Frozen Shoulder 

What Is a Frozen Shoulder?

👉 Frozen shoulder is a condition that affects your shoulder joint. It usually involves pain and stiffness that develops gradually, gets worse and then finally goes away. This can take anywhere from a year to 3 years.

👉 Your shoulder is made up of three bones that form a ball-and-socket joint. They are your upper arm (humerus), shoulder blade (scapula), and collarbone (clavicle). There’s also tissue surrounding your shoulder joint that holds everything together. This is called the shoulder capsule.

Shoulder joint 

👉 With frozen shoulder, the capsule becomes so thick and tight that it’s hard to move. Bands of scar tissue form and there’s less of a liquid called synovial fluid to keep the joint lubricated. These things limit motion even more.

👉 Adhesive capsulitis, also known as frozen shoulder, is a condition associated with shoulder pain and stiffness. There is a loss of the ability to move the shoulder, both voluntarily and by others, in multiple directions. The shoulder itself; however, does not generally hurt significantly when touched. Muscle loss around the shoulder may also occur. Onset is gradual over weeks to months. Complications can include fracture of the humerus or biceps tendon rupture.

Symptoms📚

👉 The main symptoms of a frozen shoulder are pain and stiffness that make it difficult or impossible to move it.

👉 If you have frozen shoulder, you’ll likely feel a dull or achy pain in one shoulder. You might also feel the pain in the shoulder muscles that wrap around the top of your arm. You might feel the same sensation in your upper arm. Your pain could get worse at night, which can make it hard to sleep.

You’ll typically go through three phases with a frozen shoulder. Each has its own unique symptoms and timeline.

Freezing stage:-

👉 You develop a pain (sometimes severe) in your shoulder any time you move it.

👉 It slowly gets worse over time and may hurt more at night.

👉 This can last anywhere from 6 to 9 months.

👉 You’re limited in how far you can move your shoulder.

Frozen stage:-

👉 Your pain might get better but your stiffness gets worse.

👉 Moving your shoulder becomes more difficult and it becomes harder to get through daily activities.

👉 This stage can last 4-12 months.

Thawing stage:-

👉 Your range of motion starts to go back to normal.

👉 This can take anywhere from 6 months to 2 years.

Causes📚

👉It’s not clear why some people develop it, but some groups are more at risk.

👉Frozen shoulder happens more often in women than men, and you’re more likely to get it if you’re between the ages of 40 and 60. Your risk might also go up if you’re in the process of recovering from a medical condition like a stroke, or surgery like a mastectomy that keeps you from moving your arm.

👉Certain medical conditions can increase your risk too. You may also be more likely to get frozen shoulder if you have diabetes. About 10% to 20% of people with diabetes get frozen shoulder. Other medical problems like heart disease, thyroid disease, or Parkinson’s disease are linked to frozen shoulder, too.

DIAGNOSIS 📚

👉 Adhesive capsulitis can be diagnosed by history and physical exam. It is often a diagnosis of exclusion as other causes of shoulder pain and stiffness must first be ruled out. On physical exam, adhesive capsulitis can be diagnosed if limits of the active range of motion are the same or similar to the limits to the passive range of motion. The movement that is most severely inhibited is external rotation of the shoulder.

👉Your doctor may decide you need an injection of anesthetic in your shoulder. This is a medication that will numb the pain so that she can better judge your active and passive ranges of motion.

👉 A physical exam is usually enough to diagnose frozen shoulder, but your doctor may also order imaging tests such as X-rays, ultrasound, or MRI to rule out other problems like arthritis or a torn rotator cuff that can also cause pain and limit how far it moves.

Treatment📚

👉Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin or ibuprofen can help relieve the pain and inflammation in your shoulder. If they don’t help, your doctor might prescribe a stronger medication.

👉 Your treatment might also include going to a physical therapist for strengthening and stretching exercises to improve your range of motion.

👉 If your symptoms are intense or don’t improve over time, your doctor might recommend other kinds of treatments, including:

👉A corticosteroid injection in your shoulder joint to reduce your pain and improve your range of motion.

