Marc Darrow MD,JD

Clinically we have seen many patients with various and diverse shoulder problems. One such problem is the problem of frozen shoulder. People with frozen shoulder are typically someone who had a shoulder injury or surgery that required immobilization or someone who suffers from diabetes. As we are dealing with treatments surrounding musculoskeletal repair, we will focus on post-traumatic injury or surgical cause of “frozen shoulder.” Below is also new research on the use of PRP shoulder injections in the frozen shoulder shoulders of diabetes patients.

Many people contact us after they have had tradition treatments for their frozen shoulder. This included manipulation, stretching, corticosteroids, injectable painkillers or numbing agents and various other remedies. Sometimes these treatments work well. Sometimes they work well enough. Sometimes they do not help at all and another surgery may be called for. In these cases people may reach out to us to see if Platelet Rich Plasma injections may help. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration.

Shoulder instability and shoulder immobilization as a cause of frozen shoulder

Until recently, it was common in cases of dislocation to immobilize the shoulder for long periods of time. But studies showed that while immobilization helped alleviate the pain of such injuries, it also contributed to a general weakening of the ligaments and predominance of “adhesive capsulitis,” where the arm is frozen (frozen shoulder) and can no longer be lifted. In cases of painful shoulder and instability, the shoulder ligaments and tendons within the shoulder joint capsule, when damaged, can cause a “swelling” or thickening of the tissue within the shoulder, preventing normal range of motion. It is during this time that scar tissue can form.

Frozen shoulder treatments filled with controversy

A paper published in November 2021 (1) offers us an understanding of the controversies surround frozen shoulder treatment:

“Despite being relatively common, one might say a frozen shoulder remains full of controversy. One of the debatable issues concerns the best treatment method. Through various nonsurgical procedures remaining a gold standard of treatment, many studies investigated nonsteroidal anti-inflammatory drugs, corticosteroids including oral steroids and local injectable steroids, and physiotherapy. There have also been some studies concerning the usage of acupuncture, hydrodilatation, calcitonin, extracorporeal shock wave therapy, and nerve block. The surgical treatment that consists of manipulation under anesthesia and arthroscopic capsular release is recommended only when an extended nonsurgical therapy for 6–9 months is unsuccessful.

The justification for waiting to decide on surgical treatment in patients with an idiopathic frozen shoulder is that it has always been considered a disease starting with a decreasing function in the first month in every case, with symptoms resolving spontaneously sooner or later. Some studies report even up to 90% of patients in whom nonsurgical methods or even no therapy is used will resolve the symptoms of the disease.”

From aggressive treatment to no treatment at all. How does a person know what path to take?

Exercise, physiotherapy, and conservative care treatments.

A November 2021 paper in the journal Medicine (2) offers a synopsis of treatments including the manipulation of the shoulder to break the adhesions.

“Currently, there is limited evidence to guide treatment and no standard management guidelines exist for treating frozen shoulder. A general management approach consists of initial evaluation, range of motion (ROM) exercises, intra-articular injection of glucocorticoid, home exercise program, and/or physical therapies.

However, the general approach lacks detail and has limited evidence of its effectiveness. This retrospective cohort study evaluates the short-term recovery of near-full to full-ROM technique followed by an instructed home exercise program for strengthening and coordinating shoulder girdle muscle group for frozen shoulder management.”

In this patient case review, Seven-two adult patients with frozen shoulder (46 females, 26 males; average age of 66) were included in this study. Following general management of frozen shoulder, patients received a glucocorticoid-lidocaine mixture injection administered to the respective shoulder at the glenohumeral joint space and/or subacromial separately.

“Immediately, patients underwent active manipulation of the affected shoulder in 3 directions: forward flexion, abduction, and extension in the sagittal plane. Lastly, patients were instructed to perform movements similar to the active manipulation protocol as a home exercise program. The abduction and forward flexion ROM showed significant improvements with the described protocol. Following treatment, there was a 90.20° and 77.33° increase in average shoulder abduction and forward flexion ROM, respectively. The immediate goal of this protocol was to gain maximum ROM in different directions of shoulder mobility. Following the general management of frozen shoulder, active manipulation under local anesthetic was a highly effective treatment modality for adhesive capsulitis that was time-saving and cost-effective.”

Intra-articular corticosteroid and suprascapular nerve block combination

A December 2021 study (3) evaluated the short and long-term effects of the combination of suprascapular nerve block  (an injection of painkiller near the suprascapular nerve. Typically this nerve block provides pain relief within a month and up to six months in the shoulder) and intra-articular corticosteroid injection on pain, shoulder range of motion  , disability, and quality of life in the management of patients with adhesive capsulitis.

