Frozen Shoulder? How to manage it?

Introduction

Frozen shoulderis a common and disabling condition, which affects the glenohumeral joint or shoulder joint. Frozen shoulderis affects 1 out of 40 patients, who visit the physicians for medical care. It is characterized by inflammation of the joint, shoulder pain, and stiffness of the joint. Often, the pain becomes very severe that makes it difficult for the patients to bear. Frozen shoulder is also called as adhesive capsulitis.

The prevalence of frozen shoulder is 4% of the total population, and 36% of them are commonly seen in the patients with Diabetes mellitus. It is more common in women than men, and attacks in the 5^th to 7^th decades of life. Usually, in most of the cases, the condition affects both the shoulders.

History

The term ‘frozen shoulder’ was first used by Dr. Codman, in the year 1934. He was the first person who described the diagnostic criteria of frozen shoulder, and Dudley was the one, who first recognized the disease as pathology.

Types of Frozen Shoulder:

In The Open Orthopedic Journal, it is said that, frozen shoulder is classified into two types:

Primary type: It is idiopathic (causes are unknown), and gradual in onset. The symptoms develop slowly.

Secondary type: Secondary cases are general; and occur due to any trauma and prolonged periods of immobilization, which happens in some systemic conditions, like a stroke.

Stages of Frozen Shoulder:

According to several researchers, frozen shoulder is described as a self-limiting medical problem, which resolves within 12-36 months. There are 3 stages of the painful shoulder, which are named as freezing, frozen, and thawing.

Freezing (initial phase):

It is characterized by significant pain and lasts for at least 2-8 months. Lying on the affected shoulder will be painful or impossible and also sleep may get affected. Pain may be there at rest, but it worsens during the movement of arms.

Frozen (adhesive):

It lasts for 3-9 months. The patients experience significant pain and stiffness during the movements like putting the hands behind the back or head (internal rotation). The movements remain uncomfortable even when you try to move the shoulder with your other hand.

Thawing (resolution):

It is also called as recovery phase, and lasts for 9-33 months. It is a phase with less pain, and the stiffness starts reducing gradually.

Causes of Frozen Shoulder:

The causes are mainly idiopathic (not known). This could be due to:

Primary causes:

Rotator cuff Tendinitis

Bicipital tendinitis

Fractures (clavicle, hemerus, radius, etc)

Dislocations of shoulder

Prolonged immobilization

Secondary causes:

Diabetics

Thyroid disease

Stroke

Myocardial infarction

Immune diseases

Referred pain or radiating pain

Aged people

Patients with respiratory diseases

Pathogenesis of Frozen Shoulder:

The pathogenesis of adhesive capsulitis is yet not clear. But, it is triggered by the following factors:

1. Sex: Females
2. Trauma
3. Diabetes
4. Prolonged immobilization period
5. Underlying health issues
6. Age (above 45 years)
7. Other factors:
• Excessive loads on the joints
• Repeated activities of the shoulder
• Repeated strain on the biceps and rotator cuff muscles

So, the above mentioned factors can cause the wasting of small scapular and biceps muscle, and results in the degenerative changes. They may also lead to inflammation and thickening of the shoulder capsule which result in loss of movement.

Diagnosis of Frozen Shoulder:

Plain X-ray can help in the arthrographic evaluation of the shoulder. The radiographic image evaluates the contracted capsule and the other affected parts of the joint area.

Treatment of Frozen Shoulder:

Pain is treated with non-steroidal anti-inflammatory medications and steroid injections. Steroid injections and physiotherapy can improve your motion. It will take a few weeks to see progress. It may take as long as 6 to 10 months for complete recovery. Physiotherapy could be intense and needs to be done every day.

If left untreated, the condition often gets better by itself within TWO years with little loss of movement. Risk factor for frozen shoulders, such as diabetes should also be treated. Surgery is recommended if nonsurgical treatment is not effective.

“Shoulder arthroscopy” is done. During surgery, the scar tissue around the joint is released (cut) by bringing the shoulder through a full range of motion. Arthroscopic surgery can also be used to release tight ligaments and remove the scar tissue from the shoulder.

After surgery, you may receive pain blocks (shots) so you can do physiotherapy.

Physiotherapy management

Physiotherapy includes:

Education

Advice on pain relieving modalities

Activity modification advice

Correction of movement patterns

Exercises to improve mobility

Soft tissue massage

Joint mobilization

The real culprit for the frozen shoulder is the thick and contracted capsule of the shoulder joint. Efforts are targeted at softening this capsule by passive mobilizations and manual techniques.

The following are most effective options available to a physiotherapist in achieving his goal of a mobile shoulder joint:

Thermotherapy:

Before restoring passive mobilization, the thick and contracted capsule can be relaxed and made more stretchable by deep heating using ultrasonic or other suitable modalities (IRR, SWD, IFT, etc;).

Exercises:

In the physiotherapy treatment for frozen shoulder, this is the most important treatment method of the patient healing himself by a home treatment regimen.

The following measures are suggested to the patient to be carried at home at frequent intervals:

Pendulum exercises:

In a forward stooping position, with one hand resting on a table or chair, the patient gradually swings his arm like a pendulum and later carries out a circumduction movement.

Hand to back position:

To decrease shoulder stiffness, start twisting movement such as try to put your hand behind your back or head.

Self stretch:

The Patient is instructed to stretch the affected limb gradually and periodically.

Other measures:

Apart from the above mentioned measures, the following methods are also known to help to combat the stiffness effects of the frozen shoulder.

Shoulder wheel exercises

Pulley exercises

Finger ladder exercises

Wall climbing exercises

Manipulation under General Anesthesia

Preventive measures

Early detection may help prevent stiffness. Consult a specialist if you develop shoulder pain that limits your range of motion for an extended period.

Practicing a proper body movement can help prevent frozen shoulder. Actually, our shoulder is made up of complex structure, which includes bones like shoulder blades, breast bone, clavicle, neck, and upper back. So, you should let your shoulder to do its functions naturally, without exerting excess pressure. But, if you do not maintain proper body mechanics, it can put stress on the structures. Gradually, it may lead to discomfort, and cause inflammation of the shoulder joint, which you may realize later while doing a task.

Healthy diet is another important thing you should consider to prevent shoulder pain. Include the foods in your diet which are rich in Vitamin D and calcium, because they can strengthen the shoulder bones. You should also take vitamin B complex, which is beneficial to nourish and strengthen the ligaments and veins. Maintaining a healthy diet will not only help you avoid frozen shoulder, but also all the unwanted medical conditions.