Frozen shoulder

Definition:

Frozen shoulder or adhesive capsulitis is a condition of stiffness and pain in the shoulder joint (gleno humeral joint) due to many factors. This condition is chronic and is usually affecting people between the ages of 40 to 60 and occurs with women more than men.

Frozen shoulder or AC (adhesive capsulitis) is characterized by initially painful and later progressively restricted active and passive gleno-humeral joint range of motion with spontaneous complete or nearly complete recovery over time.

It can also be named:

• Adhesive capsulitis.
• Painful stiff shoulder.
• Peri arthritis.
• Idiopathic restriction of shoulder movement

It is an inflammatory condition of the shoulder capsule, accompanied gradually by a stiffness and significant restriction of range of motion especially external rotation.

Causes

1. Primary: onset is generally idiopathic that comes with no attributable reason
2. Secondary: results from a known cause, predisposing factor or surgical event. For example, post-surgery, post-stroke and post-injury. Where post-injury, there may be an altered movement pattern to protect the painful structures, which will in turn change the motor control of the shoulder, reducing the range of motion, and gradually stiffens up the joint.

• Three subcategories of secondary frozen shoulder include:

1. Systemic (diabetes mellitus and other metabolic conditions).
2. Extrinsic factors (cardiopulmonary disease, cervical disc, CVA, humerus fractures, Parkinson’s disease).
3. Intrinsic factors (rotator cuff pathologies, biceps tendinopathy, calcific tendinopathy, AC joint arthritis).

Risk factors:

• Age and sex: women are at higher risk of developing AC , older than 40 years.
• Immobility and reduced mobility: immobilization post surgery.
• Diabetes.
• Hyperthyroidism.
• Hypothyroidism.
• Cardiovascular disease.
• Parkinson

Characteristics/clinical presentation

Patients presenting with frozen shoulder will often report an insidious onset with a progressive increase in pain, and a gradual decrease in active and passive range of motion. One of the main presenting factors is loss of external rotation (ER) in a dependent position with the arm down by the side. Patients frequently have difficulty with grooming, performing overhead activities, dressing, and particularly fastening items behind the back. Frozen shoulder is considered to be a self-limiting disease with sources stating symptom resolution as early as 6 months up to 11 years. Unfortunately, symptoms may never fully subside in many patients.

Frozen shoulder typically develops in 3 stages:

• Acute/freezing/painful phase: Gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 2-9 months.
• Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of GH motion in capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last till about 12 months.
• Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion which can last anywhere from 5 to 24 months. Despite this, some studies suggest that it’s a self limiting condition, and may last up to three years. Though other studies have shown that up to 40% of patients may have persistent symptoms and restriction of movement beyond three years. It is estimated that 15% may have persistent pain and long term disability. Effective treatments which shorten the duration of the symptoms and disability will have a significant value on reducing the morbidity.

Disturbed sleep:

In the early part and middle part of this condition (Freezing and Frozen phase, respectfully), sleeping is often interrupted and disturbed. As the patient’s condition progresses, this can get worse and there’s good evidence that the lack of sleep, pain and depression form a tightly interconnected triangle where changes in one will affect the other two. Therefore it’s important that clinician monitor sleep quality and use outcome measures to quantify signs and symptoms.

Diagnosis

During the physical exam, the health care provider will ask the patient to move the arm in certain ways. This is usually performed to check for pain and see how far the patient will move his arm actively (active range of motion). Then the provider will ask the patient to relax his muscles and will try to move his arm passively (passive range of motion). Frozen shoulder affects both active and passive range of motion.

Frozen shoulder can usually be diagnosed from signs and symptoms alone. But imaging tests such as X-Ray, Ultrasound or MRI can assure it and rule out other problems too.

Special tests

Shoulder Shrug Sign (inability to lift the arm to 90° abduction without elevating the whole scapula or shoulder girdle). Previously was associated with rotator cuff disease, but more commonly was associated with gleno-humeral arthritis, frozen shoulder, and massive cuff tears.

