Frozen shoulder treatments

This reviews of the literature for frozen shoulder treatments was reported in the American journal of occupational therapy, 2011.

Known in medical terms as an adhesive capsulitis, this is a not uncommon presenting complaint in chiropractic clinics. Having a prevalence of about five out of every hundred adults each year, it is a clearly a condition that warrants an investigation into how efficient and cost effective different forms of care are.

This review did not even mention NSAIDs, nor did they find one chiropractic research paper that warranted mentioning, though one study did consider mobilisation.

My own personal, unresearched opinion is that chiropractic is effective but everything is predicated on doing the exercises faithfully, and a dogged determination to avoid surgery, considering the normal course of this condition is two to four years of disability and pain. If it's only thirty percent better with manipulative care after six weeks, say, are you willing to continue?

Man with left frozen shoulder.

Three phases of the UNtreated frozen shoulder

  1. The initial "freezing" phase lasting three to nine months.
  2.   The extreme "frozen" phase lasting typically nine to fifteen months.
  3. A typical "thawing" phase lasting one and a half to two years.

Adding that up, your untreated frozen shoulder would typically take a little over two years at best to recover; at worst about four years.

One study (J of Shoulder and Elbow surgery) revealed that, after four years, only 6/10 patients had full function (normal or near-normal) of the shoulder. 4/10 reported some ongoing symptoms. After four years 6% still had severe pain and functional loss despite treatment.

Disabling and painful

Anyone who has worked with frozen shoulder treatments will know that Adhesive Capsulitis is one of the most painful and disabling conditions to confront the clinician. Serious sleep disturbance is the norm making the patient miserable. Dressing and undressing become extremely painful. Putting on a jacket is particularly painful.

It usually begins after some innocuous activity such as painting a ceiling or drilling above the head; looking upwards appears to be part of the cause.

Although neither anti inflammatory drugs or chiropractic had any research, this frozen shoulder page will give you some idea of the chiropractic management of this extremely painful condition that regular presents in our clinics.

Frozen shoulder treatments

Frozen shoulder treatments compares the effectiveness of conservative and surgical interventions.

1. Oral steroids

Compared with a placebo treatment, four studies found there was no long term significant improvement when measuring disability and pain reduction. One paper did reveal some temporary improvement at three weeks but, after several months, like the other three there were no significant results.

2. Cortico Steroid injections

Three RCTs found that injections into the tendon sheaths, such as the biceps or supraspinatus, the subacromial space or trigger points in muscles brought significant reduction in pain, when compared with a placebo, BUT NO INCREASE RANGE OF MOTION.

A study by Ryans reported in Rheumatology 2005 found no difference between four groups:

  1. corticosteroid injection into the joint plus PT
  2. Injection alone
  3. physiotherapy alone
  4. placebo

These medical interventions were no better than a placebo treatment.

3. Corticosteroid injections vs Physiotherapy

Six studies gave widely varying results, depending presumably on the treatment regimen and experience of the therapists.

  • Four studes revealed significant benefit of injections over PT with, after two years, only external rotation still significantly reduced. PT involved therapeutic exercises or interferential current).
  • One study found that injections + PT was more effective than either injections or PT alone.
  • Two studies found that PT had a more beneficial effect on external rotation at four months than steroid injections.

4. Steroid injections vs Arthrographic distension

Two high quality RCTs gave contradictory results. One found that hydrodilatation gave significantly better results on the range of motion than steroid injections, the other found no difference.

Out of three studies, one found that hydrodilatation plus steroid injections was more effective than the shots alone. The other two found no difference.

One study found that hydrodilatation plus physiotherapy was more effective than PT alone.

Another study found that manual therapy and directed exercises after hydrodilatation was after three months significantly more effective than sham ultrasound after hydraulic arthrographic capsular distension.

In a weak study having no controls, Piotte reported in the American J of Physical Medicine and Rehab 2004 that in a small group of fifteen patients that repeated hydrodilatation with steroid together with a home treatment for frozen shoulder programme which included exercise had a significant improvement after the first two procedures, but no further improvement thereafter.

