Frozen Shoulder And Physiotherapy Treatment :

What is Frozen Shoulder?

Frozen Shoulder

Frozen shoulder (adhesive capsulitis) is stiffness, pain, and restricted R.O.M (range of movement) in your shoulder . It may happen after an injury or overuse or from a disease such as diabetes or a stroke,Post Operative surgeory Near to shoulder joint. 

The tissues around the joint stiffen, scar tissue forms, and shoulder movements become restricted & painful. The condition usually comes on gradually, then recover slowly over the course of a year or more.

The exact cause of frozen shoulder is not well understood, but it is believed to involve the thickening and tightening of the capsule surrounding the shoulder joint. Certain risk factors may increase the likelihood of developing this condition, including diabetes, thyroid disorders, previous shoulder injuries or surgeries, and prolonged immobilization of the shoulder.

Treatment for frozen shoulder usually involves a combination of pain management, physical therapy, and occasionally, medications or corticosteroid injections to help reduce inflammation. Physical therapy exercises are aimed at improving range of motion and restoring strength to the shoulder. In severe cases that do not respond to conservative treatments, surgical interventions such as shoulder manipulation under anesthesia or arthroscopic release may be considered.

Related Anatomy:

The shoulder joint is a complex structure that allows for a wide range of motion and consists of several components. Understanding the anatomy of the shoulder can help provide context to the condition known as frozen shoulder.

• Shoulder Bones: The main bones of the shoulder include:
• Humerus: The upper arm bone that connects to the shoulder socket.
• Scapula: Also known as the shoulder blade, it is a flat triangular bone that provides attachment for various muscles involved in shoulder movement.
• Clavicle: Commonly known as the collarbone, it connects the scapula to the sternum (breastbone).
• Shoulder Joints: The shoulder joint is comprised of three joints:
• Glenohumeral Joint: This joint connects the head of the humerus with the glenoid cavity, a shallow socket in the scapula. It is the main joint responsible for shoulder movement and allows for a wide range of motion.
• Acromioclavicular (AC) Joint: It is the joint between the acromion, a bony process of the scapula, and the clavicle.
• Sternoclavicular (SC) Joint: It is the joint between the clavicle and the sternum.
• Shoulder Muscles: Numerous muscles surround the shoulder joint, providing stability and enabling movement. Some key shoulder muscles include:
• Deltoid: It forms the rounded contour of the shoulder and helps with lifting the arm.
• Rotator Cuff Muscles: These muscles, including the supraspinatus, infraspinatus, teres minor, and subscapularis, surround the shoulder joint and work together to stabilize the humeral head within the glenoid cavity.
• Biceps Brachii: Located in the upper arm, it helps with flexion and rotation of the shoulder.
• Triceps Brachii: Located in the upper arm, it assists in extending the shoulder.
• Shoulder Ligaments and Capsule: Ligaments are tough bands of connective tissue that connect bones to provide stability. The shoulder joint is supported by several ligaments, including:
• Glenohumeral Ligaments: These ligaments reinforce the front, back, and bottom of the shoulder joint capsule, providing stability to the glenohumeral joint.
• Acromioclavicular (AC) Ligament: It stabilizes the AC joint.
• Coracoclavicular (CC) Ligament: It stabilizes the AC joint and helps support the clavicle.
• Coracoacromial Ligament: It forms the roof of the shoulder joint, protecting the underlying structures.

The interaction between these bones, joints, muscles, and ligaments allows for the shoulder's wide range of motion and flexibility. When the capsule surrounding the shoulder joint thickens and tightens, as in the case of frozen shoulder, it leads to pain, stiffness, and limited movement.

Causes Of frozen shoulder :

Frozen shoulder can develop when you stop using the joint normally because of pain, injury, or a chronic health condition, such as diabetes or a stroke. Any shoulder problem can lead to frozen shoulder if you do not work to keep full range of motion.

