Frozen Shoulder

Frozen shoulder (FS) is a musculoskeletal disorder that is characteristic by the slow but progressive development of limitations of active and passive range of motion.

Etiology:

The causes of frozen shoulder are UNKNOWN and categorized as a painful and self-limited condition of all joint motion especially external rotation[i]. Joint stiffness is the main problem. Besides, sleeping on the affected side is impossible for the patient.

As this problem gradually worsens the patient avoids mobilizing the shoulder, creating a vicious circle in which movement restriction increases pain and causes atrophy resulting in further increased stiffness.

Symptoms:

FS is considered fibrosis of Glenohumeral (GH) joint capsule with chronic inflammatory response[ii]. Patients experience pain and a limited range of motion and disability generally lasting anywhere from 1 to 24 months.

The most common limitation in range of motion (ROM) are:

1. Flexion.

2. Abduction.

3. External Rotation.

Description:

Primary adhesive capsulitis is a chronic inflammatory response with fibroblastic proliferation that due to abnormal response of the immune system[i].

Secondary adhesive capsulitis may arise after a shoulder injury or surgery but is mostly associated with the condition which may include rotator cuff injury, diabetes, where diabetes has a high risk of development of frozen shoulder, thyroid dysfunction, prolonged immobility, CVA, autoimmune disease and with Parkinson disease and HIV infection.

Phases of Frozen Shoulder:

1st phase - Patients can still be performing activity daily living (ADL) even though there is a pain.

2nd phase - Pain is less but the restriction in active motion appears to limit the functional activity.

3rd phases - Increase in mobility which leads to full or almost full recovery of shoulder range of motion.

Even though this condition has spontaneous resolution within 3 years but if the frozen shoulder is not treated it can cause further complications like joint contracture.

Physical Therapy Management:

The main objective of the physiotherapy treatment is to stretch the shoulder joint, to improve ROM and relieve the pain.

Below are examples of some of the Home Exercises Program that might be recommended.

Pendulum stretches

1. Bend forward at the waist, (back parallel to ground is ideal).

2. Allow involved arm to hang down, perpendicular to the floor.

3. Keep arm and shoulder muscles relaxed.

4. Move arm slowly, increasing the arc as tolerated (This technique should cause only minimal pain).

5. Continue for 30 seconds. Each day increase the time until you can do 3 to 5 minutes.

6. Repeat 5 - 10 times per day.

7. Perform this exercise, front to back, side to side, clockwise circles, and counterclockwise circles.

Towel Stretch

1. Simply sling a towel over your shoulder and grab the lower end behind your back with the involved arm.

2. Lift the towel up with uninvolved arm until a gentle stretch is felt.

3. Hold the stretch for 30 seconds, and then slowly release.

4. Repeat 5 - 10 times per day.

External rotation

1. Hold a rubber exercise band (attached to a firm and stable object)

2. Keeping the elbows bend at a 90-degree angle close to the sides.

3. Slowly rotate the lower part of the affected arm outward two or three inches.

4. Hold for 5 seconds, return to start position.

5. Repeat 5-10 times per day.

References:

Neviaser, A. S., & Hannafin JA. Adhesive Capsulitis, A Review of Current Treatment. Am J SportsMed. 2010;38(11):2346–56. [Online] Available at https://bit.ly/2NJG5CR[Accessed on 30 March 2020 2018]

[1] Phil page and Andre Labbe (2010) ADHESIVE CAPSULITIS: USE THE EVIDENCE TO INTEGRATE YOUR INTERVENTIONS. NCBI [Online] Available at https://goo.gl/z1T4Vh (Accessed: 30 March 2020)

[1] Kelley M J et al. 2009 “Frozen Shoulder: Evidence and a Proposed Model Guiding Rehabilitation.” Journal of Orthopaedic & Sports Physical Therapy, [Online] Available at https://bit.ly/2uOJclR[Accessed on 30 March 2020 2018]