Frozen shoulder: From research to practice

Imagine trying to reach for that last slice of pizza, only to find your shoulder has decided it’s on a permanent vacation. While the term “frozen” might sound appealing for ice cream, it’s far from desirable when it comes to your shoulder!

As physiotherapists, we often feel like detectives trying to crack the case of the stubborn frozen shoulder—except our magnifying glasses are replaced with resistance bands and ice packs. It’s not just the pain and stiffness; the unpredictable progression of frozen shoulder adds another layer of complexity to our approach.

But fear not!

There is research to help guide our assessment and management of frozen shoulder. This is where Physio Network’s Research Reviews come in. By utilising these reviews, physiotherapists can develop a well-informed treatment strategy that incorporates effective exercises tailored to each patient’s stage of recovery. This blog is about how the Research Reviews helped me manage a challenging case of frozen shoulder effectively.

The case

When Mrs. Sharma, a 45-year-old school teacher, first walked into my clinic, she presented with a classic case of frozen shoulder but with an added complication: she had been living with type 2 diabetes for over a decade. Her chief complaint was the progressive pain and stiffness in her left shoulder, which had been steadily worsening over the last six months. She described the pain as a dull ache, rated 7/10 on the Visual Analog Scale (VAS), with sharp spikes at the extremes of motion. The pain was particularly bothersome at night, often disrupting her sleep. ​​Mrs. Sharma’s condition had become debilitating. Everyday activities like dressing, combing her hair, and reaching for objects overhead were nearly impossible. Despite her concern that her diabetes might slow down the rehabilitation process, she was highly motivated to regain her independence and shoulder mobility. Her belief, that diabetes was significantly contributing to her frozen shoulder, was a sentiment many patients with similar comorbidities express.

During the subjective assessment, she revealed a gradual onset of symptoms with no history of trauma. The condition seemed to have developed insidiously, as is often the case with frozen shoulder, especially in diabetic patients. She mentioned that she found some relief through rest and hot packs but noticed that overhead activities and carrying heavy objects greatly aggravated her pain.

On examination, her shoulder’s Range Of Motion (ROM) was significantly restricted. Active flexion reached only 85 degrees, abduction was limited to 75 degrees, and external rotation barely reached 15 degrees. Passive movement showed only slight improvements, with flexion reaching 95 degrees and external rotation improving to 20 degrees. These values were far from the normal ROM for a healthy shoulder. Strength testing using Manual Muscle Testing (MMT) showed her deltoid strength at 4/5, while her rotator cuff muscles, particularly the supraspinatus and infraspinatus, were at 3+/5, accompanied by sharp pain during testing, especially with external rotation.

Management strategies

The initial goal was to manage her pain and gradually restore mobility. According to this Physio Network Review, early intervention is important in the treatment of frozen shoulder. Education and advice was provided to the patient about the condition and about the benefits of sticking to an exercise program as per the Review. Understanding the nature of frozen shoulder helped the patient set realistic expectations and fostered commitment to their treatment plan. It is recommended that when patients are equipped with knowledge about their condition and the importance of compliance with home exercises, they are more likely to engage successfully in their rehabilitation.

Managing frozen shoulder requires a holistic approach that integrates clinical experience with evidence-based practices to ensure optimal recovery. This Research Review supports the effectiveness of combining manual therapy, exercise programs, and education in treating this condition. I started with Grade I and II joint mobilisations, ensuring that we stayed within her pain threshold.

The uncertainty about exercise

When managing frozen shoulder, especially in a patient with diabetes like Mrs. Sharma, there’s undeniable uncertainty surrounding the effectiveness of long-term treatments. As per this Physio Network Review, research has yet to conclusively prove that one approach is superior to another over time. Exercise, in particular, often shows promising results in the short term, offering pain relief and improved mobility, but the long-term benefits remain less clear. Despite this uncertainty, I decided to prioritise exercise in Mrs. Sharma’s rehabilitation, guided by the evidence that, while no single treatment stands out long-term, short-term gains can significantly impact quality of life.

