Frozen Shoulder

Frozen shoulder is a condition that affects the shoulder joint. Frozen shoulder is also referred to as Adhesive Capsulitis, characterized by initial pain followed by a progressive restricted active and passive joint (glenohumeral) range of motion.

 Frozen shoulder progresses through three phases:

 Freezing phase: This is a painful phase, a sharp pain is present at rest and also at extremes of movement, and night pain with disrupted sleep may last anywhere from 3-9 months.

Frozen phase: This is a phase with more stiffness and pain at extremes of movement, there is a progressive loss of glenohumeral movement in the capsular pattern. The duration of this phase is around 4 months and lasts till about 12 months.

Thawing phase: This phase is marked by progressive improvement in functional range of motion which can last from 1 to 3.5 years.

Frozen shoulder involves restricted movement of the shoulder joint and other symptoms like:

 

• Progressive increase in pain,
• Decrease in active and passive range of motion of the shoulder,
• Stiffness in the arm,
• Disrupted sleep,
• Difficulty in performing overhead activities like combing, grooming, dressing, fastening items behind the back, etc.

 Pathology:

The pathology includes chronic inflammatory response with fibroblastic proliferation which may be immunomodulated. The tissue is present with fibroblasts, proliferating fibroblasts, and chronic inflammatory cells. The infiltrate of chronic inflammatory cells is predominantly made up of mast cells, with B cells, T cells, and macrophages present. 

This condition arises spontaneously for which causes are unknown. It can have multiple reasons like:

 

• After surgical intervention,
• Stroke,
• Diabetes mellitus,
• Parkinson's disease,
• Cancer,
• Shoulder injury,
• Thyroid disorder,
• Dupuytren disease,
• Complex regional pain syndrome.

Physical examination:

The patient is examined for cervical, thoracic, shoulder range of motions (ROM) with shoulder external rotation (ER), internal rotation (IR), abduction (Abd). Neurological examination of the patient is also done, the patient is asked for aggravating and relieving factors. The severity of pain is determined by taking a proper history of the condition and medical history.

 X-ray:

X-ray of the shoulder is done to identify any bone issue, such as bone spurs.

 Magnetic resonance imaging (MRI):

Magnetic resonance imaging (MRI) is used to identify damage to soft tissues, such as a rotator cuff tear. As an MRI can potentially show inflammation, it cannot diagnose frozen shoulder

 Lab tests:

Blood tests are done to detect conditions like diabetes, polymyalgia rheumatic, shoulder tumor, etc because such patients have a high risk of developing frozen shoulder.

Medicines: Non-steroidal and anti-inflammatory, analgesics, painkillers, corticosteroid injections, etc.

Note: Medicines should not be taken without the doctor's prescription.

 Joint distension:

In this method, doctors inject sterile water into the shoulder capsule to stretch it easily and aid in a smoother movement of the shoulder.

 Surgery:

Surgery is the last option for treating frozen shoulder and is done when other treatment options fail. The procedure used is arthroscopy which requires specialized tools, which are inserted into the shoulder through small cuts.

Thermotherapy:

Heat therapy facilitates relaxation and mobilization of the joints, thus heat is found to be very effective in this condition. The patient who complains of night pain is treated by heat therapy.

 Cryotherapy:

Cold therapy helps to decrease pain and inflammation, which helps in increasing joint range of motion.

 Ultrasound therapy:

Ultrasound produces deep heat and also increases the excitability of the contracted soft tissue.

 Transcutaneous Electrical Nerve stimulations (TENS):

Transcutaneous Electrical Nerve stimulations (TENS) are used to decrease pain and swelling and thus help to improve range of motion.

 Laser therapy:

Laser therapy is highly effective for frozen shoulder. This therapy over several weeks reduces chronic inflammation within the joint and gradually helps restore range of motion and normal function.

 Kinesiology taping:

Kinesiology taping provides stability and security to the affected joint and also reduces edema. These tapes are also known to increase support for the affected joint which makes it easy to move while also decreasing shoulder pain.

 Gentle shoulder mobilization:

Gentle relaxed passive gliding movement of the head of the humerus on the glenoid is performed by giving axial traction and approximation, these are carried out along with antero-posterior glide and abduction-adduction glide. In the beginning, slow rhythmic movements are given. Mobilization by accessory movements like acromio-clavicular, sterno-clavicular, and/or scapula-thoracic joint articulation is also recommended.

 Passive movements:

Passive movements reduce pain, pathological limitation of motion. This occurs because of the neuro-modulation effect on the mechanoreceptors within the joint. Passive movements are followed by simple active movements.

 Stretching exercises:

Prolonged stretching causes an increase in the movements too. The exercises include a maximum number of combinations of various movements by minimizing the number of exercises. Graduated relaxed sustained stretching, given in PNF pattern like shoulder elevation with flexion, abduction and external rotation, shoulder internal rotation with extension, adduction, and elbow flexion i.e attaining "hand to lumbar position".

 Self -Assisted stretching:

In Self Assisted stretching method the patient uses his normal or contralateral arm for gradually stretching the affected shoulder. Pendulum stretch, towel stretch, cross-body stretch, inward-outward stretch, armpit stretch, finger walk are examples of simple stretching exercises.

 Strengthening exercises:

Strengthening exercises like closed chain isometric exercises, open chain exercises can be done, other exercises with the help of weights, therabands, pulleys, etc are also given. The weight should be tolerable and comfortable for the patient.

The patient should be advised to do regular stretching exercises even when stiffness and pain are decreased to avoid the recurrence of periarthritis or stiffness. Diabetes patient responds very slowly to the treatment and also feel much more pain as compared to those who are non-diabetic.