What is Frozen Shoulder Frozen Shoulder Treatment Frozen Shoulder Exercises Area of Symptoms Types of Symptoms Stages Types of Symptoms Assessment of Frozen Shoulder Differential Diagnosis
What is Frozen Shoulder
Adhesive capsulitis or more commonly known as frozen shoulder is a condition which results from a combination of inflammation, scarring, thickening and shrinkage of the shoulder capsule that surrounds the glenohumeral joint of the shoulder. This condition of the shoulder causes capsular adhesions where all shoulder movements become painful and greatly restricted (Donatelli 2004, pp. 319). In most patients seen by a physical therapist there is no specific cause for this debilitating disorder which effects about 3% of the general population in their lifetime (Hertling & Kessler 1996, pp. 190).
Adhesive capsulitis is more commonly seen in women than men and most commonly seen in ages of 40-60 years old. In fact 70% of frozen shoulder patients are women aged between 40–60 years old. Frozen shoulder is more prevalent with people with diabetes. Patients who have Frozen Shoulder and diabetes are considered more serious condition than in the non-diabetic population with a longer recovery (Carnes & Vizniak 2010, pp. 104).
Frozen Shoulder Treatment
There are studies that show some forms of treatment are less effective in increasing ROM and reducing pain for frozen shoulder (Donatelli 2004, pp. 332). Myotherapy treatment of frozen shoulder is gentler than other aggressive forms of manipulation where traditionally the aim was to forcefully break adhesions of the joint capsule. These aggressive physical therapy programs are uncomfortable and difficult for the patient to tolerate during the treatment and the pain often increases that night or the next day (Ferguson & Gerwin 2005, pp. 93).
Exercises can help with progressing the condition but it is important to understand the process of treatment for frozen shoulder will be gradual and long-term to avoid any disappointment or frustration (Hertling & Kessler 1996, pp. 192). It is not uncommon that physical therapy can be performed for up to 6 months or more. The stage of the condition is important when preparing an individual treatment program as it will affect the treatment undertaken (Donatelli 2004, pp. 332).
The treatment objective during the acute painful stage is pain control and reduction of inflammation. This is achieved with medications usually NSAID’s, ice for its analgesic effect, superficial heat to increase blood flow and increase muscle pliability and grade 1 or 2 joint play movements to promote accessory joint motion (Donatelli 2004, pp. 332). In addition, a home exercise program should be administered to promote ROM and education of aggravating activities. (Donatelli 2004, pp. 332).
During the stiff/frozen and thawing phases the treatment objective should focus on pain reduction and regaining ROM. Initiation of active assisted strengthening exercises e.g. pendulum swing and resisted isometric stretching to the home exercise program. Mobilization of the shoulder is used to attempt to restore joint mobility (Donatelli 2004, pp. 332).
If the condition progresses, often an injection called a hydrodilatation of the glenohumeral joint can be beneficial where cortisone and saline are used to suppress the inflammation. For extreme cases the shoulder may require manipulation under an aesthetic if the condition has not improved and is often the last resort (Ferguson & Gerwin 2005, pp. 99).
Exercises for Frozen Shoulder
1. Pendulum stretch
The pendulum exercise is one of the most popular exercises for relief of symptoms related to Frozen Shoulder. Firstly relax your shoulder and let hang as you stand and lean slightly forward. Swing the hand first in first clockwise rotation in a small circle to go anti-clockwise with 10 revolutions for each, once a day. As symptoms improve, increase the diameter of the swing. The next progression is holding a light weight whilst doing the swings.
2. Towel stretch
This stretch is a nice stretch that you can control depending on your symptoms. Hold a small towel at each end behind your back in a horizontal position. Using your good arm pull the affected arm upward to stretch it. Hold the stretch for 15 - 20 seconds and do 10 times a day.
3. Finger Walk
This is a good assisted exercise when other exercises are too painful or restricted perform. Firstly face a wall about three-quarters of an arm's length away, then reach out and touch the wall at waist level with the fingertips of the affected arm. Slowly walk your fingers up the wall with your elbow slightly bent, until you've raised your arm as far as you comfortably can without too much pain. Your fingers should be doing the work, not your shoulder muscles. Slowly lower the arm (with the help of the good arm, if necessary) and repeat. Perform this exercise 10 to 20 times a day.