3 function related tests:

1. Hand to neck :

Shoulder flexion + abduction + ER

Similar to DLAs (daily life activities) such as combing hair, putting on a necklace.

2. Hand to scapula:

Shoulder extension + adduction + IR

Similar to DLAs such fitting a bra, putting on a jacket, getting into back pocket.

3. Hand to opposite scapula:

Shoulder flexion + horizontal adduction.

These tests require appropriate elbow, scapulothoracic, and thoracic mobility and these areas should be cleared of pathology first. If a patient is unable to complete the motion, other structures outside of the shoulder joint may be the limiting factor.

Reliability of the three tests was excellent and correlation between them was moderate.

Treatment

Most frozen shoulder treatment involves controlling shoulder pain and preserving as much range of motion as possible.

• Medications

Pain relievers such as aspirin and ibuprofen (Advil, Motrin IB, others) can help reduce pain and inflammation associated with frozen shoulder. In some cases, a health care provider might prescribe stronger pain-relieving and anti-inflammatory drugs.

• Therapy

A physical therapist can teach you range-of-motion exercises to help recover your shoulder movement. Your commitment to doing these exercises is necessary to regain as much movement as possible.

• Surgical and other procedures

Most frozen shoulders get better on their own within 12 to 18 months. For severe or persistent symptoms, other treatments include:

• Steroid injections

Injecting corticosteroids into the shoulder joint might help decrease pain and improve shoulder mobility, especially if given soon after frozen shoulder begins.

• Hydro dilatation.

Injecting sterile water into the joint capsule can help stretch the tissue and make it easier to move the joint. This is sometimes combined with a steroid injection.

• Shoulder manipulation

This procedure involves a medication called a general anesthetic, so you’ll be unconscious and feel no pain. Then the care provider moves the shoulder joint in different directions to help loosen the tightened tissue.

• Surgery

Surgery for frozen shoulder is rare. But if nothing else helps, surgery can remove scar tissue from inside the shoulder joint. This surgery usually involves making small incisions for small instruments guided by a tiny camera inside the joint (arthroscopy).

Physical therapy treatment

Physical therapy treatment plan in frozen shoulder cases is based on the stage and severity of the inflammation.

• Initial Phase: Painful, Freezing

Pain relief and the exclusion of other potential causes of your frozen shoulder is the focus during this phase. Very gentle shoulder mobilization, muscle releases, acupuncture, dry needling and kinesiology taping for pain-relief can assist during this painful inflammation phase. During this time, any activities that cause pain should be avoided.

Better results have been found in patients who performed simple pain free exercise, rather than intensive physical therapy. In patients with high irritability, range of motion exercises of low intensity and short duration can alter joint receptor input, reduce pain, and decrease muscle guarding. Stretches may be held from one to five seconds in a pain free range, 2 to 3 times a day.

A pulley may be used to assist range of motion and stretch, depending on the patient’s ability to tolerate the exercise. Core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately 40 degrees of abduction in the plane of the scapula, and active assisted range of motion in extension, horizontal adduction, and internal rotation.

• Second Phase: Decreased Range of Movement

Gentle and specific shoulder joint mobilization and stretches, muscle release techniques, acupuncture, dry needling and exercises to regain your range and strength are used for a prompt return to function. Care must be taken not to introduce any exercises that are too aggressive. In particular, mobilization with movement (MWM) style techniques appears the most effective and more effective than stretching exercises alone.

• Third Phase: Resolution

Provide you with exercise progressions including strengthening exercises to control and maintain increased range of movement. Physiotherapy is most effective during this thawing phase .Progressed primarily by increasing stretch frequency and duration, whilst maintaining the same intensity, as tolerated by the patient. The stretch can be held for longer periods and the sessions per day can be increased. As the patient’s irritability level reduces, more intense stretching and exercises using a device, such as a pulley, can be performed to influence tissue remodeling.