an effective technique for short-term improvements in pain, range of movement and function, but there is no good evidence to suggest any superiority to other treatments. These findings support that of a previous Cochrane review by Buchbinder and colleagues in 2008 (10). The major side effect reported with Hydrodilatation appears to be pain, with most adverse effects primarily related to pain during or shortly after the procedure (1). It concluded that additional high quality studies comparing hydrodilatation to other common treatments, such as arthroscopic capsular release, are needed. It did not include the 2013 Clement study which showed benefits in function and pain maintained long-term (average of 14 months), however the study did not compare with placebo or report benefits in ROM (11). The long term benefit of hydrodilatation still remains equivocal.

Arthroscopic Capsular Release

An arthroscopic capsular release is a procedure performed during phase 2 (frozen) of frozen shoulder under general anaesthesia by an orthopaedic surgeon. Standard anterior and posterior portals (keyholes) are made, diagnosis is confirmed by arthroscopy and following this, part of the synovium (membrane lining the joint) and the tightened joint capsule (coraco-humeral ligament and rotator interval) are released using diathermy. This procedure will vary slightly between surgeon, with some also incorporating a small manipulation. The procedure enables greater freedom of movement of the glenohumeral joint (12).

Overall, the evidence reviewed demonstrates that arthroscopic capsular release appears to be a safe and effective treatment that can provide a rapid improvement in reported shoulder function. Some of the strongest evidence comes from the Smith et al., 2014 study, which also included an intra-articular steroid injection and a controlled manipulation. By week 1, 50% of patients had marked pain relief and 60% had uninterrupted sleep, with further improvements at 6 weeks (12).

MUA – Manipulation Under Anaesthesia

For phase 2 (frozen) or 3 (thawing) of frozen shoulder, this surgical technique requires a general anaesthetic and the shoulder joint is then manipulated to improve shoulder movement. The joint capsule is gently stretched by moving the humerus into flexion, abduction and finally (optionally) by moving the adducted humerus into external rotation (stop sign position). There are risks with this procedure including, humeral fracture, glenohumeral dislocation, rotator cuff tears, glenoid fractures, brachial plexus injuries, labral tears and haematomas (1).

The review concluded that manipulation under anaesthesia has been shown to be an effective treatment. However, the results of manipulation when compared to hydrodilatation and steroid injection are equivocal (1). A 2013 systematic review (13) identified research comparing MUA to arthroscopic release. It concluded that the quality of evidence available is low and to date capsular release demonstrates little benefit instead of, or in addition to, an MUA.

Summary

Frozen shoulder is a poorly understood condition that typically involves substantial pain and movement restriction. Although function improves overtime, full and pain free range of movement, can take years to recover and may not be completely restored in everyone. Recent systematic reviews and research presented above highlight the difficulty in reaching consensus on best treatment pathways for frozen shoulder.

Based on current evidence initial stage 1 (freezing phase) management should involve education, physiotherapy with activities and home exercises based within pain levels, and corticosteroid injection. With the possibility of follow up corticosteroid injections if pain is not well controlled.

Stage 2 (frozen) or 3 (thawing)  management options could then include the conservative procedure of arthrographic distension, followed by more invasive procedures of manipulation under anaesthesia, or arthroscopic capsular release. All have been shown to reduce pain and improve function and range of movement. Current evidence has not able to clearly determine if one method is superior to another.

If you have questions or perhaps comments, or anecdotes relating to frozen shoulder please feel free to leave them in the below comments box.

References:

1. Uppal, H. S., Evans, J. P., & Smith, C. (2015). Frozen shoulder: A systematic review of therapeutic options. World journal of orthopedics, 6(2), 263.
2. Lewis, J. (2015). Frozen shoulder contracture syndrome – aetiology, diagnosis and management. Manual Therapy, 20(1), 2-9. doi:10.1016/j.math.2014.07.006
3. Paul, A., Rajkumar, J. S., Peter, S., & Lambert, L. (2014). Effectiveness of sustained stretching of the inferior capsule in the management of a frozen shoulder. Clinical Orthopaedics and Related Research®, 472(7), 2262-2268.
4. Kelley, M. J., Shaffer, M. A., Kuhn, J. E., Michener, L. A., Seitz, A. L., Uhl, T. L., … & Wilk, K. (2013). Shoulder pain and mobility deficits: adhesive capsulitis: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 43(5), A1-A31
5. 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 of Systematic Reviews 2014, Issue 8. Art. No.: CD011275. DOI: 10.1002/14651858.CD011275.
6. Maund E, Craig D, Suekarran S, Neilson AR, Wright K, Brealey S, et al . Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technol Assess 2012;16 (11).
7. Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev 2006; (4): CD006189 [PMID: 17054278 DOI: 10.1002/14651858.CD006189]
8. Neviaser, A. (2010). Adhesive capsulitis: A review of current treatment. Am J Sports Med, 38(11), 2346-2356. doi:10.1177/0363546509348048
9. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003; (1): CD004016 [PMID: 12535501 DOI: 10.1002/14651858.CD004016]
10. Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD007005. DOI: 10.1002/14651858.CD007005.
11. Clement, R. G., Ray, A. G., Davidson, C., Robinson, C. M., & PERks, F. J. (2013). Frozen shoulder?: long-term outcome following arthrographic distension. Acta orthopaedica Belgica, 79(4), 368-374.
12. Smith, C. D., Hamer, P., & Bunker, T. D. (2014). Arthroscopic capsular release for idiopathic frozen shoulder with intra-articular injection and a controlled manipulation. Annals of The Royal College of Surgeons of England, 96(1), 55-60.
13. Grant, J. A., Schroeder, N., Miller, B. S., & Carpenter, J. E. (2013). Comparison of manipulation and arthroscopic capsular release for adhesive capsulitis: a systematic review. Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons … [Et Al.], 22(8), 1135-1145. doi:10.1016/j.jse.2013.01.010

PAIN-FREE. PERFORM. PROLONG

Lewis Craig (APAM)

Physiotherapist