Frozen shoulder: evidence and a proposed model guiding rehabilitation

Abstract

Frozen shoulder or adhesive capsulitis describes the common shoulder condition characterized by painful and limited active and passive range of motion. The etiology of frozen shoulder remains unclear; however, patients typically demonstrate a characteristic history, clinical presentation, and recovery. A classification schema is described, in which primary frozen shoulder and idiopathic adhesive capsulitis are considered identical and not associated with a systemic condition or history of injury. Secondary frozen shoulder is defined by 3 subcategories: systemic, extrinsic, and intrinsic. We also propose another classification system based on the patient's irritability level (low, moderate, and high), that we believe is helpful when making clinical decisions regarding rehabilitation intervention. Nonoperative interventions include patient education, modalities, stretching exercises, joint mobilization, and corticosteroid injections. Glenohumeral intra-articular corticosteroid injections, exercise, and joint mobilization all result in improved short- and long-term outcomes. However, there is strong evidence that glenohumeral intra-articular corticosteroid injections have a significantly greater 4- to 6-week beneficial effect compared to other forms of treatment. A rehabilitation model based on evidence and intervention strategies matched with irritability levels is proposed. Exercise and manual techniques are progressed as the patient's irritability reduces. Response to treatment is based on significant pain relief, improved satisfaction, and return of functional motion. Patients who do not respond or worsen should be referred for an intra-articular corticosteroid injection. Patients who have recalcitrant symptoms and disabling pain may respond to either standard or translational manipulation under anesthesia or arthroscopic release.

Level of evidence: Level 5.