Frozen shoulder main cause:

• post operative surgery near to sholder.
• After surgery or injury.
• Most often in people 40 to 70 years old.
• More often in women (especially in postmenopausal women) than in men.cover
• Most often in people with chronic diseases.
• chest pain and diabetes are often associated with.

Symptoms of Frozen Shoulder

The symptoms of frozen shoulder, or adhesive capsulitis, typically develop gradually and worsen over time. They can vary in severity from person to person. The primary symptoms include:

• Shoulder pain: The pain is usually persistent and may be dull or aching in nature. It is often felt deep within the shoulder joint and can radiate down the arm. The pain may worsen with movement or pressure on the shoulder.
• Stiffness: Stiffness is a hallmark symptom of frozen shoulder. The shoulder joint becomes increasingly difficult to move, and the range of motion progressively decreases. Activities such as reaching overhead, putting on clothes, or reaching behind the back may become challenging or impossible.
• Limited range of motion: As the condition progresses, the shoulder's range of motion becomes significantly restricted. Both active movement (using your own muscles) and passive movement (someone else moving your arm) may be limited. The shoulder may have difficulty with abduction (lifting the arm away from the body), flexion (lifting the arm forward), and external rotation (rotating the arm outward).
• Gradual onset and progression: Frozen shoulder typically develops in three stages, each characterized by different symptoms. The freezing stage is marked by increasing pain and stiffness. In the frozen stage, the pain may subside, but stiffness remains prominent. Lastly, in the thawing stage, the range of motion gradually improves.
• Sleep disturbances: Shoulder pain and discomfort can interfere with sleep, particularly when lying on the affected side or trying to find a comfortable sleeping position.

It's important to note that these symptoms can also be indicative of other shoulder conditions, so it's recommended to consult with a healthcare professional for an accurate diagnosis and appropriate treatment plan.

Stages of Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, progresses through three stages, each characterized by different symptoms and duration. These stages are as follows:

Freezing Stage (Painful Stage):

Duration: This stage typically lasts 2 to 9 months.

Symptoms: The primary symptom during this stage is pain, which gradually increases in intensity. The pain may be persistent and worsen at night, making it difficult to sleep on the affected side. Shoulder movement becomes restricted, and there is a progressive loss of range of motion. Activities that involve reaching or lifting the arm become challenging.

Frozen Stage (Stiffness Stage):

Duration: The frozen stage typically lasts 4 to 12 months.

Symptoms: During this stage, the pain may decrease or become more intermittent, but stiffness and limited range of motion become the prominent symptoms. The shoulder joint becomes significantly stiff, making it difficult to move the arm in various directions. Everyday activities, such as putting on clothes or reaching behind the back, become extremely challenging or impossible.

Thawing Stage (Recovery Stage):

Duration: The thawing stage can last from several months to a couple of years.

Symptoms: In this stage, the shoulder gradually begins to regain its range of motion. The stiffness and pain gradually diminish, and day-to-day activities become easier to perform. The recovery is typically slow and gradual, with some variability among individuals.

It's important to note that the duration of each stage can vary from person to person. Some individuals may experience a faster progression through the stages, while others may have a prolonged course. It is also possible for the condition to resolve spontaneously over time without specific treatment, although treatment can help manage symptoms and expedite recovery.

Risk Factor

Several risk factors have been associated with an increased likelihood of developing frozen shoulder (adhesive capsulitis). These risk factors include:

