Frozen Shoulder

What is Frozen Shoulder ?

Adhesive capsulitis, another name for frozen shoulder, is an inflammatory illness with an unclear etiology that results in pain, stiffness, and a noticeable loss of active and passive range of motion in the shoulder. Typically, the patient’s history, physical examination, and radiographic evaluation result in no notable findings that could account for the pain and limited range of motion.

Frozen shoulder is more common in people recovering from diseases or surgeries that affect arm movement, such as stroke or mastectomy, and in people who have diabetes. For the treatment of frozen shoulder, range-of-motion exercises are utilized in along with injections of corticosteroids and anesthetics into the joint capsule.

Exercise therapy, which focuses shoulder flexion and extension, is the primary treatment for frozen shoulder.
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Anatomy

Basic knowledge about the anatomy and function of the shoulder joint is necessary in order to comprehend frozen shoulder. Your humerus, scapula, and clavicle are your shoulder blades, collarbone, and upper arm. Your shoulder joint’s surrounding tissue is also that holds everything together. We refer to this as the shoulder capsule.

Shoulder bone structure:

• The “ball” of the shoulder is the humerus, also known as the upper arm bone.
• The scapula contains attachment points for numerous muscles and ligaments.
• Connect with one another to form a “ball and socket” structure at the shoulder.
• The clavicle, another name for the collarbone, has a ‘S’ shape, despite showing straight at first.
• It is within the thorax, or rib cage, that ligaments and muscles are attached.

Shoulder bone junctions or joints;

Glenohumeral joint

• The main joint of the shoulder is this one.
• The glenoid of the scapula and the head of the humerus meet in the joint.
• The flat socket of the glenoid surrounds only twenty to thirty percent of the humeral head.
• The joint is mainly supported by the soft tissue surrounds it because of its weak fit.
• The labrum, a ring of fibrocartilage tissue connected to the glenoid, connects a greater area of the humerus.

Acromioclavicular joint

• It represents the peak of the bony tip of the shoulder.
• Scapula stability on the chest is achieved by connecting the scapula’s acromion to the clavicle, or collar bone.
• Shock absorbers in the spaces between the bones are large fibrocartilage disks.
• The joint’s support system consists of the surrounding capsule and ligaments.

Scapulothoracic articulation

• The scapula, which is a muscle, moves over the thoracic rib cage in this region.
• The surrounding muscles and ligaments keep the scapula in its natural posture so that the arm can move properly.

The shoulder cartilage:

There are two different types of cartilage in the shoulder joint.

Articular cartilage

• The bright white covering that covers the end of the humeral head is the glenoid’s inner layer.
• Easy mobility is made possible by cartilage’s smooth, slippery surface.
• It has evolved into a covering for the underlying bone that reduces shock.

Fibrocartilage

• The glenoid supports the thick tissue that forms the SC joints, the disk of the Acromioclavicular joint, and the labrum.
• Fibrous cartilage has three functions;
• Function as a cushion for shocks.
• Help in joint support by improving the fit of the bones.
• Function as a cushion that improves the surface contact of the articular cartilage.

Ligaments of the shoulder:

• For the shoulder, the ligament offers a lot of support.
• It is attached from bone to bone and gives the joint static stability.
• It will alternately become loose and tight with regular motion.
• They are going to keep the joint in its normal range of motion.
• The glenohumeral ligaments are layered in two places: the glenoid labrum and the humeral joint capsule.
• The coracoacromial arch is the ligamentous group that spans the bony projections known as the acromion and the coracoid process.
• These two ligaments the coracoclavicular and acromioclavicular provide the majority of the support for the AC joint.

Shoulder Tendons and Muscles:

Both support the shoulder joint’s “dynamic” stability.
Four groups of muscles make up the shoulder.

Rotator cuff muscles:

• Among the rotator cuff muscles are the teres minor, supraspinatus, infraspinatus, and subscapularis muscles.
• The shallow socket for the humerus may offer insufficient protection.
• The four muscles surround the humeral head to provide adequate security in the socket.
• The name of this group of muscles indicates that they also rotate the arms.
• These muscles allow the large muscles that control the shoulder and give the arm a great deal of movement while protecting the glenohumeral joint from dislocation.

