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FROZEN SHOULDER-Stages & Treatment

 INTRODUCTION

A frozen shoulder is a very common cause of stiffness and pain in the shoulder joint. It is also termed as, Adhesive Capsulitis as the capsule that encloses the shoulder joint becomes thick, stiff, and inflamed leading to discomfort, pain, and movement restriction in the glenohumeral (shoulder) joint.

The joint capsule is a fibrous sheath lined by the synovial membrane, responsible for producing synovial fluid to provide lubrication to the joint.  

CONTENTS

  1.  Introduction to Frozen Shoulder
  2.  Shoulder joint
  3.  Symptoms and stages
  4.  Causes
  5.  Risk factors
  6.  Diagnosis
  7.  Treatment and physical therapy

SHOULDER JOINT:

The shoulder joint is a ball and socket synovial joint formed by the articulation between the humerus and scapula. The head of the humerus behaves as a ball while the glenoid fossa of the scapula is referred to as the socket. It is a highly mobile joint that allows movement in various directions that are made possible by the overall structure of the joint, the surrounding muscles, tendons, and ligaments. 

 THE SHOULDER JOINT COMPLEX:

The shoulder joint complex comprises the following four main joints:
  • Glenohumeral joint
  • Acromioclavicular joint
  • Sternoclavicular joint
  • Scapulothoracic joint
The glenohumeral joint being the primary joint of the shoulder is a ball and socket synovial joint, allowing various types of movements including, flexion, extension, abduction, adduction, and internal and external rotation. 

TYPES OF MOVEMENTS:

The shoulder joint allows movement in multiple directions, ROM for each type of movement is also mentioned below:
  • Flexion (0-180 degrees) sagittal plane
  • Extension (0-60 degrees) sagittal plane
  • Abduction (0-180 degrees) coronal plane
  • Adduction (0-45 degrees) coronal plane
  • Medial Rotation (0-90 degree) coronal plane
  • Lateral Rotation (0-90 degrees)
  • Horizontal abduction ( 0-45 degrees) transverse plane
  • Horizontal adduction (0-130 degrees) transverse plane
  • Circumduction 

SYMPTOMS OF FROZEN SHOULDER

The signs and symptoms of a frozen shoulder include pain, stiffness, discomfort,, and a restricted pattern of joint movement. This condition progresses through three main stages. The progressive loss of flexion, extension, external rotation,, and abduction is observed with the advancement of stages. These include the following:

STAGE 1: "FREEZING STAGE"

This stage is also referred to as the "painful stage", that can last from 6 weeks to 9 months. Inflammation of the joint capsule as it becomes thickened and tight leading to the formation of adhesions, severe and persistent pain that can occur during rest and intensify at night causing sleep disturbance is the primary symptom of the freezing stage. The pain usually worsens during activity leading to progressive loss of movement mainly affecting the external rotation of the shoulder joint.

STAGE 2: "FROZEN STAGE"

Stage 2, also known as the "stiffening stage" can last from 4 to 12 months. Stiffness and decreased pain are the most significant symptoms. Stiffness leads to a further reduction in the range of motion and loss of movement, external rotation, and abduction of the shoulder joint significantly. ADLs become challenging i.e. a person's daily activities include brushing teeth, combing hair, dressing, reaching for certain items, eating with a spoon, etc. 
The joint capsule continues to thicken and the adhesions within the joint become more established, limiting the pattern of movement further.

STAGE 3: "THAWING STAGE"

This stage, also termed as "resolution stage" can actually last from 6 to 14 months or even, 2 years.
The symptoms at this stage begin to resolve gradually, and the stiffness and pain reduce significantly leading to improvement in the mobility of the shoulder. The range of motion improves slowly with time. 
The adhesions begin to resolve at this point, allowing restoration of normal joint movement. 

Overall, frozen shoulder or adhesive capsulitis can be a lengthy yet, challenging condition to manage. However, most people can achieve improvement and return to their usual activities through proper treatment and guidance as soon as possible. 

CAUSES

Depending upon the causes, the frozen shoulder has been classified into two main types. These include,

 PRIMARY FROZEN SHOULDER:

In most cases, a frozen shoulder occurs due to idiopathic causes i.e. without any known cause or underlying condition. This is often referred to as idiopathic or primary frozen shoulder. Commonly observed in individuals of age 40-60 and prevailing more among women than men.
It usually includes inflammation and fibrosis of the joint capsule.
More common among women than men

SECONDARY FROZEN SHOULDER

In this case, the frozen shoulder usually results from a trauma or injury. Fractures of the shoulder joint resulting from an accident or fall, rotator cuff injury including tears or inflammation lead to pain, stiffness, and difficulty in performing movement. Some other risk factors contributing to the occurrence of frozen shoulder may typically include:

  • Prolonged immobilization or inadequate rehabilitation following surgery of the shoulder joint including rotator cuff repair or shoulder arthroscopy
  • Diabetes Mellitus
  • Thyroid disorders such as hypothyroidism or hyperthyroidism
  • Cardiovascular diseases or any previous heart attacks
  • Neurological conditions such as Parkinson's disease can alter muscle tone and movement patterns
  • Autoimmune inflammatory diseases such as Rheumatoid arthritis, Scleroderma, or lupus
  • Casting or Splinting

DIAGNOSIS

For diagnosis of a frozen shoulder, a combination of clinical evaluation is involved, the patient history, physical examination, and some imaging tests are required to confirm the presence of the condition. 
A physical therapist may perform the following tests to diagnose the condition:

APLEY'S SCRATCH TEST

The patient is instructed to touch the opposite shoulder blade from above and below to assess the shoulder ROM and flexibility during abduction and external rotation of the shoulder (when the patient touches above the shoulder blade), adduction, and internal rotation (when the patient touches below), respectively.   

