Managing Shoulder Pain & Stiffness: Updated Treatment Approach to Frozen Shoulder Contracture Syndrome

[Peak PT Administrator 0]

  

 

Peak Performance Physical Therapy & Sports Training

 

EVIDENCE-BASED PRACTICE UPDATE

February 2021

 

Managing Shoulder Pain & Stiffness:  Updated Treatment Approach

 to Frozen Shoulder Contracture Syndrome

 

WHAT WOULD YOU DO?

A 47yr old female with 5 mo h/o a shoulder overuse episode from painting her ceilings and trim that was  followed by tennis OH serve lesson for 60min two days later.  She developed shoulder soreness within hrs of her lesson that did  not resolve over the next several weeks, causing limited elevation and reaching ADL.  She noticed by the 3 month mark she was unable to fully reach overhead, behind her back, or out to the side, assuming her pain and limitations  confirmed a tendonitis.  

 

Physical Exam showed AROM painfully limited to 1200 flexion, 500 ext, Abd ER 600, and IR to S2.  Isometric screening shoulder was painful and weak especially for Jobe, Abd’d IR & ER, and Abd.  Tender at supraspinatus insertion > LHB tendon.  (+) Neer’s and Kennedy’s tests.  PROM 600 ext.   

 

Which test would be key in determining whether the patient has RC tendinopathy vs frozen shoulder contracture syndrome?

1. AROM horizontal adduction

2. PROM Abd ER

3. Abduction AROM

4. Isometric flexion

 

SUMMARY:            

Duenas et al demonstrate in 11 patients with frozen shoulder contracture syndrome (FSCS) that once weekly manual therapy customized to their acute condition/status combined with 5 d/wk HEP stretching results in significant gains in measures of pain, self-rated disability, ROM and strength impairment measures following 12 wks of the program as well as at 6 and 9 month follow ups.   Reeves et al in a recent systematic review showed that complete resolution without treatment is unfounded.  Clinically it’s critical to identify these cases early - an often missed key differential diagnosis finding for FSCS is PROM not signficantly higher than AROM. Many other studies have supported the contention that BIW manual therapy/joint mobilizations is effective in these cases.  Our experience has certainly found faster and more substantial ROM gains leading to reduced sx and better function gains with BIW over once weekly sessions.  A key finding of this study was confirmation that customizing mobilization intensity/type etc with symptom status/responsiveness is effective.  

 

 

CURRENT EVIDENCE

Lirios Duenas, Merce Balasch-Bernat, et al.  A Manual Therapy and HOme Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series.  J Orthopedic & Sports  PT 2019: 49 (3): 192- 200 

 

Background: Manual therapy has been a key factor to reducing pain and improving function in patients with frozen shoulder contracture syndrome (FSCS), however there is no one form of manual therapy that has been proven more beneficial over another. This series provides short and long term outcomes of specific impairments and level of tissue irritability in patients with FSCS. 

 

Methods: Eleven patients selected by an inclusion criteria were treated with an individually tailored, multimodal manual therapy approach of PT once a week for 12 visits, coupled with a home stretching program once daily, 5 days a week.  Pain, disability, range of motion (ROM) , and muscle strength, of the affected shoulder, were measured at baseline,post treatment, at 6 months and 9 months.

 

Results: Significant improvements in self reported pain, disability, shoulder ROM, and strength post treatment , 63.6% of the patients improved in their overall disability scores, 36% of patients pain improved exceeding minimal clinically important difference ( MCID)  and 72.7% of patients pain improved at 6 and 9 months post treatment. 

 

Author’s Conclusion:  Significant clinical changes were seen in pain, disability, ROM, and muscle strength with a multimodal and tailored approach of both manual therapy techniques and stretching exercises. 

 

 

THE PEAK PERFORMANCE PERSPECTIVE

Rachele Jones, PTA, ATC, CAFS

 

As a physician, that first exam opportunity of a painful, stiff shoulder has significant implications on treatment orders.  While Physical Therapy is an appropriate starting point for a RC tendonitis/tendinopathy case, it would be projected to have an earlier positive outcome and manual therapy may or may not be a necessary component of treatment in comparison to someone with FSCS.   For FSCS,  PT orders will most definitely include manual therapy specifically.   This is important because too often literature has suggested that “frozen shoulder” is a self-limiting condition that  may/will spontaneously resolve  within 1-2 years on its own.  Other studies have suggested that PT is questionably effective.  

