1. Evidence Based etiology and Treatment of Frozen shoulder
Jerod Miler

2. Frozen Shoulder Etiology and Pathology1
The precise cause of frozen shoulder is still unclear.
Typically thought of as an inflammatory disorder
Thought process is that some insult to the capsuloligamentous complex initiates a runaway cycle of inflammation and subsequent fibrosis.
Patients with frozen shoulder exhibit elevated levels of cytokines, an important part of the inflammatory process.

3. Frozen Shoulder Etiology and Pathology1
The idea inflammation idea has been challenged
Multiple studies found no significant evidence of inflammatory cells in tissue samples.
Some investigators have visually seen and described synovitis, while others have found angiogensis and even evidence of nerve propagation.

4. Classification of Frozen Shoulder1,2
JOSPT has two classification systems for patient’s with frozen shoulder.
Degrees of irritability
High, Intermediate, and low
Stages of frozen shoulder progression
Pre-adhesive, Adhesive, Frozen, and Thawing phases

5. Irritability Levels

6. High Irritability1,2 High pain levels
7+/10 pain reported
Constant night and/or resting pain
High levels of disability reported on outcome measures
Pain occurs before end-range in both AROM and PROM
AROM is less than PROM due to pain

7. Intermediate Irritability1,2
Patient reports 4-7/10 pain ranges
Intermittent night and/or resting pain
Moderate levels of disability reported on outcome measures
Pain occurs at end-range of movements
AROM is similar to PROM

8. Low Irritability1,2 Minimal levels of pain reported
No night or resting pain
Outcomes measures report low level of disability
Pain occurs with overpressure past end-range
AROM is the same as PROM

9. Stages of Frozen Shoulder

10. Stage 1: Pre-adhesive Stage1
Duration: 0-3 months
Pain with active and passive ranges of motion
Limitations begin to manifest at end-range flexion, abduction, IR, and ER
Patient’s are often misdiagnosed with shoulder impingement.
Only slight limitations of ROM when patient is under anesthesia
Synovitis is typically seen during arthroscopy.

11. Stage 2: Freezing Stage1 Duration of 3-9 months
Chronic pain with active and passive range of motion
ROM deficits in flexion, abduction, IR, and ER are significant
ROM is essentially the same when under anesthesia as when the patient is awake.
During arthroscopy, capsule is found to be tight, with rubbery end-feel.

12. Stage 3: Frozen Stage1 Duration 9-15 months
Minimal pain except at very end-range of motion.
Significant ROM loss with ridged end-feel.
ROM is the same under anesthesia as when awake.
Arthroscopic findings
No hypervascularity, remnants of fibrotic synovium, diminished capsular volume, capsule is thick and full of scar tissue.

13. Stage 4: Thawing Stage1 15-24 month duration Minimal pain
Severe capsular restriction but ROM can gradually increase due to lack of pain.

14. Evidence of Treatment Methods

15. Stretching Exercises
Stretching exercises do affect pain and increase ROM
May not be more beneficial than other methods
No consistent evidence has determined the optimal duration, intensity, and frequency for stretching interventions2
JOSPT recommendations state that stretching intensity should be related to irritability level
Low duration, low intensity, pain free AAROM with high irritability
Longer duration, higher intensity for low irritability1
Poorer outcomes are paired with stretching beyond painful limits2
JOSPT recommendation level: B, moderate evidence

16. Joint Mobilizations
There is some evidence that it may help improve outcomes
Little evidence to prove efficacy over other interventions
May be used to increase physiological motions at the GH2
Recommendations are similar to stretching
Low-grade (I &II) should be used during high irritability
High-grade (III&IV) should be used during low irritability
JOSPT recommendation level: C, weak evidence

17. Patient Education
The insidious nature of frozen shoulder can be hard for patients to understand and can be frightening to them.
Adequate descriptions and explanations of the stages of the pathology can help adequately prepare them for their long recovery process.
Physical therapists are recommended to:
Explain the process and stages of frozen shoulder
Promote activity modifications of functional, pain-free motion.
Explain the matching of treatment intensity to irritability levels
JOSPT recommendation level: B, moderate evidence

18. Modalities
Heating and electrical modalities theoretically have applicable effects on pain for this population
Difficult to assess individual efficacy of each modality
Usually applied to adjuncts of other treatments
Ultrasound
Evidence is mixed on the efficacy1,2

19. Modalities cont. Superficial heat TENS concurrent with stretching
Has been shown to relax muscles and in theory could help with muscle guarding1
More recent studies have shown no improvements for target population
Short wave diathermy showed more promising outcomes2
TENS concurrent with stretching
May be used to blunt pain response in irritable patients1,2
JOSPT recommendation level: C, weak evidence

20. Corticosteroid Injection
Administered to blunt inflammation of frozen shoulder
Some studies hint that muscle guarding may be primary mechanism for ROM restriction in early cases
Research shows that patients that receive intra-articular corticosteroid injections in conjunction with mobility and stretching showed the best short term outcomes
Correlation less strong for long term
JOSPT recommendation level: A, strong evidence

21. Proposed Treatment Guidelines1,2
High Irritability
Mod. Irritability
Low Irritability
Modalities
Heat/Ice/Electrical stimulation
Heat/Ice/Electrical Stimulation
None
Activity Modification
Yes
ROM/stretch
Short duration (3-5s) pain-free passive AAROM
Short duration (5-15s) passive, AAROM, and AROM
End range/overpressure, increased-duration, cyclic loading
Manual
Low-grad mobilization
Low to high-grade mobilization
High-grade mobilization/sustained hold
Strengthening
Low to high resistance end-ranges
Functional activities
Basic
High demand
Patient education
Other
Intra-articular steroid injections

22. Questions

23. References
Kelley M, McClure P, Leggin B. Frozen Shoulder: Evidence and a Proposed Model Guiding Rehabilitation. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. n.d.;39(2): Available from: Science Citation Index, Ipswich, MA. Accessed July 11, 2016
Kelley, Martin J., et al. "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 (2013): A1-A31.