Summary
Highlights
Ariana Parks introduces Jared Paul, a physical therapist with a PhD in shoulder complex management, who will discuss frozen shoulder. Jared outlines his professional journey, including his online courses, telehealth practice, and personal life, before diving into the main topic.
Jared explains frozen shoulder as a painful and stiff shoulder, typically starting with pain and evolving into characteristic stiffness after six weeks to a few months. He highlights that the most common form is primary idiopathic (without known cause) and emphasizes the importance of communicating the condition's natural history and favorable prognosis to patients.
The discussion covers the two main stages: initial excruciating pain, often affecting sleep, followed by severe stiffness. Jared describes the pain phase (pain greater than stiffness) and the later stiffness phase (stiffness greater than pain). He provides a general timeline, suggesting a 2 to 2.5-year process for full resolution, though some limitations can persist longer.
Jared identifies key risk factors: age (40-60 years, with an average of 50), women being more commonly affected than men, and comorbidities such as diabetes (especially Type 1) and thyroid issues. He also mentions an association with Dupuytren's contracture.
Diagnosis should be clinical, based on age, significant rest pain, and minimal passive range of motion, particularly in external rotation, abduction, and internal rotation. Jared stresses that imaging is mostly for confirmation, not initial diagnosis, and discusses ruling out conditions like glenohumeral joint osteoarthritis, locked dislocation, and sinister pathologies, which are rare.
Non-surgical management, primarily physiotherapy combined with an intra-articular corticosteroid injection, is the most evidence-based approach. The injection aims to reduce pain, improving sleep, although it doesn't always affect stiffness. Exercise programs are individualized and gentle during the painful phase, gradually progressing as pain diminishes. Aggressive stretching and manual therapy are discouraged due to limited evidence and potential harm.
Jared advises patients to maintain general physical activity, such as cardio and exercising unaffected limbs, as it has anti-inflammatory benefits and helps avoid kinesiophobia. He emphasizes that the primary role of a physical therapist is to provide advice, education, and tailored exercise programs, focusing on managing expectations and encouraging self-efficacy.
Beyond general pain relievers and anti-inflammatories, new immune-suppressing drugs show promise for the future, targeting the immune-mediated inflammatory response of frozen shoulder. This research direction is exciting due to increased understanding of the condition's pathophysiology.
Jared dispels myths: frozen shoulder is not rare and cannot be quickly cured. Aggressive treatments like forceful manipulations or intense stretching are discouraged, as they lack evidence and can cause more harm. He warns against misinformation from social media, emphasizing that significant improvement takes months, not weeks.
Surgical options like arthroscopic capsular release or manipulation under anesthetic can be effective, but a major study (the FROST trial) found they do not outperform physiotherapy combined with an intra-articular injection, which is safer and more accessible. He notes that manipulation under anesthetic was the most cost-effective, but also a more invasive procedure.
Early recognition and injection during the inflammatory phase are crucial. Clinicians should be vigilant in identifying early signs, though caution is needed before recommending injections if stiffness isn't evident, to avoid unnecessary painful procedures. Jared stresses the importance of patients trusting healthcare professionals and avoiding online rabbit holes for information.
Jared recommends a textbook on frozen shoulder edited by Philip Struff and a paper he co-authored, 'Dear newly graduated physiotherapist: advice that we wish we had received,' for new clinicians. He also promotes his extensive online shoulder course and encourages interaction on his social media channels (@shoulderphysio on Instagram, @Jaredpaul2 on Twitter/X, YouTube, and his 'Shoulder Physio Podcast').