Non-surgical treatments for Frozen Shoulder – Adhesive Capsulitis

Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida

Shoulder Adhesive Capsulitis – Frozen Shoulder Treatment

A typical new patient will come into our Oak Park or Ft. Myers clinic. They will sit on the examination table and they will tell us a story that sounds something like this:

“I have a frozen shoulder. It is not getting better. My doctor and my physical therapist tell me that if I do not treat it, it will probably go away by itself. It may be in a few months, in a few years, but maybe not at all. Physical therapy has helped me, but I yo-yo, some days my shoulder feels really good, some days it does not feel that good, some days it is really very painful.”

“I do a lot of exercises at home to keep my shoulder mobile and keep the range of motion from getting worse. I did not like my continued care choices the doctor and my therapist were offering. More painkillers, more anti-inflammatories, more physical therapy, the schedule of 2-3 times a week is more than I can keep. I have been offered cortisone which I would like to avoid unless absolutely necessary and I have been offered to be put under (manipulation under anesthesia), but I did not like the risks my doctor told me about and she told me the frozen shoulder may just come back again anyway. I am looking for something to help me on a more permanent basis.”

There are some people with Adhesive Capsulitis of the shoulder, or more commonly a “frozen shoulder,” who get great benefit from cortisone injections, ART or Active Release Therapy, chiropractic manipulations, and sometimes no treatment at all, the problem “thaws,” out. These are not the people we see in our clinics. We see the people for who treatments have not helped their frozen shoulder and they are thinking about manipulation under anesthesia or shoulder arthroscopic surgery and are exploring other options. Or simply we see people like this, where frozen shoulder has become a long-term problem

I have had frozen shoulders for over four years, it is not better it is getting worse. I still have very limited mobility in my shoulders. I can’t get my hands over my head. No matter how I move my arms, my shoulders hurt.

What caused your shoulder to freeze is open to debate

In our experience, we have seen many patients whose shoulder adhesive capsulitis or frozen shoulder started with a rotator cuff injury. This then developed into a rotator cuff tendinosis or tendinopathy of the rotator cuff tendon. Other people have no idea what caused this shoulder problem. Over time their shoulder hurt. They would get up in the morning with pain reach for some aspirin or Advil or Tylenol and be on their way hoping that their shoulder would not be a problem all day long. The common term adhesive capsulitis refers to scar tissue that forms inside a joint due to lack of movement. In the simplest terms, “use it or lose it.” If you do not move your shoulder through its normal range of motion, you may lose your ability to do so.

  • Research suggests that frozen shoulder can simply appear spontaneously without a cause. It may disappear in that same fashion.
  • Immobilization following an injury or surgery is also speculated.  Many people come into our office after prolonged periods of shoulder immobilization. The capsule of tissue surrounding his/her shoulder is inflamed and shrink. This is what causes a very painful condition and to have an extremely limited range of motion. The pain may have died down after a few weeks or months but their lack of range of motion continued.

Frozen shoulder appears to occur in three main phases:

  • In the first stage, shoulder pain increases with movement and gets worse at night. As the pain increases, so does the loss of motion. This phase usually lasts 2 to 9 months.
  • During the second stage, the arm may be easier to move, but the range of motion is limited – close to 50 percent less than the other arm. This phase may last 4 to 12 months.
  • The third stage involves a resolution of the condition. Over a 12 to 24-month period, the sufferer will experience gradual improvement in the mobility of the shoulder. However, treatment is usually necessary to achieve proper motion.

As controversial as the origins of shoulder adhesive capsulitis are, so are the treatments. Especially treatments that may make a patient’s shoulder worse.

For some people, surgery is necessary and there will be good improvement. This was reported by the Orthopaedic Research Institute, St George Hospital Campus, University of New South Wales, in their study, reported in the Journal of shoulder and elbow surgery (1).

In the journal Pain Physician, doctors noted that some patients will move onto a shoulder nerve block if surgery or other treatments are not successful.(2

A 2016 study recommended that some patients may “get away” with a cortisone injection that will offer temporary relief.(3). A July 2019 study suggested while “no therapeutic intervention is universally accepted as the most effective treatment for adhesive capsulitis. An intra-articular corticosteroid injection with a suprascapular nerve block (SSNB), may help with pain and restoration of shoulder range of motion.(4) Again, we like to point out that these may be effective treatments for many people. These are not the people that we see in our office. We see the people who have had nerve blocks and cortisone that helped temporarily with their frozen shoulder problem but the underlying problem of shoulder instability and weakness remains.

