A frozen shoulder, medically termed adhesive capsulitis, is a condition characterized by stiffness and pain in the shoulder joint. The connective tissue surrounding the joint, known as the shoulder capsule, thickens and tightens, severely restricting movement. Physical therapy (PT) is the primary non-surgical treatment recommended for managing this condition. PT aims to reduce pain and restore the shoulder’s full range of motion.
Understanding Frozen Shoulder and Its Stages
Adhesive capsulitis is defined by the inflammation and subsequent scarring of the glenohumeral joint capsule. This process causes the capsule to shrink and adhere to itself, leading to a profound loss of both active and passive shoulder movement. The condition progresses predictably through a series of phases, which dictate the appropriate therapeutic approach.
The first phase is the Freezing Stage, or painful phase, which can last from two to nine months. During this period, pain gradually increases, and movement progressively becomes more limited. This stage is marked by high irritability, and aggressive movement can worsen the inflammation.
Following this is the Frozen Stage, or stiff phase, which typically lasts between four and twelve months. Pain often begins to subside, but stiffness reaches its maximum, making simple daily tasks difficult. The final phase is the Thawing Stage, where the shoulder’s motion slowly begins to return. This recovery phase can be lengthy, often lasting from six months up to two years.
The Goal of Physical Therapy
The goal of physical therapy is to manage symptoms and guide the shoulder through its natural recovery timeline. PT helps reduce the overall duration of the condition, which can otherwise take up to three years to resolve spontaneously. The approach must be specific to the stage of the condition to be effective.
In the initial freezing stage, the primary purpose is pain management and preventing further irritation of the inflamed capsule. The focus shifts in the later stages to restoring the full range of motion (ROM) and improving joint function. By addressing pain and stiffness at the appropriate times, PT minimizes the risk of permanent loss of motion. An individualized, phased rehabilitation program is a central component of treatment.
Key Techniques and Approaches Used in PT
Physical therapists employ specific techniques tailored to the patient’s current stage. During the painful, Freezing Stage, treatment prioritizes gentle range of motion exercises and pain-relieving modalities. Techniques include passive and active-assisted range of motion exercises, such as pendulum swings, which keep the joint moving without provoking inflammation. Heat or ice application is often used to relax muscles and reduce discomfort before and after exercise.
As the patient moves into the Frozen and Thawing Stages, the focus shifts to more aggressive stretching and manual therapy. The therapist introduces joint mobilization techniques to help break up adhesions and stretch the tight joint capsule. Home exercise programs are intensified to include longer-duration stretching holds and exercises like wall slides and pulley stretches. Once sufficient range of motion is achieved, strengthening exercises are added to rebuild muscle strength lost due to disuse.
When Alternative Medical Interventions Are Necessary
While physical therapy is the mainstay of treatment, medical interventions may be necessary to facilitate progress or address severe cases. Corticosteroid injections are often used early in the freezing stage to manage intense pain and inflammation. Injecting a steroid directly into the joint calms inflammation, allowing the patient to participate more effectively in physical therapy. Evidence suggests that injections combined with a home exercise program are most beneficial when symptoms have been present for less than six months.
For cases that do not respond to months of dedicated physical therapy and injections, more invasive options are considered. Hydrodilatation is a procedure where sterile fluid is injected into the joint capsule to stretch and break up scar tissue. Surgical intervention, such as manipulation under anesthesia (MUA) or arthroscopic capsular release, is reserved as a last resort. MUA involves forcibly moving the shoulder while the patient is unconscious to tear the restrictive scar tissue. Arthroscopic capsular release is a keyhole surgery where the surgeon cuts the tightened parts of the joint capsule.