👉Joint distension:- This means your doctor will inject sterile water into your shoulder capsule to stretch it. This can help you move your shoulder more easily.

👉Physical therapy:- Results with this are mixed, and it may be more useful during certain phases of frozen shoulder than others.

👉Surgery:- This is very rarely necessary to treat frozen shoulder. But if other treatments haven’t helped, your doctor may suggest surgery. It likely would be an arthroscopic procedure. That means it’s done with lighted, pencil-sized tools that are inserted through tiny cuts in your shoulder.

👉Shoulder manipulation :- can help loosen up your shoulder tissue, but is very rarely done anymore because arthroscopic surgery has replaced it. Surgeons would forcefully move the shoulder under general anesthesia. With this method, there was an increased risk of complications including fractures. 

Physiotherapy management 

Freezing phase:-

👉Pain is often most severe during the freezing phase and patients in this phase would benefit from learning pain-relieving techniques. These exercises include gentle shoulder mobilisation exercises within the tolerated range (e.g. pendulum exercise, passive supine forward elevation, passive external rotation, and active assisted range of motion in extension, horizontal adduction, and internal rotation). 

👉A heat or ice pack can be applied as a modality to relieve pain before the start of these exercises. The application of moist heat in conjunction with stretching has been shown to improve muscle extensibility. Certain patients might also find it useful to take analgesics before physical therapy.

👉Patients should begin with short-duration (1–5 seconds) range of motion exercises, which should be in a relatively pain-free range. 

 👉  commonly performed stretching exercises that are particularly useful for patients in this painful stage. 

👉Pendulum exercises can be used in flexion or abduction or circular motion. Patients can also try pulley exercises, as tolerated, and neck or scapular muscle releases. It is important not to aggravate a frozen shoulder, as aggressive stretching beyond the pain threshold can result in inferior outcomes, particularly in the early phase of the condition.

👉 There has also been evidence that patients should avoid a forward shoulder posture as it may cause a loss of glenohumeral flexion and abduction.

Photographs show examples of stretching exercises: (a) active assisted shoulder forward flexion with wand; (b) active assisted shoulder external rotation with wand; and (c & d) pendulum exercise.

Frozen phase:-

👉Similar to the freezing phase, a heat or ice pack can be applied during the frozen phase to relieve pain before commencing exercises.

👉 particular, stretching exercises for the chest muscles and muscles at the back of the shoulder should be maintained. Rotation before elevation exercises, such as an external rotation stretch, are also recommended to avoid increasing pain and inflammation.

👉At this stage, strengthening exercises are added to maintain muscle strength. Isometric or static contractions are exercises that require no joint movement and can be done without worrying about increasing pain in the shoulder.

👉 strengthening exercises that can be performed at home. The scapular retraction exercises gently stretch the chest muscles and serve as basic strengthening for the scapular muscles. Isometric shoulder external rotation can also be used for flexion or abduction, within the available range, but care should still be taken to avoid introducing aggressive exercises, as overenthusiastic treatment could aggravate the capsular synovitis and subsequently cause pain.

Photographs show examples of strengthening exercises: (a) scapular retraction; (b) posterior capsule stretch; and (c) isometric shoulder external rotation. In scapular retraction, the scapulae are pulled towards each other (arrows in a).

Thawing phase:-

👉In the thawing phase, the patient experiences a gradual return of range of motion. It is crucial to get the shoulder back to normal as quickly as possible by regaining full movement and strength.

👉 Strengthening exercises are important, as the shoulder is considerably weakened after a few months of little movement. Compared to the frozen phase, the patient can perform more mobility exercises and stretches with a longer holding duration, within tolerated boundaries. 

👉Strengthening exercises can also progress from isometric or static contractions, to exercises using a resistance band, and eventually to free weights or weight machines. 

👉Rotator cuff exercises, as well as posture exercises and exercises for the deltoid and chest muscles, can be included in the treatment as well.