• Age: Frozen shoulder most commonly affects individuals between the ages of 40 and 60. It is less common in younger individuals.
• Gender: Women are more likely to develop frozen shoulder than men.
• Previous Shoulder Injury or Surgery: Individuals who have had a previous shoulder injury, trauma, or surgery may have an increased risk of developing frozen shoulder. Immobilization of the shoulder joint for an extended period due to injury or surgery can contribute to the development of adhesive capsulitis.
• Systemic Diseases: Certain systemic conditions or diseases are associated with an increased risk of developing frozen shoulder, including:
• Diabetes: People with diabetes are at a higher risk of developing frozen shoulder, and the condition may be more severe in individuals with poorly controlled blood sugar levels.
• Thyroid Disorders: Hypothyroidism, in particular, has been linked to an increased risk of developing adhesive capsulitis.
• Cardiovascular Disease: Some studies have suggested a possible association between cardiovascular diseases and frozen shoulder, although the exact mechanisms are not fully understood.
• Dupuytren's Contracture: Dupuytren's contracture is a condition characterized by the thickening and tightening of the tissue beneath the skin of the palm and fingers. It has been associated with an increased risk of developing frozen shoulder.
• Prolonged Immobilization: Keeping the shoulder joint immobile for an extended period due to factors such as post-surgical recovery, shoulder sling usage, or prolonged bed rest can increase the risk of developing frozen shoulder.

It's important to note that while these risk factors may increase the likelihood of developing frozen shoulder, the condition can still occur without any identifiable cause or risk factors. If you have concerns about your risk of developing frozen shoulder, it is advisable to consult with a healthcare professional for a comprehensive evaluation and appropriate management.

Differential Diagnosis

When evaluating a patient with symptoms suggestive of frozen shoulder, healthcare professionals consider several other conditions in the differential diagnosis. These conditions share some similarities with frozen shoulder but may have distinct characteristics that help differentiate them. Some common conditions to consider include:

• Rotator Cuff Tendinitis or Tears: Inflammation or tears in the rotator cuff tendons can cause shoulder pain and limited range of motion. However, unlike frozen shoulder, the pain in rotator cuff injuries is often more localized to the front or side of the shoulder, and there may be specific movements or positions that exacerbate the pain.
• Shoulder Impingement Syndrome: This condition involves compression or pinching of structures, such as the rotator cuff tendons, in the space beneath the acromion (a bony process of the scapula). Shoulder impingement syndrome can cause pain, weakness, and limited range of motion. Pain is typically felt during overhead activities and may radiate down the arm. However, in frozen shoulder, the primary issue is stiffness and restricted motion, while pain may be more constant.
• Glenohumeral Osteoarthritis: Osteoarthritis of the shoulder joint can lead to pain, stiffness, and limited range of motion. However, osteoarthritis typically presents with a different pattern of pain and may involve additional symptoms, such as joint swelling and crepitus (grating or popping sensations).
• Bursitis: Inflammation of the bursa, which are small fluid-filled sacs that reduce friction between tissues, can cause shoulder pain and limited range of motion. Bursitis pain is often localized to the outer aspect of the shoulder, and there may be tenderness over the affected bursa. Unlike frozen shoulder, bursitis usually does not result in significant stiffness.
• Referred Pain: Pain originating from other structures, such as the neck or upper back, can radiate to the shoulder, mimicking symptoms of frozen shoulder. Evaluating for signs of referred Neck pain and performing a comprehensive examination can help identify the actual source of the symptoms.

Other less common conditions, such as shoulder instability, calcific tendinitis, and certain neurological disorders, can also present with shoulder pain and limited range of motion. A thorough evaluation by a healthcare professional, including a detailed medical history, physical examination, and possibly imaging studies, is crucial to reach an accurate diagnosis and develop an appropriate treatment plan.

Frozen shoulder Diagnoses : 

Your doctor specially phsiotherapist may suspect frozen shoulder if a physical exam reveals restricted shoulder movement. An X-ray may be done to see whether symptoms are from another condition such as arthritis or a broken bone.

The diagnosis of frozen shoulder typically involves a comprehensive evaluation by a healthcare professional, such as an orthopedic specialist or a physical therapist. The process usually includes the following:

Medical History: The healthcare provider will inquire about your symptoms, including the onset, duration, and progression of shoulder pain and stiffness. They will also ask about any previous injuries or surgeries involving the shoulder, as well as any underlying medical conditions, such as diabetes or thyroid disorders, which may increase the risk of developing frozen shoulder.