4. Cross-body Reach
This is a stretch for mobility of your shoulder which you might have done before. Either sitting or standing use your good arm to lift your affected arm at the elbow, and stretch by bringing it across your body and applying a gentle stretch. Hold the stretch for 15 to 20 seconds and perform 10 to 20 times per day.
5. Armpit Stretch
This is a good stretch and requires very little shoulder strength to perform. Lift the affected arm with your good arm onto a shelf about 80 - 90 degrees. Gently bend your knees to open up the armpit area and then straighten to a level which is bearable and not painful. Do this 10 to 20 times each day.
Causes, Onset and Duration
With poor understanding of frozen shoulder, there are many theories of what may cause it. There can be a spontaneous onset of the condition for no particular reason referred to as idiopathic frozen shoulder and then can be a primary frozen shoulder. It is thought by some that the cause is probably an alteration of scapulohumeral alignment which occurs with thoracic kyphosis (Hertling & Kessler 1996, pp. 190). Others may say the possible causes include immunologic, inflammatory and biomechanical alterations (Donatelli 2004, pp. 320). Secondary adhesive capsulitis is caused by mainly trauma but other factors can trigger frozen shoulder. The onset of pain is very gradual and varies from a constant dull ache to pain felt at the end of restricted shoulder movement (Hertling & Kessler 1996, pp. 190).
Frozen shoulder predisposing factors include:
Injury and trauma - increase of cases due to altered scapulohumeral alignment and/or immobilisation for long period of time.
Surgery - not only including after shoulder surgery but also after breast or lung surgery.
Inflammatory disease
Diabetes -a more troublesome condition than in the non-diabetic population affecting 10% to 20%, often presents bilaterally and the recovery is longer.
Patients with hyper and hypothyroidism
Parkinson's disease
Various shoulder problems and regional conditions (rheumatoid arthritis, Lyme disease and bicipitalten dinitis can accompany frozen shoulder)
Secondary to whiplash and motor vehicle accident
Inactivity (due to pain e.g. shoulder fracture/injury, brachial plexus neuropathy, MTP of muscles especially and shingles)
Autoimmune disease (autoimmune component where the body attacks healthy tissue in the capsule)
Cervical cancer
(Carnes & Vizniak 2010, pp. 104, Ferguson & Gerwin 2005, pp. 99, Hertling & Kessler 1996, pp. 190).
Without physical treatment, 60% of frozen shoulder patients usually recover to daily activities with no symptoms after 2 years (Carnes & Vizniak 2010, pp. 105). Results with treatment however can be achieved within 3 to 4 months, and may well take 1 year in duration to completely recover depending on the individual’s motivation and compliance (Carnes & Vizniak 2010, pp. 105).
A typical patient presents when the restriction of shoulder motion interferes with their daily activities. Until this point most people feel little pain and are often unaware of the problem (Hertling & Kessler 1996, pp. 190). Women may first become aware and find it difficult when brushing their hair or fastening a bra. Men may find it tough when they are reaching into their hip pocket. Both will most likely have trouble sleeping with an awakening pain at night on the affected shoulder (Hertling & Kessler 1996, pp. 190). This is an important characteristic of the pain. Patients seek medical help when the shoulder has lost about 90° abduction, 60° flexion, 60° external rotation and 45° internal rotation (Hertling & Kessler 1996, pp. 190).
Area of Symptoms
The site of pain is the outer shoulder region which is often referred distally into the C5 or C6 dermatome area. In the acute stage pain can radiate down below the elbow and as it becomes more severe it spreads down towards the wrist
(Hertling & Kessler 1996, pp. 190). In the chronic stage pain can be felt during restricted shoulder movement particularly at end range.
Type of Symptoms
The typical symptoms are loss of both active and passive range of motion (ROM) in all directions. Pain can be worsened with attempted motion. If the patient is in the acute stage of frozen shoulder, pain may progress becoming more diffuse and even present without movement (Ferguson & Gerwin 2005, pp. 99).
