Frozen shoulder is a common shoulder disorder, characterized by gradual decrease of range of motion (ROM) in the glenohumeral joint, accompanied by increasing pain. In spite of many investigations, the origin and mechanism are still poorly understood. Multiple labels have been attributed to this condition, from “adhesive capsulitis”, over “waste can diagnosis” to the more recent term “frozen shoulder contracture”, suggesting a more dynamic (muscular) component in this disorder. In particular, the subscapularis has been suggested to be in a constant contracture, leading to this significant loss of external rotation ROM. A recent (small case series) study revealed significant increase in ROM in frozen shoulder patients under general anesthesia, suggesting an important role of muscle guarding in frozen shoulder patients (Hollman et al. MSP 2018)
Traditionally 3 stages (freezing, frozen, thawing) are recognized in this condition, mainly based on a time-based, self-limiting process. However, from the practice, we know that these traditional stages do not always match with the actual clinical and daily-life limitations of the patient. Therefore, the traditional protocols for each of these phases do not always match the needs of the patient.
Rather than referring to a time-based protocol, the clinician should refer to “tissue-irritability” as a basis for his clinical reasoning and choice of treatment. This concept of high versus low irritability was described in the clinical paper of McClure & Michener (Phys Ther 2015) for shoulder pain in general (figure 1) and was specified for frozen shoulder contracture syndrome by Lewis et al. (JOSPT 2015) by dividing the disorder into 2 clinically relevant stages: “more pain than stiff”, and “more stiff than pain”.
According to this concept, the therapist should be guided by the perceived tissue irritability during his clinical reasoning approach, and tailor the treatment into “decreasing the load” versus “increasing loadability” (figure 2). Recently a (small case series) study demonstrated significant improvement with a tailored program based on tissue irritability (Duenas et al. JOSPT 2019) in a population of frozen shoulder patients.
Written by: Ann Cools
Lewis J. Frozen shoulder contracture syndrome – Aetiology, diagnosis and management. Man Ther. 2015 Feb;20(1):2-9. doi: 10.1016/j.math.2014.07.006. Epub 2014 Jul 18. ReviewMcClure PW, Michener LA. Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Phys Ther. 2015 May;95(5):791-800. doi: 10.2522/ptj.2014015
Hollmann L, Halaki M, Kamper SJ, Haber M, Ginn KA. Does muscle guarding play a role in range of motion loss in patients with frozen shoulder? Musculoskelet Sci Pract. 2018 Oct;37:64-68. doi: 10.1016/j.msksp.2018.07.001.
Dueñas L, Balasch-Bernat M, Aguilar-Rodríguez M, Struyf F, Meeus M, Lluch E. A 12-Week Tailored Manual Therapy and Home Stretching Program Based on Level of Irritability and Range of Motion Impairments in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series With 9-Months Follow-Up. JOSPT 2019 Jan 18:1-24. doi: 10.2519/jospt.2019.8194. [Epub ahead of print]