Physical Therapy for Frozen Shoulder
Frozen shoulder is characterized by structural changes in the shoulder joint, primarily thickening of the tissues of the shoulder joint capsule which “freezes” movement and range of motion in the shoulder. Frozen shoulder can result from diabetes, thyroid disease, Parkinson’s disease, or due to a period of enforced immobility of the shoulder due to trauma to the joint, shoulder surgery, or overuse injuries to the shoulder. Physical therapy is the first line of treatment for frozen shoulder and is highly effective in speeding up the recovery process and regaining shoulder mobility at any stage of the condition.
Anatomy of the Shoulder
The shoulder is made up of three bones that form the ball and socket joint: the humerus (upper arm), scapula (shoulder blade), and clavicle (collarbone). The shoulder blade, acromion, and collarbone meet to form the acromioclavicular joint, while the humeral head and the socket (glenoid) meet to form the ball and socket, the glenohumeral joint.
The humerus and the scapula are joined by the rotator cuff muscles and tendons, keeping the humerus tightly in the socket. The socket, or glenoid, is rimmed with the labrum, which is made up of soft tissue cartilage that molds to fit the humeral head.
The shoulder joint capsule, a fluid-filled sac that lubricates the joint and is made up of ligaments that hold bone to bone, surrounds and stabilizes the shoulder joint.
What is Frozen Shoulder?
Frozen shoulder is characterized by structural changes in the shoulder joint, primarily thickening of the tissues of the shoulder joint capsule which “freezes” movement and range of motion in the shoulder. With frozen shoulder, there can be scarring and thickening of the joint capsule tissues, including bursae, tendons, ligaments, and cartilage between the ball and socket joint. The inflammation causes these structures to swell and take up space around the shoulder, preventing normal gliding and mobility of the shoulder joint.
Frozen shoulder affects 3 to 5% of the general population, primarily those between the ages of 40-60. Women experience frozen shoulder at a higher rate than men, most often in the non-dominant shoulder. Frozen shoulder affects 10 to 38% of individuals with diabetes.
The exact cause of primary frozen shoulder is unknown, but secondary frozen shoulder can result from diabetes, thyroid disease, Parkinson’s disease, or due to a period of enforced immobility of the shoulder due to trauma to the joint, shoulder surgery, or overuse injuries to the shoulder.
There are three phases of frozen shoulder with distinct symptoms:
Freezing Phase: The freezing phase can last 3 to 9 months and is characterized by loss of movement and significant pain with shoulder movement. Symptoms often worsen at night.
Frozen Phase: The frozen phase can last 4 to 12 months after symptoms begin. It is characterized by a dramatic decrease in pain, but major shoulder mobility limitations occur, significant stiffness is present, and the individual’s range of motion in the shoulder joint is virtually gone.
Thawing Phase: The thawing phase can last from 12 to 24 months after the start of symptoms. At this point, the patient begins to experience “thawing” of the frozen shoulder with increases in shoulder range of motion and a gradual return to full function in the shoulder and arm.
With frozen shoulder, there is a “capsular pattern” to the loss of mobility in the shoulder: the individual loses range of motion in external rotation (inability to reach overhead) first followed by loss of shoulder flexion and abduction (inability to lift the shoulder) and then loss of internal rotation (inability to reach behind the back).
Physical Therapy for Frozen Shoulder Syndrome
Physical therapy is the first line of treatment for frozen shoulder and is highly effective in speeding up the recovery process and regaining shoulder mobility at any stage of the condition. In 90% of frozen shoulder cases, the condition goes away with time and targeted physical therapy. Surgery is extremely rare for frozen shoulder.
Physical therapy focuses on gently moving the shoulder to maintain as much function as possible during each stage of the condition. Moving the shoulder is essential as resting the shoulder can actually worsen the condition and allow more adhesions to develop around the shoulder capsule.
Physical therapy for frozen shoulder is customized to the stage of the condition in the presenting patient:
Freezing phase treatment: The aim of treatment during this phase is to manage pain, reduce inflammation, and begin manual therapy and gentle stretching to help maintain normal shoulder mobility. The therapist may use heat and ice modalities to relax muscles and relieve pain. Manual therapy involves soft tissue and joint mobilizations of the shoulder to gently improve range of motion. The therapist also implements a gentle therapeutic exercise program to slow down range of motion restriction.
Frozen phase treatment: After inflammation subsides and the shoulder moves into the frozen phase, the therapist focuses on regaining as much range of motion as possible through more intensive mobilizations and targeted therapeutic exercises moving the affected shoulder. The therapist may also implement aerobic conditioning for the whole body, which helps support lubricated and supple joints.
Thawing phase treatment: Physical therapy can speed up the thawing phase of frozen shoulder, helping the patient regain full function, mobility, stability, and strength in the shoulder through targeted strengthening of the shoulder, upper back, and core muscles, manual therapy, and targeted end range of motion exercises. The therapist may also implement proprioceptive neuromuscular facilitation (PNF), a stretching technique to improve muscle elasticity and restore functional activity range in frozen shoulder patients.
Numerous research studies have shown that physical therapy is highly effective in treating frozen shoulder and restoring shoulder function and mobility. A systemic review that assessed 33 studies on physical therapy interventions for frozen shoulder showed improvements in pain, range of motion, and functional arm use after physical therapy. In these studies, physical therapy interventions included various modalities, range of motion and stretching exercises, manual therapy, acupuncture, and biofeedback techniques.
A meta-analysis showed that PNF treatment can also significantly improve the range of motion in patients with frozen shoulder. A systematic review of 39 studies noted that therapeutic exercise and mobilizations are strongly recommended for reducing pain and improving range of motion and function in patients in the frozen and thawing phases of frozen shoulder.
Frozen shoulder can be a debilitating condition that dramatically affects your shoulder mobility. Work with a physical therapist to address frozen shoulder and speed up your recovery!