PAINFUL ARC TEST

The patient is instructed to laterally abduct his arm (0-180 degrees) to identify the rotator cuff pathology or shoulder impingement.

NEER'S TEST

While stabilizing the scapula with one hand, the therapist passively flexes the patient's shoulder to assess for impingement syndrome. 

HAWKIN'S-KENNEDY TEST

The therapist passively flexes the patient's shoulder and elbow to 90 degrees and then, internally rotates the shoulder. Pain observed during internal rotation usually indicates impingement.

IMAGING TESTS

  • X-rays
  • MRI scans
  • Ultrasound
It is important to rule out other conditions that may be causing shoulder pain and symptoms similar to a frozen shoulder. 

TREATMENT FOR FROZEN SHOULDER

Usually, a frozen shoulder does not require any special treatment and would resolve on its own. Here are some treatment options that may help to relieve the pain, and discomfort and speed up the recovery process:

NSAIDs ( NON-STEROIDAL ANTI-INFLAMMATORY DRUGS)

These drugs are used to reduce pain and inflammation. They are available in various forms such as tablets, creams, gels, syrups, etc. Some common over-the-counter NSAIDs used for relieving pain in the case of a frozen shoulder include ibuprofen and naproxen. 
Use the medications as per your doctor's advice.

CORTICOSTEROID INJECTIONS

A corticosteroid injection is considered most effective in the early stages of a frozen shoulder as it helps in reducing the pain and inflammation that can result in an improved range of motion of the shoulder joint. A healthcare professional will inject a corticosteroid medication directly into the shoulder joint while, using imaging guidance such as ultrasound or fluoroscopy to ensure accuracy. The process usually requires only a few minutes. 

PHYSICAL THERAPY

Physical therapy sessions regularly can significantly help in reducing pain and improving the range of motion of the shoulder joint. It helps in improving the flexibility and strength of the muscles around the joint. By performing certain stretching and strengthening exercises, you may be able to speed up the recovery process. In the early stages of a frozen shoulder, pain relief techniques that are found to be the most effective include:
  • HEAT THERAPY: Applying a heat pack to the shoulder for approximately 15-20 minutes can help improve circulation in the targeted area, loosen the tight muscles, and relieve pain.
  • CRYOTHERAPY: Also referred to as "cold therapy" involves the application of ice or cold packs on the shoulder for 10-15 minutes to reduce inflammation and speed up the recovery process.
  • TENS: A transcutaneous electrical nerve stimulation device is used to manage the pain by stimulating the nerve endings.
  • ROM EXERCISES: Passive range of motion exercises may be performed by the therapist to prevent further stiffness. The therapist will move the patient's arm through the available pain-free range of motion of the joint. 
  • PENDULUM EXERCISES: The patient is required to lean forward with an unaffected arm supporting the affected arm and then, gently swinging it back and forth to form small circles. The range of motion is increased gradually as per the tolerance of the patient. 
  • STRENGTHENING EXERICSES: These usually include, isometric and light weight exercises. Strengthening exercises play a major role in speeding up the recovery process and regaining mobility as soon as possible. They help in rebuilding strength in the muscles that surround the joint without applying stress to the joint.
  • STRETCHING EXERCISES: Stretching techniques help in improving flexibility and regaining mobility. Some most common stretching exercises performed to treat a frozen shoulder include, Codman exercises and doorway stretches. 
  • MANUAL THERAPY: Massage and joint mobilization techniques can also help in reducing the pain and tension in the muscles.
Posture correction is also taken into consideration when treating a patient with a frozen shoulder. The therapist may also provide exercises to the patient to improve the posture and overall body mechanics. A good posture plays an important role in distributing the joint evenly on the shoulder joint thus, helps in successful recovery. 
As the stages of frozen shoulder progress, the intensity and duration of exercises being performed change. Proprioceptive and functional exercises are also added to the routine exercises to regain mobility and attain a normal range of motion as soon as possible. 

SURGERY 

Surgical intervention for a frozen shoulder is the last treatment option available. It is typically only considered when the medications and physical therapy have failed to provide significant relief in symptoms for several months or a year. The types of surgical procedures performed for treating a frozen shoulder usually include the following:
  • SHOULDER JOINT MANIPULATION UNDER ANESTHESIA: MUA ( manipulation under anesthesia) involves putting the patient to sleep using general anesthesia, as shoulder manipulation in such a condition can be extremely painful if performed while keeping the patient awake. The surgeon gently forces the shoulder joint of the patient through a series of motions to break up the scar tissue and stretch the tight capsule and muscles around the joint to relieve discomfort and restore the normal functioning and range of motion of the shoulder joint. 
  • ARTHOSCOPIC CAPSULAR RELEASE: It is a minimally invasive surgical procedure that typically involves making small incisions in the shoulder to insert an arthroscope to visualize the shoulder joint and the surgical tools to cut and release the tight portions of the joint capsule. It is considered less painful than the above-mentioned procedure and offers restoration of movement with faster recovery. 
While, surgery has its own potential risks and complications including, bleeding, infection at the surgical site, nerve damage,, or stiffness. The recovery process can take up to several months, depending upon the severity of the condition and the surgical procedure that was performed. 

HOME EXERCISES FOR TREATING A FROZEN SHOULDER

Some of the most effective and easy-to-perform home exercises for frozen shoulder include the following:
  • CROSS-ARM STRETCH


  • DOORWAY STRETCH


  • PENDULUM EXERCISE

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