Other treatments for frozen shoulder include shoulder exercise, manual therapy, and anti-inflammatory or NSAIDs which have been shown to produce short-term pain benefit, but both have been shown to result in long-term loss of function and even more chronic pain by inhibiting the healing process of soft tissues and accelerating cartilage degeneration.

Particular in arthroscopic frozen shoulder procedures is a significantly worse result in diabetic patients (of whom frozen shoulder can be as common as occurring in nearly 20% of diabetic patients) with a tendency towards persistent limitation of movement two years after operation.(5)

Summary- what we look for in a patient with Frozen Shoulder

  • Frozen shoulder is an interesting entity, we are not really sure why it happens it seems to be more prevalent in people with diabetes. There appears also to be a connection with some type of autoimmune reaction (inflammation) in the shoulder.

Extended reduced mobility in the shoulder

  • In some patients, they have a shoulder injury like a rotator cuff tendon tear. They then stop using that shoulder because of pain and function issues. With this lack of movement, the soft tissue of the shoulder capsule compresses or shrinks down. This is the body’s natural way to limit injury, by limiting motion, as it does with bone spurs however, this is also painful.

History of pain and severity

  • We are looking for extremely painful shoulder episodes with a very limited range of motion. We are also looking for a patient history where this pain may have been significantly reduced on its own 8 – 12 weeks after the onset. This will help determine how we will progress with treatment.

Determining the extent of muscle atrophy and muscle weakness.

  • Many patients we see have had frozen shoulder problems for years. They have developed significant muscle atrophy and weakness. It has also impacted neck and arm movements.

Determining the cause of loss of range of motion

  • In a physical examination, we are going to try to determine the cause of the loss of range of motion. Is it from advancing osteoarthritis and bone spur formation? If needed an ultrasound examination of the shoulder will be performed to make sure a rotator cuff or other problems such as a shoulder impingement is not hiding from us.

What about high-intensity laser therapy?

High-intensity laser therapy can be beneficial to some patients. An August 2020 study in the journal Lasers in Medical Science (6) offered this assessment of the treatment:

The purpose of the study is to evaluate the effects of high-intensity laser therapy (HILT) on pain, disability, and quality of life in patients with adhesive capsulitis. The study was designed as a prospective, double-blinded, and sham-controlled randomized trial.

  • Thirty-six patients diagnosed with adhesive capsulitis were randomized into
    • high-intensity laser therapy plus therapeutic exercises,
    • sham-laser plus therapeutic exercises,
    • and control-therapeutic exercises only groups.

All groups received 25 minutes of exercises to the shoulder joint supervised by a physiotherapist.

  • Patients in both the high-intensity laser therapy and the sham-laser group were blinded to their group randomization. The interventions were performed five times a week for 3 weeks (a total of 15 sessions).
  • The primary outcome measure was pain scores. The secondary outcome measures were disability and range of motion of the shoulder joint.
  • Assessments were performed at pre-intervention, post-intervention, and 12-week follow-up by an investigator who was blinded.

High-intensity laser therapy plus therapeutic exercises showed significant differences in pain scores. Fifteen sessions of High-intensity laser therapy are superior to improve pain and quality of life but not superior in terms of disability or function in patients with adhesive capsulitis.

Pain relief is always a good thing. Pain relief with functional improvement would be better.

Prolotherapy for Frozen Shoulder

After we do a physical examination to access the amount of damage from osteoarthritis and the possibility of bone spurs causing limitations in range of motion, we may also perform an ultrasound to look for rotator cuff tear. Then we typically inject a shoulder capsule with a large amount of Prolotherapy numbing solution to stretch out the shoulder joint. The numb shoulder can then be gently manipulated. Often several sessions of this treatment regimen are needed to achieve the shoulder’s original full range of motion.

In our clinical observations, we have seen Prolotherapy offer good results as a frozen shoulder treatment at getting the shoulder more motion, eliminating pain, and restoring the structures of the joint.