There were several reasons behind this clinical decision. First, exercise is inherently safe and cost-effective, making it a low-risk intervention for managing symptoms early on. It also empowers the patient, giving them an active role in their recovery, which is critical for long-term adherence to any rehabilitation program. Secondly, the short-term benefits of exercise—reducing pain, improving range of motion, and strengthening the rotator cuff—can help break the cycle of disuse and stiffness, offering functional improvements that can be maintained with consistent movement. Lastly, conservative treatment, especially in diabetic patients, must strike a balance between not exacerbating inflammation while promoting healing. Exercise fit this balance by improving joint mobility without overwhelming her system.

In light of the ambiguity, I leaned on the practical, immediate benefits of exercise, tailoring Mrs. Sharma’s plan to her needs while remaining mindful of the broader uncertainty about long-term outcomes. Pendulum exercises, passive-assisted flexion and abduction, and external rotation stretches using a wand along with resistance band exercises were performed to start with as tolerated with time.

Regional interdependence approach

As guided by this Physio Network Review, in addition to focusing on Mrs. Sharma’s shoulder, I also addressed adjacent joints of the shoulder girdle and spine, recognising that frozen shoulder often leads to compensatory movement patterns in these areas. This Research Review highlighted the potential benefits of treating the entire upper extremity and spine, which guided my approach. Through manual therapy, I worked on scapulothoracic and cervical mobility, ensuring that her thoracic spine and scapula remained functional. Functional training and strengthening exercises were introduced to the scapular musculature, while ROM exercises targeted the neck and upper back to correct deficits. This holistic approach helped restore balanced movement and prevent secondary dysfunctions, facilitating a more complete recovery.

Addressing pain beliefs and promoting self-efficacy

Addressing Mrs. Sharma’s pain-related fear and improving her self-efficacy was critical, especially since research suggests that pain catastrophising, muscle guarding, and low self-efficacy can significantly reduce range of motion in patients with frozen shoulder. Guided by this Physio Network Review that emphasised these psychological barriers, I incorporated strategies to help her gradually confront her pain without reinforcing fear-avoidance behaviors. Through education, I reassured her that movement, even when uncomfortable, was not harmful and emphasised small, consistent gains. I set achievable, measurable goals that built her confidence and sense of control over her recovery. Additionally, I used graded exposure to more challenging movements, which helped reduce her muscle guarding and improved her belief in her ability to regain shoulder function. These approaches contributed to increased ROM and better long-term outcomes.

The progress

By the end of four weeks, we saw slight improvements in her range of motion, with her flexion increasing to 110 degrees and abduction to 100 degrees. However, external rotation remained severely restricted. As her pain lessened, I progressed to heavy-slow resistance training and eccentric loading. This shift in focus from purely passive to more active participation was supported by recent evidence in the Reviews, which emphasised the need for strengthening to complement the restoration of mobility in diabetic patients.

Over the course of 16 weeks, Mrs. Sharma showed marked improvement. By this time, her Disabilities of the Arm, Shoulder and Hand (DASH) score had dropped from 65/100 to 40/100, and her Shoulder Pain and Disability Index (SPADI) score showed a 30% reduction in pain and disability. Her range of motion continued to improve, with flexion reaching 150 degrees, abduction 145 degrees, and external rotation increasing to 50 degrees. Strengthening exercises were further progressed to mimic functional tasks, allowing her to comfortably perform overhead activities and other daily tasks that had once been painful.

Wrapping up

As physiotherapists strive to provide effective treatment plans, the importance of research cannot be overstated. Utilising resources like Physio Network’s Research Reviews is crucial in staying informed about the latest findings and evidence-based practices in physiotherapy. These reviews offer insights into various treatment modalities that have been shown to benefit patients with frozen shoulder, helping practitioners make informed decisions tailored to individual needs.

By leveraging this research, physiotherapists can better understand the nuances of frozen shoulder management—recognising when to implement specific interventions such as manual therapy or exercise regimens. Ultimately, these resources empower clinicians to navigate the complexities of treatment more effectively, fostering improved outcomes for those struggling with this challenging condition.

So next time you’re wrestling with a frozen shoulder, remember: while it may feel like an uphill battle, armed with the right research and some humor, you can get your patient back on track—hopefully just in time for another pizza party!

Want to keep up to date with the latest research the easy way? Physio Network has you covered, check out their Research Reviews HERE.