In this study Forty patients (ages 30-70 years) who were diagnosed with adhesive capsulitis stages 1 and 2 were randomly assigned to one of two groups:

  • Group-1 received intra-articular corticosteroid and suprascapular nerve block combination, while group-2 only-intra-articular corticosteroid. The difference the research found between the two groups was the suprascapular nerve block as an adjunct to intra-articular corticosteroid in adhesive capsulitis positively affected the immediate pain relief and functional improvement after the intervention; however, it did not yield any additional benefit in the short and long-terms.

Extracorporeal shock wave therapy for frozen shoulder

Two papers in the Journal of physical therapy science suggest that some patients may benefit from extracorporeal shock wave therapy. The concept behind extracorporeal shock wave therapy or shock wave therapy is that a focused shock or pressure waves created by an electric charge may impact the frozen shoulder tissue with enough force to cause an inflammation and circulation to come to the area of injury to start a repair.

The first of the two studies mentioned above (4) compared outcomes in 15 patients receiving extracorporeal shock wave therapy for frozen shoulder against a group of 15 patients who had conservative physical therapy. Both groups showed improvement in pain reduction and better range of motion. The extracorporeal shock wave therapy group showed better improvement than the conservative physical therapy group.

The second study (5) compared the effectiveness of extracorporeal shock wave therapy versus ultrasound therapy. The patients in this group suffered from diabetic frozen shoulder. The doctors in this study found improvement in both patient groups pain and function scores. The extracorporeal shock wave therapy showed significantly better results in reduced pain.

A November 2021 paper (11) compared the clinical and functional outcomes of patients diagnosed with an idiopathic frozen shoulder with symptom onset of a maximum of six months, treated by arthroscopic capsular release followed by corticosteroid injection and physiotherapy to patients who received only corticosteroid injection followed by physiotherapy.

  • The patients of the study were divided into two groups:
    • Those who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy, or
    • Those who received only corticosteroids injection and physiotherapy.
  • Both groups were examined in terms of shoulder range of motion (ROM), pain intensity, and function before a given treatment and three, six, and twelve months later.
  • The groups were comparable pre-treatment in terms of ROM, pain, and functional outcome.
    • Group I, those who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy had statistically and clinically significantly better ROM and function at three and six months post-treatment than Group II. Those who received only corticosteroids injection and physiotherapy.
    • Despite being statistically significant, the between-group differences at twelve-month follow-up in ROM and function were too small to be considered clinically notable. The between-group comparison of pain revealed no significant differences at any post-treatment point of time. The early arthroscopic capsular release preceding corticosteroid injection and physiotherapy seemed more effective at three- and six-month follow-up; however, it brought a comparable result to corticosteroid injection and subsequent physiotherapy at twelve months follow-up.

Research on Platelet Rich Plasma injections – PRP may help frozen shoulders

There are many treatments that can work for to get the shoulder “unstuck” or “unfrozen” as described in the above research. Platelet Rich Plasma is seen as a treatment that can help frozen shoulder by addressing the problems of shoulder instability which can cause a thickening of the shoulder capsule.

A January 2021 (6) study suggested PRP injections could help frozen shoulder.

This was triple blind study, the doctors did not know what they were injecting, the patients didn’t know what they were being inject with and the researcher analysis did not know what treatment offered the results they were examining.

  • Methods: 32 adult patients with adhesive capsulitis (21 female, 11 male with an average age of 57, ranging from 23 to 70) were included in this study.
  • Patients had to have shoulder pain and restrictions in movements (at least 25% when compared to the other side, and at least in two directions) for three months minimum and nine months maximum.
  • Patients were randomized to two groups, and one group took PRP injections for three times every two weeks, while the other group took saline injections in same frequency and volume.
  • A standardized exercise program was also applied to all patients.
  • Patients were evaluated with Shoulder Pain and Disability Index (SPADI), Visual Analogue Scales for pain and disability, ranges of movements, and use of analgesics in before, after, and third month after the initiation of the therapy.

Results: Baseline comparisons between groups showed no differences.

  • Shoulder Pain and Disability Index  and ranges of motion in all directions showed significant improvements with therapy, and the group which took PRP injections showed better improvements when compared to the control group. Visual Analogue Scale was found to be better for the PRP group after therapy and third month, and not for the control group. Use of analgesics was not found to be significant for both groups.

