Frozen Shoulder: Are We Missing the Boat?

Frozen shoulder has historically been both difficult to diagnose and treat. To complicate matters the long-held belief that the frozen shoulder progresses through a natural history from painful to stiff and then recovery/thawing has been incredibly pervasive despite the paucity of evidence in support of this theory. 

Wong et al. conducted a systematic review of frozen shoulder research over the last 125 years seeking to evaluate the evidence regarding the proposed natural history of a progression through painful, stiff and recovery phases. In addition, they sought to evaluate the evidence for full recovery without supervised treatment. 503 citations were whittled down to 13 articles based on their inclusion criteria. Of those 13 studies, 7 were included in the systematic review after eliminating studies that did not provide adequate follow-up time or included supervised treatment. 

Non-treatment groups within the included 7 studies incorporated interventions such as analgesic medication, home exercise programs, reassurance, and education booklets but none of their interventions were supervised. Three of the included studies were RCTs while the other four were cohort studies. 

Wong et al. found that none of the studies included in the review demonstrated a pattern consistent with a progression through painful, stiff and then recovery phases. In fact, the three higher quality RCTs found that there was actually faster recovery of ROM and function earlier after diagnosis. This is contrary to the commonly held belief that the 3rd phase in the natural history model, recovery/thawing, is when most gains are made. Additionally, Wong et al. found that full recovery of pain, function and ROM did not occur in the groups without supervised treatment. 

While the notion of the natural history of frozen shoulder with sequential progression through painful, stiff, and then thawing phases has pervaded the literature on management of frozen shoulder, this study found that belief in this model has been based on low quality studies and specious dogma. Furthermore, despite the non-treatment groups in the included studies incorporating home exercise programs, analgesic medications, education and reassurance, participants failed to fully recover function, ROM or pain. The clinically important implications of this study are two-fold:  

1. The accepted theory of recovery following a natural history of frozen shoulder may impact the attitude of patients and practitioners resulting in an unrealistic prognosis with the expectation of full recovery without intervention
2. Given that this review found that early restoration of ROM and function occurred early as opposed to late, failure to participate in supervised treatment may result in missing the early window for recovery of ROM and function before the patient plateaus

Assessment and treatment of frozen shoulder is commonly and effectively done in select physiotherapy clinics. Clinicians at Parkway Physiotherapy + Performance Centre are receiving, diagnosing and effectively treating patients with frozen shoulder on a daily basis.

Wong CK, Levine WN, Deo K, Kesting RS, Mercer EA, Schram GA, Strang BL (2017). Natural history of frozen shoulder: Fact of fiction? A systematic review. Physiotherapy 103 (1)40-47