In this video, a general demonstration of Prolotherapy and PRP treatment is given.
Danielle Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:

  • PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
  • In the shoulder procedure, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
  • The patient in this video is not sedated. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
  • This patient, in particular, came to us for a history of repeated shoulder dislocations. His MRI findings showed multiple shoulder labral tears and rotator cuff problems.
  • The patient complained of shoulder instability typical of the ligament and shoulder tendon damage multiple dislocations can do.
  • With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
  • PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
  • PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments, in this case, it was in his anterior shoulder attachments to address the chronic dislocations.

In independent research, doctors writing in the journal The Archives of Bone and Joint Surgery (7) commented on a case history of a patient treated with Platelet Rich Plasma injections for frozen shoulder.

The doctors noted that Platelet-rich plasma can produce collagen and growth factors, which increases stem cells and consequently enhances the healing.

  • A 45-year-old man with shoulder adhesive capsulitis underwent two consecutive platelet-rich plasma injections at the seventh and eighth month after initiation of symptoms. He was measured for pain, function, and Range of Motion ROM.
  • After the first injection, the patient reported a 60% improvement regarding shoulder pain and no night pain.
  • Also, two-fold improvement for ROM and more than 70% improvement for function were reported.

A July 2019 study in the American Journal of Physical Medicine & Rehabilitation (8)  found that patients who were given a single PRP injection versus a single cortisone injection had better results from the PRP in terms of improving pain, disability, and shoulder range of movement at a 12 week follow up.

An August 2018 study in the International Journal of Clinical Pharmacology and Therapeutics (9) found that one injection of PRP was more effective than procaine in treating frozen shoulderPRP had a more prolonged efficiency than the procaine control.

If you have questions about your shoulder problems, you can get help and information from our Caring Medical Staff.

References

1 Barnes CP, Lam PH, Murrell GA. Short-term outcomes after arthroscopic capsular release for adhesive capsulitis. J Shoulder Elbow Surg. 2016 Sep;25(9):e256-64. [Google Scholar]
2 Chang KV, Wu WT, Hung CY, Han DS, Yang RS, Chang CH, Lin CP. Comparative Effectiveness of Suprascapular Nerve Block in the Relief of Acute Post-Operative Shoulder Pain: A Systematic Review and Meta-analysis. Pain Physician. 2016 Sep-Oct;19(7):445-56. [Google Scholar]
3 Koh KH. Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials. Singapore Med J. 2016 Aug 29.  [Google Scholar]
4 Jung TW, Lee SY, Min SK, Lee SM, Yoo JC. Does Combining a Suprascapular Nerve Block With an Intra-articular Corticosteroid Injection Have an Additive Effect in the Treatment of Adhesive Capsulitis? A Comparison of Functional Outcomes After Short-term and Minimum 1-Year Follow-up. Orthopaedic journal of sports medicine. 2019 Jul 19;7(7):2325967119859277. [Google Scholar]
5 Mehta SS, Singh HP, Pandey R. Comparative outcome of arthroscopic release for frozen shoulder in patients with and without diabetes. Bone Joint J. 2014 Oct;96-B(10):1355-8. doi: 10.1302/0301-620X.96B10.34476.  [Google Scholar]
6 Atan T, Bahar-Ozdemir Y. Efficacy of high-intensity laser therapy in patients with adhesive capsulitis: a sham-controlled randomized controlled trial. Lasers in Medical Science. 2020 Aug 18:1-1.  [Google Scholar]
7 Aslani H, Nourbakhsh ST, Zafarani Z, et al. Platelet-Rich Plasma for Frozen Shoulder: A Case Report. Archives of Bone and Joint Surgery. 2016;4(1):90-93. [Google Scholar]
8 Barman A, Mukherjee S, Sahoo J, Maiti R, Rao PB, Sinha MK, Sahoo D, Tripathy SK, Patro BK, Bag ND. Single Intra-articular Platelet-Rich Plasma Versus Corticosteroid Injections in the Treatment of Adhesive Capsulitis of the Shoulder: A Cohort Study. American journal of physical medicine & rehabilitation. 2019 Jul 1;98(7):549-57. [Google Scholar]
9 Lin J. Platelet-rich plasma injection in the treatment of frozen shoulder: A randomized controlled trial with 6-month follow-up. International journal of clinical pharmacology and therapeutics. 2018 Aug 1;56(8):366. [Google Scholar]

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