Management of Frozen Shoulder

• Frozen Shoulder Management:

  • primary aim: reduce pain and restore range of motion (especially in the earlier phases)
  • restoring range of motion is desirable but can be a challenge with frozen shoulder - it can cause a high level of discomfort to your patient with very little gains or rewards
• Frozen Shoulder Management:

  • research suggests in short term, conservative treatments are no better than placebo injections
  • conservative rehabilitation:
  • gentle and specific shoulder joint mobilisations and stretches
  • muscle release techniques
  • acupuncture and dry needling
  • exercises to regain range and strength, such as
  • isometric strengthening in all ranges
  • theraband exercises in all planes
  • scapular stabilisation exercises
  • advanced muscular strengthening with dumbbells
• Frozen Shoulder Management:

  • Pain management:
  • anti-inflammatory medications
  • corticosteroid injections to reduce inflammation and pain
  • local anaesthetics to reduce pain and improve motor control
• Frozen Shoulder Management:

  • depending on the symptoms and phase of frozen shoulder, you can integrate motor control exercises
  • Motor control exercises help with:
  • restoration of normalised recruitment patterns of muscles
  • balanced recruitment of agonist, antagonist and synergist of shoulder muscles
  • appropriate level of muscle recruitment for low and high loads
• Frozen Shoulder Management:

  • Patient Education:
  • emphasising that full range of motion may not recover, but condition will spontaneously resolve and stiffness will reduce with time
  • creating appropriate home exercise programme (HEP) thats easy to comply with
  • encouraging daily exercise to relieve symptoms
• Frozen Shoulder Management:

  • Other interventions:
  • mobilisation with movement (MWM) techniques - shown to be effective in reducing pain and improving range of motion
  • heat or cold therapy to reduce pain, muscle spasms and stiffness
• Frozen Shoulder Management:

  • goal of conservative management is to reduce pain, improve range of motion and restore function, rather than to completely eliminate the condition
• Frozen Shoulder Management:

  • restore range of motion any way you can - particularly in external rotation and abduction
  • manual therapy/exercises/gentle stretches
  • patient needs to be compliant with moving the shoulder, especially at home - need to move even into those extreme movements, even if theres a slight pain and discomfort
  • basic strengthening with improving range - strengthen muscles that have been weakened due to disuse
• Frozen Shoulder Management:

  • if conservative treatment fails, other options pt 1:
  • corticosteroids/painkillers to try stop the chronic inflammatory cycle
  • oral corticosteroids and/or intraarticular steroid injection
  • ? best option short term, but insufficient evidence of efficacy with physiotherapy
• Frozen Shoulder Management:

  • if conservative treatment fails, other options pt 2:
  • capsular distension - pumping fluid into the capsule, usually with an anaesthetic and steroid, to try break down adhesions, which allows greater glenohumeral movement - usually first line of attack
  • manipulation under anaesthetic - arm is moved into external rotation and abduction in all directions to try and tear and break some adhesions
  • arthroscopic capsular release or open capsular release - cuts capsule to increase mobility
• Frozen Shoulder Management:

  • if conservative treatment fails, other options pt 3:
  • even after adhesions are broken, you'll get new ones with the evolution of frozen shoulder, so its important to maintain and to push through those pain barriers, to try and keep pts going and maintaining some mobility and flexibility
• Frozen Shoulder Management:

  • if conservative treatment fails, other options pt 4:
  • with all the other options, physiotherapy should follow immediately afterwards to improve effectiveness of treatment/procedures
  • stretching
  • heat
  • gentle ROM
  • mobilisation techniques
  • integrate strengthening exercises into routine, even if primary aim is ROM, you want to strengthen within available range and start to integrate isometrics in different positions
• Frozen Shoulder Management:

  • advice & education
  • slow progression/painful/encouragement/controlled
  • need for compliance in exercising
  • symptom control
  • analgesia mostly - NSAIDs, codeine based meds
  • avoid supports and immobilisation as you want to encourage movement as much as possible
  • build capacity
  • regain range - stretching, manual therapy
  • add strengthening as range increases
  • isotonic if possible, small range, gradually increasing
  • return to function
  • specific to individual
  • final acceptable outcome may be individualised
• Management strategies for frozen shoulder:

  • contract relax involving external rotation - causes muscle to be switched on and off and going further into the stretch - good stretch for the rotators
  • progress stretching in external rotation
  • sleeper stretch in internal rotation - targets external rotators of shoulder
  • active assisted abductions rolling arm along ball