Frozen Shoulder

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Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.

Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.

Anatomy:
Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

Description:
In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.

The hallmark sign of this condition is being unable to move your shoulder - either on your own or with the help of someone else. It develops in three stages:

1 . Freezing Phase
In the"freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

2. Frozen Phase
Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

3. Thawing Phase
Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

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In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.
Causes Of Frozen Shoulder:
The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes: Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

Other diseases: Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization: Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Symptoms
Of Frozen Shoulder:
Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Inverstigation:
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Doctor Examnination: After discussing your symptoms and medical history, your doctor will examine your shoulder. Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion."  Your doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.



Imaging Tests
Other tests that may help your doctor rule out other causes of stiffness and pain include:
X-rays;Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.
Magnetic resonance imaging (MRI) and ultrasound; These studies can create better images of problems with soft tissues, such as a torn rotator cuff.


                 Frozen Shoulder Treatment


Even though adhesive capsulitis is believed to be a "self limiting" process, it can be severely disabling for months to years and, as a result, requires aggressive treatment once the diagnosis is made. Initial treatment should include an aggressive frozen shoulder exercises to help regain shoulder motion. For patients in the initial painful or freezing phase, pain relief may be obtained with a course of anti-inflammatory medications, the judicious use of GH joint corticosteroid injections, or therapeutic modality treatments. Intra-articular corticosteroid injections help to abort the abnormal inflammatory process often associated with this condition.

Operative intervention is indicated in patients who show no improvement after a three month course of aggressive management that includes medications, corticosteroid injection and physical therapy.


Frozen Shoulder Exercises (Rehabilitation Protocol):

Phase 1: Weeks 0-8

Goals
  • Relieve pain
  • Restore Motion
No restriction or immobilization.


Pain Control
  • Medications
  • NSAIDS- first line medication for pain control
  • GH joint injection: corticosteroid/local anesthetic combination
  • Oral steroid taper- for patients with refractive or symptomatic frozen shoulder.
  • Therapeutic modalities
  • Ice, ultrasound, HVGS
  • Apply moist heat before therapy and ice pack at the end of session.
Motion: Frozen Shoulder Exercises
  • Initially focus on forward flexion and internal and external rotation with the arm at the side, and the elbow at 90 degrees.
  • Active ROM exercises.
  • Active assisted ROM exercises.
  • Passive ROM exercises.
  • In home these Frozen Shoulder Exercises should be performed 3-5 times per day.
  • A sustained stretch, of 15-30 seconds, at the end ROMs should be part of all ROM routines.
Phase 1: Weeks 8-16

Criteria for progression to Phase 2
  • Improvement in shoulder discomfort.
  • Improvement in shoulder motion.
  • Satisfactory physical examination.
Goals
  • Improve shoulder motion in all plane
  • Improve strength and endurance of rotator cuff and scapular stabilizers
Pain Control: By same means as used in 1st 8 weeks.

Motion: Frozen Shoulder Exercises
  • Perform active, active assisted and passive range of motion exercises to obtain around 140 degree of forward flexion, 45 degree of external rotation and internal rotation to twelfth thoracic spinous process.
Muscle Strengthening

Start with rotator cuff strengthening exercises 3 times per week, 8-12 repetitions for three sets.
  • Closed chain isometric strengthening with the elbow flexed to 90 degrees and the arm at the side. Perform internal rotation, external rotation, abduction and forward flexion.
  • Progress to open chain strengthening exercises with theraband for same greoup of muscles.
  • Progress to light weight dumbbell exercises for internal rotators, external rotators, abductors and forward flexors.
  • Perform strengthening of scapular stabilizers.
  • Deltoid strengthening.
Phase 3: 4 months and beyond

Criteria for progression to Phase 3
  • Significant functional recovery of shoulder motion.
  • Successful participation in activities of daily living.
  • Resolution of painful shoulder.
  • Satisfactory physical examination.
Goals
  • Home maintenance frozen shoulder exercises.
  • ROM exercises 2 times a day.
  • Rotator cuff strengthening 3 times a week.
  • Scapular stabilizer strengthening 3 times a week.
Please check with your Physical Therapist before starting with this frozen shoulder exercises.

Warning Signs:
  • Loss of motion
  • Continued Pain
Treatment of Complications:
  • These patients may need to move back to earlier routines
  • May require increased utilization of pain control modalities as outlined above
  • If loss of motion is persistent and pain continues, patients may require surgical intervention
  • Manipulation under anesthesia
  • Arthroscopic release





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