Physical Examination: The healthcare provider will perform a physical examination of the shoulder joint, assessing range of motion, strength, and any areas of tenderness. They will also check for signs of other shoulder conditions that may mimic frozen shoulder, such as rotator cuff injuries or shoulder impingement syndrome.

Imaging Tests: While imaging tests are not always necessary for diagnosing frozen shoulder, they may be performed to rule out other underlying causes of shoulder pain and stiffness. These tests may include:

X-rays: X-rays can help evaluate the bones and rule out conditions such as osteoarthritis or fractures.

Magnetic Resonance Imaging (MRI): An MRI may be ordered to assess the soft tissues of the shoulder, including the muscles, tendons, and ligaments, and to rule out other conditions.

Diagnostic Injections: In some cases, diagnostic injections may be used to help confirm the diagnosis. A local anesthetic or a corticosteroid medication may be injected into the shoulder joint to determine if it provides temporary pain relief or improves range of motion, suggesting that the symptoms are related to the capsule and not another condition.

Physical Therapist check your available passive range of motion of Shoulder joint. 

Shoulder Joint movement( R.O.M) :

• Flextion : 0-180 degree
• Extension : 0-60 degree
• Abduction:  0-180 degree
• Adduction : 0-45 degree
• Int.Rotation : 0-90 degree
• Ext. Rotation : 0-90 degree

It's important to note that the diagnosis of frozen shoulder is primarily based on clinical evaluation, including the characteristic symptoms of pain and progressive shoulder stiffness. Other conditions with similar symptoms must be carefully ruled out through a combination of history, physical examination, and diagnostic tests.

Treatment Of Frozen Shoulder :

Treatment for frozen shoulder usually starts with Analgesic Drugs,Hot Pack, followed by gentle stretching.  And physical therapy can help increase your range of motion. A frozen shoulder can take a 2 month to 3 months or more to get better.

The treatment of frozen shoulder aims to reduce pain, improve shoulder mobility, and restore functional use of the affected arm. The specific treatment approach may vary depending on the severity of symptoms and the stage of frozen shoulder. Common treatment options include:

Pain Management:

Nonsteroidal anti-inflammatory drugs (NSAIDs): Over-the-counter or prescription NSAIDs may be recommended to help reduce pain and inflammation.

Analgesics: Pain-relieving medications may be prescribed to manage severe pain that is not adequately controlled with NSAIDs.

Physical Therapy:

Stretching and Range-of-Motion Exercises: A physical therapist can guide you through specific exercises to gradually stretch and improve the range of motion of your shoulder joint.

Strengthening Exercises: Once pain and range of motion improve, exercises to strengthen the muscles around the shoulder joint can be introduced.

Heat or Cold Therapy: Applying heat or cold to the shoulder may help alleviate pain and improve mobility.

Corticosteroid Injections:

In some cases, a corticosteroid injection into the shoulder joint may be recommended to reduce inflammation and provide temporary pain relief. These injections are typically used if conservative measures alone are insufficient.

Hydrodilatation:

This procedure involves injecting a sterile fluid (saline) into the shoulder joint to stretch and expand the capsule. It can help improve range of motion and reduce pain.

Manipulation Under Anesthesia (MUA):

In severe cases where other treatments have not been successful, MUA may be considered. It involves manipulating the shoulder joint while the patient is under anesthesia to break up adhesions and improve range of motion.

Surgical Intervention:

Surgery is typically considered a last resort and is reserved for cases where other treatments have failed. The surgical procedure, known as arthroscopic capsular release, involves cutting through tight and thickened portions of the shoulder joint capsule to improve mobility.

It's important to note that the treatment duration for frozen shoulder can be prolonged, ranging from months to years, and individual responses to treatment may vary. Regular follow-up with a healthcare professional is essential to monitor progress and adjust the treatment plan as needed.

If you are experiencing symptoms of frozen shoulder, it is recommended to consult with a healthcare professional, such as an orthopedic specialist or a physical therapist, for an accurate diagnosis and appropriate treatment plan based on your specific condition.