5. Laser

Three studies report that laser therapy was more beneficial than placebo at 16 weeks (or after 15 treatments) regarding both pain and disability. Range of motion was not specifically mentioned.

However, another double blind RCT by Gingol et al (J of Photomedicine and Laser surgery, 2005) found no benefit.

6. Mobilisation plus Exercise

One high quality Randomised clinical trial found more benefit from exercise and mobilisation than exercise alone, but only in the short term.

In another, deep friction massage combined with exercise was found to be more beneficial that heat and diathermy, improving the range of motion.

High grade mobilisation was found to be slightly more effective that low grade mobilisation, both increasing mobility and lessening disability at one year.

Posterior joint mobilisation with external rotation was found to be more effective than anterior joint mobilisation.

Mobilisation at the end-range, and mobilisation with movement were found to be more effective than mid-range mobilisation at twelve weeks.

Another study found that home exercises frozen shoulder were more effective when combined with manipulation under anaesthetic, than exercises for frozen shoulder alone.

A study by Guler-Uysal and Kozanoglu (2004) provided promising results. A "Cyriax group" of 20 patients were treated with deep friction massage and joint manipulation resulting in significantly increased shoulder flexion, internal and external rotation, and pain reduction, very significantly in a decreased time compared to a standard physiotherapy group using deep and superficial heat treatments.

Vermeulen et al (2006) found that patients responded better to "high-grade" mobilisation than "low-grade" mobilisation in terms of both pain and disability over a twelve month period.

7. Acupuncture plus exercises

One high quality RCT revealed that acupuncture plus exercises was more effective than exercises for frozen shoulder treatments alone.

8. Exercises for frozen shoulder

Diercks and Stevens (J of Shoulder and Elbow surgery) compared intensive physical therapy that surpassed the pain threshold with less aggressive therapy such as active exercises within the painless range, pendulum exercises and easily tolerated activities. Those techniques that passed the pain threshold were found to be less effective. Both groups took more than a year to attain painfree full range of motion.

9. Chiropractic frozen shoulder treatments

It is of course reprehensible that Chiropractic has not produced one high quality study (assuming there was no bias in this literature search), particularly when I consider (from my humble experience) that we can do far better than any of these frozen shoulder treatments would suggest. More about that in a separate article.

Frozen Shoulder causes

* First rib fixation

A first rib fixation and associated anterior and medial scalene spasm is frequently found in an adhesive capsulitis. Key to assessing what is effectively a Thoracic Outlet syndrome is key to the effective treatment of many frozen shoulder treatments.

Adson's test, albeit subjective is the diagnostic test of choice.

Interscalene triangle.

* Cervical rib

Personally, I always thought a cervical rib clinically insignificant, but latterly I have changed my mind.

* Neck extension

One of the frozen shoulder causes appears to be working above the head; for example painting the ceiling or using a heavy tool. Extension of the neck closes down the foramena through which the nerves exit from the spine.

Those with known degenerative arthritis in the neck should exercise great care when looking up.

Frozen shoulder treatments: NSAIDs

No effective studies were mentioned amongst frozen shoulder treatments using NSAIDs. It would appear that there is no place for anti inflammatories (or Chiropractic!) in the management of adhesive capsulitis.

Home treatment for frozen shoulder

There are no proven home treatments but if you are simply unable to afford any treatment I would consider:

  • Alternating ice and heat packs done several times a day.
  • After the heat, ask a family member to massage the shoulder.
  • Then do the exercises in the video above.

Did you find this page useful? Then perhaps forward it to a suffering friend. Better still, Tweet or Face Book it.

Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I have left alone. After seven treatments his pain and stiffness is 50 percent better, and he is happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti-inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He is doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost pain-free. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he is well pleased; sixty-five percent better after three treatments.

5. Mr T is a wise man; he has taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily stroll has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift; he has a short leg.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. X-rays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65-year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88-year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done. 

10. Mr X is a 71-year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a few months ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It is a non-complicated upper cervical facet syndrome, and she is doing well.

12. Mr D is a 38-year old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he could not sleep on that shoulder.

13. Mr D, a 71-year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors should not be treating the elderly most medical sites state but that is so much bunkum.



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