Biceps tendon complex:

• Maintaining the humeral head in the glenoid and raising the arm are further benefits of these muscles.

Scapulothoracic muscles:

• The scapulothoracic muscles attach to both the thorax and the scapula.
• The main function of the muscles is to maintain the scapula in order to allow the shoulder to move freely.

Muscles that are superficial:

• These make up the numerous, strong layers of external muscle in the shoulder.
• All-around shoulder functionality depends on these muscles.
• Include in this group is the deltoid muscle, which is responsible for covering the rotator cuff.

Bursa of the shoulder:

• A bursa is a cavity that is partially filled with fluid, just like a cushion.
• Reduced friction and a smooth transition between two hard structures, like a bone and a tendon or a bone and muscle, are the goals of plural bursae.
• A total of fifty bursae are found in the human body, with the subacromial bursa, located below the shoulder acromion, being the largest.
• There is a tendency to consider the subacromial bursa and the subdeltoid bursa, which are situated between the deltoid muscle, to be one and the same.
• This bursa is located between the rotator cuff and deltoid muscles, away from the acromion.

The pathophysiology of Frozen Shoulder:

The anterior-superior joint capsule, the lateral pause, and the coracohumeral ligament were all impacted by this disease process.
The patient has mild to severe synovitis, axillary fold loss, a tight anterior capsule, and a small joint without a true adhesion.
It has also been shown that patients with frozen shoulders have rotator cuff contracture, which may account for some of their limited range of motion. These are in opposition to the underlying pathology, which could be a fibrosing illness, a goneurodystrophic process, or an inflammatory disease.

Phases / stages of Frozen Shoulder

There are three phases of Frozen Shoulder

• Freezing
• Frozen
• Thawing

• Freezing phase : It is a painful phase which lasts about 2-9 months. In this phase there is a gradual onset of diffuse, a person feels severe shoulder pain specifically during night time.

• Frozen phase : It is an adhesive phase which lasts about 4-12 months. In this phase pain will decrease. In frozen phase there will be a characteristic loss of shoulder movements. The individual is incapable of performing shoulder flexion, shoulder abduction, external rotation, and internal rotation, for instance.

• Phase of thawing: During this period, which lasts roughly five to twenty-six months, the person gradually resumes shoulder movements.

It usually takes 1-3 years for frozen shoulder to return its range of motion on it’s own without treatment.

Causes of frozen shoulder

There are two types of causes

• Primary cause
• Secondary cause

Primary frozen shoulder is often related to other diseases or conditions such as diabetes mallitus, Parkinson’s disease and thyroid conditions.

Secondary frozen shoulder is caused due to immobilisation of shoulder for longer period of time. There can be various reasons for immobilisation of shoulder for example injury to rotator cuffs.

Frozen shoulder symptoms:

• Pain in the shoulder is usually dull or painful. It usually gets worse in the little hours of the day.
• Usually found over the outer shoulder, but it are sometimes found as well over the upper arm.
• The main symptoms of a frozen shoulder are pain and stiffness, which can make it difficult or impossible to move the shoulder.
• Swelling is present in the frozen shoulder.
• In addition to experiencing problems with daily activities, the patient’s range of motion (ROM) at the shoulder has decreased.

Risk factor

• Injury to the shoulder recently

You run a higher risk of developing frozen shoulder if you have shoulder surgery or an injury that requires you to immobilize your shoulder (using a brace, sling, shoulder wrap. Rotator cuff tears and fractures to the upper arm, collarbone, or shoulder blade are a few examples.

• Age

Adults with frozen shoulder most frequently experience it between the ages of 40 and 60.

• Diabetes is a condition

Ten to twenty percent of diabetics experience frozen shoulder.