Physiotherapy Treatment:

Physiotherapy plays a crucial role in the treatment of frozen shoulder (adhesive capsulitis) and focuses on reducing pain, improving range of motion, and restoring shoulder function. A physiotherapy treatment plan for frozen shoulder may include the following components:

• Gentle Range-of-Motion Exercises: Initially, the physiotherapist will guide you through gentle exercises to gradually improve the range of motion of your shoulder joint. These exercises may involve pendulum swings, wand exercises, or passive range-of-motion movements performed with the assistance of the therapist.
• Stretching Exercises: As pain permits, stretching exercises are introduced to target the specific muscles and structures that are tight or contributing to limited shoulder mobility. These exercises are performed within a pain-free range and aim to gradually increase flexibility.
• Strengthening Exercises: Once pain and range of motion improve, the focus shifts to strengthening the muscles around the shoulder joint. The physiotherapist will prescribe specific exercises to target the shoulder girdle muscles, including the rotator cuff muscles, to improve stability and support for the joint.
• Manual Therapy Techniques: The physiotherapist may utilize manual therapy techniques, such as joint mobilizations and soft tissue mobilizations, to help improve joint mobility, reduce muscle tightness, and alleviate pain. These techniques are applied directly by the therapist to specific areas around the shoulder joint.
• Modalities for Pain Relief: Modalities such as heat or cold therapy, ultrasound, Interferential Therapy(IFT), or transcutaneous electrical nerve stimulation (TENS) may be used to help manage pain, reduce inflammation, and promote tissue healing.
• Home Exercise Program: The physiotherapist will provide you with a customized home exercise program consisting of stretching and strengthening exercises. Consistent adherence to the prescribed exercises is essential for optimal recovery and long-term shoulder function.
• Education and Activity Modification: The physiotherapist will educate you about the condition, proper posture, body mechanics, and strategies to protect the shoulder joint during daily activities. They may also provide advice on activity modification to prevent aggravation of symptoms.

The frequency and duration of physiotherapy sessions will depend on the severity of your condition and your individual progress. Regular follow-up appointments with the physiotherapist allow for monitoring of your response to treatment and appropriate modifications to the program as needed.

It's important to note that physiotherapy is most effective when initiated early in the course of frozen shoulder and is often a crucial component of the overall treatment plan. Working closely with a skilled physiotherapist can help optimize your recovery and improve your shoulder function.

Exercise for Frozen Shoulder

Exercise plays a vital role in the treatment of frozen shoulder (adhesive capsulitis) by helping to improve shoulder mobility, reduce stiffness, and restore function. Here are some exercises commonly recommended for frozen shoulder:

Pendulum Swing Exercise:

Stand with your unaffected hand resting on a stable surface, such as a table or chair.

Lean forward and let your affected arm hang freely.

Gently swing your arm back and forth, side to side, and in circles to facilitate gentle movement in the shoulder joint.

Perform this exercise for a few minutes, several times a day.

Wand Exercises:

Hold a wand or a broomstick with both hands, palms facing down, and hands shoulder-width apart.

With your unaffected hand, gently guide the affected hand along the wand to perform the following movements:

Flexion: Raise the wand forward, keeping the elbows straight.

Abduction: Raise the wand to the side, keeping the elbows straight.

External Rotation: Rotate the wand away from your body.

Perform each movement for 10-15 repetitions, several times a day.

Wall Climbing:

Stand facing a wall with your fingers pointing upwards.

Walk your fingers up the wall as far as possible, maintaining a pain-free range of motion.

Hold the stretched position for a few seconds, then slowly walk your fingers back down.

Repeat this exercise 10-15 times, several times a day.

Passive Range-of-Motion Exercises:

Using your unaffected arm or with the assistance of a partner, gently move the affected arm to its pain-free range of motion.