Conclusion: PRP injections were found to be effective in both pain and disability, and showed improvements in a restricted shoulder due to adhesive capsulitis. These findings might point out PRP as a therapeutic option in the management of adhesive capsulitis.

PRP compared to physical therapy in treating frozen shoulder

A December 2020 study (7) evaluated the effect of ultrasound guided injection of PRP into the shoulder joint in patients with adhesive capsulitis  and compared its effect with that of conventional physiotherapy

  • Methods: Sixty-four subjects with adhesive capsulitis were included and randomly allocated into two groups, as follows:
    • PRP (32 patients) : Conservative physical therapy (CPT); short wave diathermy and exercise therapy were performed at three sessions/week for 6 weeks).
    • Treatment outcomes evaluated therapeutic effectiveness before and at 1, 3, and 6 weeks after PRP injection and CPT initiation.

Results: Subjects in both groups showed a significant decrease in the visual analogue scale score for pain and shoulder and hand scores, and they a significant increase in shoulder passive range of motion at all evaluation time points. There was no significant difference in the measured outcomes between the two groups. However, there was less acetaminophen consumption after PRP injection compared with that after conservative physical therapy.

Prior to this research there was very limited studies. In fact a search of the medical literature shows two case histories. Both are discussed below.

A December 2021 paper (12) aimed to investigate the effectiveness of intra-articular platelet-rich plasma (PRP) injection in adhesive capsulitis. A total of 40 patients (21 males, 19 females; average age: 57) with idiopathic adhesive capsulitis were included. The patients were randomly assigned into two equal groups as the PRP and the control group.

  • The PRP group received two doses of PRP via intra-articular route biweekly under ultrasound guidance.
  • No injection was performed to the control group.

Results: There were significant differences in pain and function scores at all time points after treatment compared to baseline in both groups. At the end of the study, there were significant differences in the active flexion, passive flexion, active abduction, passive abduction, and active external rotation scores at 12 weeks between the groups. No significant difference was observed between the groups in terms of pain and disability scores and the other parameters (active and passive extension, active and passive internal rotation, passive external rotation) at 2, 6, and 12 weeks. Conclusion: “The addition of PRP to exercise treatment can improve patients’ joint mobility, but not pain and disability in patients with adhesive capsulitis.”

Doctors report case histories using PRP for frozen shoulder

One case history was published in the publication The archives of bone and joint surgery (8). It describes the situation and treatment of frozen shoulder in a 45-year-old-man.

“Platelet-rich plasma can produce collagen and growth factors, which increases stem cells and consequently enhances the healing. To date, there is no evidence regarding the effectiveness of platelet-rich plasma in frozen shoulder. A 45-year-old man with shoulder adhesive capsulitis volunteered for this treatment. He underwent two consecutive platelet-rich plasma injections at the seventh and eighth month after initiation of symptoms. We measured pain, function, range of motion by the visual analogue scale (VAS), scores from the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and goniometer (to measure improvement in arm angles); respectively.

After first injection, the patient reported 60% improvement regarding diurnal (during the day) shoulder pain, and no night pain. Also, two-fold improvement for ROM and more than 70% improvement for function were reported. This study suggests the use of platelet-rich plasma in frozen shoulder to be tested in randomized trials.”

Frozen shoulder treated with PRP in a patient with chronic kidney disease

A published case history from 2020 (9) describes how PRP helped a patient with her adhesive capsulitis brought on by chronic kidney disease. (A point here, we do not treat kidney disease, this case history is about the patient’s frozen shoulder treatment with PRP). Here is the case:

“Adhesive capsulitis is a common problem in patients with chronic kidney disease. Patients suffer from joint stiffness and painful joint movement. Conservative treatments consist non-steroid anti-inflamatory drugs, intraarticular injections and physical therapy. Newer approaches such as platelet-rich plasma injections (PRP) also can be applied but there is little evidence for the effectiveness of PRP in patients with adhesive capsulitis.

A 70 year-old woman, receives dialysis treatment admitted to our out-patient clinic with stiffness and pain in her right shoulder. Her diagnosis was confirmed with MRI as adhesive capsulitis. PRP injection began to be applied as planned; 3 times, 15 days between each injection.

At the last assessment average ROM increased on flexor, abductor and internal rotator sides.” The patient did not however note pain improvement.

In this case the patient noted improvement in range of motion. The study was on three single injections spaced 15 days apart. It may be possible that the patient would have had pain improvement and increased range of motion with further treatment.