 

As clinicians we know that FSCS, also commonly termed adhesive capsulitis, lacks a definitive cause but is more likely to develop for primary risk factors such as: 40-60 y.o, female, has diabetes or thyroid disease, or secondary complications of shoulder surgery or shoulder injury (ie: humeral fx, biceps tendon repair etc).  Classic signs of FSCS are significant pain and range of motion loss ( ROM) where PROM or AROM with overpressure are comparably limited to AROM.  

 

One critical criteria that is easily overlooked during an examination, which is the best indicator of diagnosis to differentiate between a tendonitis and FSCS is PROM. Typical shoulder tendonitis presentation typically would reveal PROM > AROM.  Errors here could result in a provider recommending temporary sling use, rest + med’s, or not recognizing the need to order manual therapy techniques.  While this may seem a  routine consideration we see a surprising number of FSCS cases from prior “failed” therapy where little or no manual therapy was done outside of simple PROM overpressure.    

 

A recent systematic review by Reeves B. et al,  The natural history of the frozen shoulder syndrome. Scand JRheumatol. 1975;4:193-196, https://doi.org/10.3109/03009747509165255,has reported early improvements in shoulder ROM with treatment and found that long term complete resolution back to normal without treatment is unsupported.    And we can’t forget that  Increased ROM can effect the reduction of pain however it does not always  immediately result  in optimal function.   That  may take more time and integration of ROM ease with strengthening stimuli. 

 

This article uniquely emphasized a multi-modal use of manual therapy, similar in concept to what we use at Peak Performance, based on the patient’s most recent symptom responsiveness.   Most studies have simply applied the same grade and type of mobilization to all shoulders - possibly limiting the results.  The home stretching program used the same “current irritability status” to guide stretching doses.  

 

The study by Duenas et al, despite the small population size, shows both good HEP compliance and a high success rate with customizing each patient's program of manual and HEP together. It was interesting that the authors did not specify whether the patients performed HEP stretching within some specific window of time after the once weekly PT visits.  At Peak Performance we definitely find that immediately post-mobilizations is best for PROM and neuromotor integration AROM work to be done.  

 

Certainly in FSCS cases there are other areas often needing attention...thoracic spine extension, pectoralis minor hypertonus and shortening, 1st rib mobility.  While this study did not address these it should be expected in a well rounded manual therapy approach.  

 

PEAK PERFORMANCE EXPERIENCE

Chris said:  “ My ROM is getting better.  I hit tennis balls for about 15 minutes.  I was  surprised I tolerated it fairly well.”   

 

History: 53 y.o. female with symptom onset over 1 year ago lifting something overhead -  then exacerbated 4 mo ago playing paddle tennis and the last month was worsening further regarding  pain, ROM, weakness, and function limitations.  

 

Subjective:  7/10 intermittent pain 2x/wk , ADL’s limited ie: bra strap, taking care of son with special needs. 

 

Objective:  

 

* = sx 

 

R shoulder	Eval	ReEval 5 wks ( 7x @ BIW )
Quick Dash	69%	38%
Self rating Overall	50%	70%
AROM  / PROM:            Flexion	1300 */ 130*	1440
Horiz Abd	1250* / 125 *	550
Abd ER	650 */NT	1050
ER n	65  * /NT	65 deg *
Abd  IR	50	220
IR “applye’s scratch test”	L2 *	L1 *
Pec Minor	max limitation	mod
Thoracic Rot L/R	35 0 /350	420 /450
Isometric Flex	2.5 kg *	3.3 kg *
ER	4.2kg *	5.8kg*
IR	4.4 kg *	6.2 kg*
Function Testing  3# Abd	120 *	140 *
Lateral reach	23” *	30” *

 

Treatment: Joint mobilization of shoulder, soft tissue release of pec minor;   AROM, AAROM, PROM, resistance training, and eventually began speed/power training for  functional  racquet  sport return.    

 

Discharge ReEvaluation: Pt was discharged prior to full recovery due to extenuating circumstances with family responsibilities. Pt was still in need of formal care but was advised to continue with her HEP.  She showed increased ROM, increased strength, decreased symptoms and was able to get back to paddle tennis for at least 15 mins with very limited symptoms.