If your shoulder gradually begins to lock up on you, making most movements painful and stiff, there's a chance you are dealing with frozen shoulder. Otherwise known as adhesive capsulitis, this condition often comes on out of the blue, although it can also occur after a trauma like a fall or surgery. This can be a very frustrating condition that mostly affects women between 45-65 years of age and can last 9 -24 months. But knowing how to treat it can greatly reduce the time you spend in pain and dysfunction, and even help you avoid painful or risky procedures. Fortunately, some very recent studies help shed some light on what works best.
First, a little more background on this unique shoulder condition.
What is Frozen Shoulder?
Frozen shoulder occurs when the shoulder capsule starts sticking to itself. This prevents the capsule from extending, causing pain and a gradual restriction in range of motion. Treating this condition is a big challenge and diagnosing it is even more challenging.
But going through it is the real problem for several reasons. First, it can be frustrating having a condition where you often don't know how or why it developed. Second, knowing the condition can limit you for up to a year can be daunting. Third, suggestions for treatment vary between surgery to physical therapy, to doing nothing.
What Works To Fix Frozen Shoulder?
Fortunately, there is an excellent landmark study published recently that for the first time compares the most common treatments for frozen shoulder to see what works. Researchers in the UK designed a randomized control study to compare surgery (capsular release) plus PT, manipulation under anesthesia plus PT, and 12 Weeks of PT only for treating adhesive capsulitis. All participants also had a cortisone injection.
At 12 months, there were no differences in outcomes: all groups had improved to achieve the same level of function and pain. However, several people in the surgery and manipulation group experienced adverse effects, while none in the PT group did. Thus, PT was just as effective and lower risk compared to the other treatments. (Rangan A, et al. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicenter, pragmatic, three-arm, superiority randomized clinical trial. Lancet. 2020 Oct 3). While many studies have shown PT to be effective, and some in combination with an injection, this is the first to directly compare PT with surgery or manipulation.
This provides some clarity to what can seem to be a murky situation for those trying to decide what is the best course of action to fix their frozen shoulder. The recent evidence supports what I have seen in the clinic and what other research has shown: using physical therapy alone is likely the best way to fix frozen shoulder.
Do You Have Frozen Shoulder?
But there is another vital reason to start with physical therapy: the diagnosis. Determining whether you have frozen shoulder in the first place is a huge challenge for even the most experienced shoulder specialist.
Fortunately, my colleagues have an unusually high amount of experience diagnosing adhesive capsulitis. This is partly due to seeing it dozens of times over the last couple decades and knowing what to look for. But it is also due to an important luxury uniquely afforded to PTs versus other practitioners: Time!
PTs have more time to do an involved exam, plus we can repeat it several times a week and assess reactions to treatment. This is important because it is really difficult to get a proper diagnosis in just one 20-minute exam. Adhesive capsulitis can present with similar findings as other conditions, such as rotator cuff tears or cervical radiculopathy.
And imaging like x-rays and MRI can make things even more complicated. Such imagining will often show arthritis and tears in over 50% of people that don't have any pain or limitation so it's possible that someone with adhesive capsulitis will be misdiagnosed as a rotator cuff tear. This could be a big problem, leading to someone undergoing a surgery to "fix" something that wasn't a problem in the first place. Also, frozen shoulder plus rotator cuff rehabilitation is quite painful and difficult. In fact, surgery can often trigger one type of frozen shoulder (secondary adhesive capsulitis). One of the distinguishing factors of frozen shoulder is that the pattern of range of motion restriction is unique.
For example, most with frozen shoulder will be restricted with internal rotation (reaching your bra strap), external rotation (reaching the seat belt), and reaching out to the side. This limitation is found with both passive AND active motion as the rotator cuff is not the cause of the problem. Another distinguishing factor is that strength remains relatively high and pain free in the early phases in those with frozen shoulder.
In contrast, those with rotator cuff issues will have greater passive motion. This is because the rotator cuff is involved in active motion but does not restrict passive motion. Also, those with rotator cuff problems test as weak and painful as the irritated rotator cuff is not able to produce normal force.
Cervical problems can be differentiated from adhesive capsulitis as movements of the neck will reproduce the shoulder pain and a neuro exam will often reveal deficits. Several other factors in a thorough exam performed by a specialist in both cervical and shoulder disorders will distinguish a frozen shoulder from these conditions.
So, it is very important to get the diagnosis right, and the best environment to do so is during PT. At the very least, you can learn some important self-management strategies about frozen shoulder and become informed about what to expect from this condition. At best, and most likely, PT will resolve the condition completely. The good news is that, in our experience, frozen shoulder can resolve in a much shorter timeline with proper PT compared to the usual 9-24 months. Also, no matter what treatment you pursue, full recovery is very likely.
But there is a very important distinction between treatment options that rarely is discussed: preserving strength of the involved arm as well as health and fitness of the rest of the body.
How to Properly Treat Frozen Shoulder
Unfortunately, many are led to believe that when they have frozen shoulder, they should rest and protect that arm, and by association, avoid upper body exercise. Evidence shows that this is not the case. In fact, adding rotator strengthening exercises to the effected arm resulted in superior outcomes compared to those who did not. (Rawat P, et al. Effect of rotator cuff strengthening as an adjunct to standard care in subjects with adhesive capsulitis: A randomized controlled trial. J Hand Ther. 2017 Jul-Sep;30 Also, dozens of studies have proven that training the unaffected arm will have positive effects on the effected arm. This is known as the cross over effect. While one arm may be strong or tolerate more range of motion, both arms should be trained, and can be trained separately to accommodate for these differences.
For example, instead of a pushup, you can do a 1 arm dumbbell press with separate weights. Or instead of a pull down with a bar, you can do single arm pull downs with a handle. And of course, all aerobic, core, and lower body exercises can be modified and should be continued.
Having some help with making these modifications and encouraging continued participation with a comprehensive exercise program is a vital, but often forgotten advantage of seeking physical therapy care compared to all other options. Too often, the pain and inconvenience of an orthopedic problem is compounded by the side effects of general deconditioning. This can be avoided with proper physical therapy care.
Here's What To Do If You Think You Might Have a Frozen Shoulder:
- Make sure you get a firm diagnosis. This is best done by a physical therapist that specializes in shoulders with a keen ability to differentiate adhesive capsulitis from rotator cuff and cervical radiculopathy.
- Once the diagnosis is confirmed based on a clinical exam (not imaging), focus on physical therapy treatment that involves manual PT and exercise that targets the shoulder but also teaching modifications to a general exercise program.
- Also, consider augmenting physical therapy with a corticosteroid injection.
- Avoid manipulation under anesthesia and surgical release, as the evidence does not show this is more effective, yet it carries significant risks.
- While typical cases can take between 9 and 24 months, expect that timeline to be made shorter by proper PT.
- Finally, although this is a frustrating and painful condition, be assured that the overwhelming majority will make a full recovery.
Reach out if you suspect you have adhesive capsulitis to get proper treatment by clicking here.
If you have already had physical therapy for frozen shoulder and are looking to get your arm strong again without getting hurt, click here.