• Additional illnesses and ailments

This includes heart disease, Parkinson’s disease, stroke, hyperthyroidism (overactive thyroid gland), and hypothyroidism (underactive thyroid gland). Because of the potential for limited arm and shoulder movement, stroke is a risk factor for frozen shoulder.

Diagnosis:

Physical Examination:

• The patient’s medical history and symptoms are discussed, and then the physiotherapist performs an examination of the shoulder.
• The physiotherapist will carefully move the shoulder in every direction to observe shoulder mobility.
• Individuals who suffer from frozen shoulders encounter discomfort during movements and have a limited range of motion.
• Similar to giving a patient a stretch after engaging in active range of motion, physiotherapists perform passive movement after active movement.
• Individuals who suffer from frozen shoulders are limited in their range of motion in both the active and passive domains.

Imaging Examinations:

Additional tests, such as X-rays of dense structures like bones, help the doctor rule out alternative causes of pain and stiffness.

X-rays

• X-rays may reveal more shoulder issues, such as arthritis.

A review of magnetic resonance imaging (MRI) and ultrasound

Both magnetic resonance imaging (MRI) and ultrasound have the potential for better imaging of soft tissues. While it’s not necessary to rule out other shoulder conditions like a torn rotator cuff, it helps in the diagnosis process of frozen shoulder.

Treatment:

For frozen shoulders, symptomatic therapy is the main approach. Medical, physiotherapy, and physical activity are helpful when trying to recover from a frozen shoulder. Surgery is the last option if none of these approaches work.

Non-Surgical Treatment:

The majority of frozen shoulder patients get better with comparatively easy pain management and range of motion exercises.

• Making the most of any other medical issues that may be contributing to or worsening your frozen shoulder is among your most important options.
• For example, creating a plan with your primary care physician  to modify your diabetes medication to improve your glucose control can actually improve the healing process for your frozen shoulder in the event that you have diabetes and an elevated A1C.

Anti-inflammatory non-steroidal medications (NSAIDs)

• Pain and swelling are lessened by prescription medications like ibuprofen and aspirin.

Injections of steroids

• An injection of the potent anti-inflammatory medication cortisone is given right into the shoulder joint.

Physiotherapy

• Certain exercises will help in regaining motion.
• These can be completed at home with a program or under the guidance of a physiotherapist.
• Exercises involving shoulder range of motion or stretching are part of therapy.
• Sometimes applying heat to the shoulder before stretching helps relax it up.
• Pain management techniques such as TENS, LASER, Interferential Therapy and ultrasound therapy are used to reduce pain and relax associated signs like muscle spasms.

Home care:

• Pain can be reduced by applying an ice pack to your shoulder for fifteen minutes at a time, several times a day.
• The exercises you perform at home with a physiotherapist can be done at your residence.
• You will receive instructions from your physiotherapist regarding the kinds of exercises you need to perform, how often to perform them, and when to challenge yourself more.
• Without surgery, the majority of patients with frozen shoulders are able to recover.

Exercise for frozen shoulder:

Electrotherapy modalities are the key component of physiotherapy, as are exercises designed to strengthen weak muscles, improve range of motion, and stretch tight muscles in the shoulder region.

Exercise’s positive health effects for frozen shoulders;

• Improve the quality of your movements.
• Support your independence from other people.
• Decrease pain
• Reduce pain
• Maintain your physical strength.
• Expand range of motion, improve lymphatic and venous drainage, and promote relaxation.

Pendulum

• Taking a few deep breaths, stand straight on the ground.
• Bend forward and place one hand on a counter or table for support.
• The other arm ought to remain at your side.
• Gently swing your arm back and forth.
• As you repeat the exercise, step your arm from side to side and then in a circular motion.
• Then return to your neutral position.
• Then relax.
• Repeat this exercise 5 to 10 times.

Wand flexion

• Place yourself on the ground in a comfortable standing position.
• When grasping a stick, your hands should be shoulder-width apart.
• Gently spread your arms out in front of you.
• Simultaneously move your affected arm with your unaffected arm and relax your affected arm.
• Move gently when doing the exercises.
• Hold this position for a few seconds.
• Slowly lower your arms.
• Then return to your neutral position.
• Then relax.
• Repeat this exercise 5 to 10 times.