Frozen shoulder can be divided into three stages of progression. Although not all patients follow the same course, awareness of the typical clinical stages of frozen shoulder is helpful in assessment, treatment, management and prognosis.
Frozen Shoulder Stages
Painful Stage
Is associated with a great deal of pain with and stiffness of the shoulder
Lasting 3-8 months
The onset of symptoms may be spontaneous or due to minor injury
Initially pain may be described as constant or generalised, progressing to severe pain which may radiate down the arm
Sleep is frequently disrupted
At the end of this stage the glenohumeral capsule volume is greatly reduced (Ferguson & Gerwin 2005, pp. 92, Donatelli 2004, pp. 320, Carnes & Vizniak 2010, pp. 104).
2. Adhesive Stage (freezing stage)
Is associated with increasing stiffness but decreasing of general pain
Restricted ROM in a characteristic capsular pattern and painful at the end of ROM
Lasting 4-6 months (Carnes & Vizniak 2010, pp. 104).
3. Recovery Stage (thouring stage)
Pain is minimal
There is characterised by the gradual improvement of shoulder ROM and reduction of stiffness
A number of patients permanently lose full ROM, however few experience serious disability.
Lasting >5 months (Ferguson & Gerwin 2005, pp. 99).
Activities like computer use, driving a car or throwing a ball seem to aggravate the pain of frozen shoulder. Classically sleeping is difficult and will aggravate the pain at night and interrupting sleep (Ferguson & Gerwin 2005, pp. 97).
To alleviate and manage the symptoms a combination of treatments are used. Medication (usually NSAID’s) are used to relieve pain and inflammation seen commonly in the acute stage, TENS & dry needling used for it analgesic affect and thermal therapy such as heat to increase blood circulation & ice packs for its analgesic effect and to relieve inflammation (Donatelli 2004, pp. 332).
It is often seen with frozen shoulder patients that they will put more stress on other joints of the cervical, thoracic and lumbar spine along with their ribs to achieve the ROM needed in activities of daily living (ADL). (Donatelli 2004, pp. 136). This can be highlighted when abducting the arm and having to heave it up awkwardly, flexing the trunk with the weight of their body. This can lead to hypermobility or overuse injuries that need to be assessed and treated to put less stress on the glenohumeral joint (Donatelli 2004, pp. 136).
Assessment of the Condition
Full medical history is taken; assess predisposing factors including trauma, diabetes, inflammatory conditions, recent surgery etc.
Diagnosis is normally made based on signs and symptoms and physical examination of the shoulder
Assessment of PROM and AROM in capsular pattern also note location and degree of pain at the end of range. External rotation being the most restricted followed by abduction then mild to moderate loss of flexion and internal rotation should be found (Donatelli 2004, pp. 320).
Joint play of shoulder where there is restriction of most joint-play movements especially inferior glide (Hertling & Kessler 1996, pp. 190).
Palpation often tenderness over the lateral brachial region because of increased muscle tone. (Hertling & Kessler 1996, pp. 190).
X-Rays may identify joint space narrowing and bone density reduction, however in early adhesive capsulitis they are often normal
An arthrogram or an MRI scan may confirm the diagnosis
Differential Diagnosis
1. Bicipital tendinopathy
2. Osteoarthritis
3. Rotator cuff strain/sprain
4. Impingement syndrome (Carnes & Vizniak 2010, pp. 105).
Reference List
Donatelli, RA 2004, Physical Therapy of the Shoulder, 4th edn, Churchill Livingston, USA.
Ferguson, LW & Gerwin, R 2005, Clinical Mastery in the Treatment of Myofascial Pain, Lippincott Williams and Wilkins, USA.
Hertling, D & Kessler, RM 1996, Management of Common Musculoskeletal Disorders, 3rd edn, Lippincott Williams and Wilkins, USA.
Carnes, M & Vizniak, N 2010, Quick Reference Evidence-Based Conditions Manual,3rd edn, Professional Health Systems Inc, Canada.