Frozen shoulder treated with PRP in a patient with diabetes. A comparison with physical therapy

A November 2021 study (10) compared the efficacy of platelet-rich plasma (PRP) injection with an institution-based physical therapy program for adhesive capsulitis  of the shoulder in patients with diabetes mellitus.

  • A total of seventy diabetic patients with adhesive capsulitis of the shoulder for less than 6 months were assigned to two groups:
    • PRP group and physical therapy group.
    • In the PRP group, 35 patients were administered a single shot of PRP (4 mL) into the glenohumeral joint.
    • In the physical therapy group, 35 patients were given institution-based physical therapy that included 10 30-minute sessions of planned physical therapy over a 2-week period.
    • After the interventions, all patients were prospectively followed for 12 weeks. Intensity of shoulder pain, function, and range of motion were assessed at baseline and then at 3, 6, and 12 weeks.

Results: Thirty-three patients in the PRP group and 32 in the physical therapy group completed the 12-week study. At 12 weeks, patients who received PRP injections showed greater improvement in shoulder pain than those recruited to the physical therapy group.

 

Do you have questions? Ask Dr. Darrow

 

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References

1 Satora W, Brzóska R, Prill R, Reichert P, Oleksy Ł, Mika A, Królikowska A. Surgical versus Nonsurgical Multimodality Treatment in an Idiopathic Frozen Shoulder: A Retrospective Study of Clinical and Functional Outcomes. Journal of clinical medicine. 2021 Jan;10(21):5185.
2 Li K, Bichoupan K, Gilchriest JA, Moosazadeh K. Real-world experience of treating frozen shoulder using active manipulation under local anesthetic: A retrospective study. Medicine. 2021 Nov 24;100(47).
3 Kurt S, Kaplan E, Yağcı İ. Clinical effects of suprascapular nerve block in addition to intra-articular corticosteroid injection in the early stages of adhesive capsulitis: A singleblind, randomized controlled trial. Acta Orthopaedica et Traumatologica Turcica. 2021 Dec 1;55(6):459-65.
4 Park C, Lee S, Yi CW, Lee K. The effects of extracorporeal shock wave therapy on frozen shoulder patients’ pain and functions. Journal of physical therapy science. 2015;27(12):3659-61.
5 Muthukrishnan R, Rashid AA, Al-Alkharji F. The effectiveness of extracorporeal shockwave therapy for frozen shoulder in patients with diabetes: randomized control trial. Journal of physical therapy science. 2019;31(7):493-7.
6 Ünlü B, Çalış FA, Karapolat H, Üzdü A, Tanıgör G, Kirazlı Y. Efficacy of platelet-rich plasma injections in patients with adhesive capsulitis of the shoulder. International Orthopaedics. 2020 Nov 18:1-0.
7 Thu AC, Kwak SG, Shein WN, Htun LM, Htwe TT, Chang MC. Comparison of ultrasound-guided platelet-rich plasma injection and conventional physical therapy for management of adhesive capsulitis: a randomized trial. Journal of International Medical Research. 2020 Dec;48(12):0300060520976032.
8 Aslani H, Nourbakhsh ST, Zafarani Z, Ahmadi-Bani M, Ananloo ME, Beigy M, Salehi S. Platelet-rich plasma for frozen shoulder: a case report. Archives of Bone and Joint Surgery. 2016 Jan;4(1):90.
9 Özen S. Platelet-rich plasma injection in a patient with adhesive capsulitis due to chronic kidney disease. Agri: Agri (Algoloji) Dernegi’nin Yayin organidir= The journal of the Turkish Society of Algology. 2020 Apr 1;32(2):113-4. —1308
10 Barman A, Mukherjee S, Sinha MK, Sahoo J, Viswanath A. The benefit of platelet-rich plasma injection over institution-based physical therapy program in adhesive capsulitis patients with diabetes mellitus: prospective observational cohort study. Journal of the Korean Shoulder and Elbow Society. 2021 Nov 11.
11 Satora W, Brzóska R, Prill R, Reichert P, Oleksy Ł, Mika A, Królikowska A. Surgical versus Nonsurgical Multimodality Treatment in an Idiopathic Frozen Shoulder: A Retrospective Study of Clinical and Functional Outcomes. Journal of clinical medicine. 2021 Nov 5;10(21):5185.
12 Karabaş Ç, Topaloğlu US, Karakükçü Ç. Effects of platelet-rich plasma injection on pain, range of motion, and disability in adhesive capsulitis: A prospective, randomized-controlled study. Turkish Journal of Physical Medicine and Rehabilitation. 2021 Dec 1;67(4):462-72.

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