Wand extension

• First, try to arrange yourself in a comfortable standing position on the ground.
• Behind your back, grasp a stick with both hands.
• Reach back with the stick.
• Hold this position for a few seconds.
• Then return to your neutral position.
• Then relax.
• Repeat this exercise 5 to 10 times.

Shoulder pulley

• Secure it to the door while you’re seated right below the shoulder pulley.
• Take hold of the pulley’s two ends, palms facing each other.
• The handle can be pulled down to and over the knee with your “good” hand to raise the right arm.
• As high above your head as you can, raise and maintain your stiff arm.
• Then return to your neutral position.
• Then relax.
• Repeat this exercise 5 to 10 times.

Finger ladder Exercises

• The patient stands facing a ladder that extends over a wall.
• Instruct them to gently rest their affected hands on the ladder’s lowest step.
• After that, proceed climbing the finger ladder gradually all the way to the top before lowering again.
• Then return to your neutral position.
• Then relax.
• Repeat this exercise 5 to 10 times.

Surgery

• Arthroscopic capsule release is another term for the surgical method used to treat frozen shoulders.
• This procedure involves inserting the tiny camera into the shoulder joint.
• Small instruments are also inserted to treat the issue through tiny incisions made by other people.
• The tight and thickened capsule surrounding the shoulder is the cause of frozen shoulder.
• Consequently, in order to increase the joint’s mobility, the procedure entails cutting the tight capsule.
• Patients will occasionally give their arms specialized splints to keep their shoulder capsules stretched.

Summary:

Adhesive capsulitis, commonly referred to as frozen shoulder, can make daily living challenging. Shoulder joint stiffness and discomfort can make it harder or even impossible for you to perform daily tasks that you used to be able to complete without any problems.

If self-care techniques such as rest and painkillers don’t work, consult your healthcare provider. They might advise starting with non-invasive techniques like physical therapy. Surgery may be necessary if the frozen shoulder doesn’t go away after a significant amount of time. To figure out the best course to take for you, speak with your physician.

FAQ:

References:

• On April 15, 2024b, Ladumor, D. The Cause, Management, and Exercises of Frozen Shoulder. Exercise and Physical Therapy Treatment. http://frozen-shoulder.us/physical-therapy

• C. C. M., Professional (n.d.). Adhesive capsulitis resulting in frozen shoulder. Cleveland Clinic: https://my.clevelandclinic.org/health/diseases/adhesive capsule inflammation of the frozen shoulder

• Adhesive Capsulitis – Frozen Shoulder – Ortho Info – AAOS (n.d.). A frozen shoulder can be caused by a number of diseases and conditions.

• Image 1, M. Spark (2020b, Apr. 20). Countryside Orthopaedics explains what a frozen shoulder is. Backyard Orthopaedics. What does the term “frozen shoulder” mean? https://www.countrysideortho.com/

• Image 2, Try these seven exercises to help stretch and strengthen your frozen shoulder. August 1, 2024b. Harvard Medical. https://www.health.harvard.edu/freezing-shoulder-exercises

• Image 3, S. S. Ekka (2023) February 11. Four Simple Shoulder Wand Exercises to Help with Stiff, Achy Shoulders. Physios unit. See https://physiosunit.com/#google_vignette for shoulder-wand exercises # 2.

• Image 4, Wand (Standing) ROM Extension. (n.d.–b). The URL for this page is https://iris.hattiesburgclinic.com/patadv/exkit/Orthopedic/English/0290000930shld094m_English.html.

• Image 5, Atemi Sports, “Shoulder Pulley Exercises for Physical Therapy and Rehab” (2023, February 7). Shoulder pulley exercises: Atemi Sports. https://atemi-sports.com/

• Image 6, Fabrication Enterprises Retail Sales Corp. – Shoulder Finger Ladder Archives (n.d.). The Fabrication Enterprises Retail Sales Corp.