Perform exercises such as forward flexion, abduction, external rotation, and internal rotation.

Aim for smooth and controlled movements, avoiding forceful or jerky motions.

Gradually increase the range of motion over time.

Shoulder Stretching Exercises:

Cross-Body Stretch: Use your unaffected arm to gently pull the affected arm across your body, feeling a stretch in the back of the shoulder.

Sleeper Stretch: Lie on your unaffected side with your affected arm at a 90-degree angle. Use your other hand to gently push the affected forearm towards the bed, feeling a stretch in the back of the shoulder.

Hold each stretch for 15-30 seconds and repeat 3-5 times, several times a day.

Remember to perform these exercises within a pain-free range and to consult with a healthcare professional or a physical therapist before starting any exercise program. They can provide specific guidance tailored to your condition and help ensure proper technique and progression. Consistency and regularity in performing the exercises are essential for optimal results.

Back Stretch with towel

shoulder ladder exercise

assisted back stretch with opposite hand

shoulder wheel and ladder exercise

If treatment is not helping, surgery is sometimes done to loosen some of the tight tissues around the shoulder. Two surgeries are often done. In one surgery, called under anesthesia Release, you are put to anaesthesize shoulder and then your arm is moved into positions that stretch the tight tissue. The other surgery uses an arthroscope to cut through tight tissues and scar tissue. These surgeries can both be done at the same time.

How to Prevent Frozen Shoulder?

Gentle, progressive range-of-motion exercises, stretching, and using your shoulder in day to day activity more may help prevent frozen shoulder after surgery or an injury. 

Experts don't know what causes some cases of frozen shoulder, and it may not be possible to prevent these. But be patient and follow your doctor's advice. Frozen shoulder nearly always gets better over time.

While it is not always possible to prevent frozen shoulder completely, there are certain measures you can take to reduce the risk or minimize the severity of the condition. Here are some tips to help prevent frozen shoulder:

• Maintain Shoulder Mobility: Regularly engage in exercises and activities that promote shoulder mobility. Perform range-of-motion exercises for your shoulders to keep them flexible and prevent stiffness.
• Avoid Prolonged Immobilization: Try to avoid keeping your shoulder joint immobilized for extended periods, especially after injury or surgery. Follow your healthcare professional's instructions regarding the appropriate use of slings or immobilizers.
• Gradually Increase Activity Levels: When resuming or initiating physical activities involving the shoulder, start gradually and progressively increase the intensity and duration. Sudden or excessive strain on the shoulder joint can increase the risk of developing frozen shoulder.
• Practice Good Posture: Maintain proper posture to minimize stress and strain on your shoulders. Avoid prolonged slouching or rounding of the shoulders, especially during activities such as sitting at a desk or working on a computer.
• Warm Up and Stretch: Prior to engaging in physical activities or exercises that involve the shoulder joint, warm up your muscles with gentle aerobic activity, and perform stretching exercises specific to the shoulders.
• Avoid Overloading the Shoulder: Be mindful of the weight and load you place on your shoulders during activities such as lifting, carrying, or participating in sports. Use proper lifting techniques and consider using assistive devices or seeking help when necessary.
• Manage Underlying Health Conditions: If you have underlying health conditions such as diabetes, thyroid disorders, or cardiovascular disease, it is important to manage these conditions effectively. Follow your healthcare professional's recommendations and maintain good overall health.
• Seek Early Treatment for Shoulder Injuries: If you sustain a shoulder injury or experience persistent shoulder pain or limited mobility, seek medical attention promptly. Early intervention and appropriate management of shoulder injuries can help reduce the risk of developing frozen shoulder.

It's important to note that while these measures can help reduce the risk of frozen shoulder, the condition can still occur in some cases without any identifiable cause or preventive measures. If you have concerns about your shoulder health or risk of developing frozen shoulder, consult with a healthcare professional for personalized advice and guidance.

Summary

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by pain, stiffness, and limited range of motion in the shoulder joint. It typically progresses through three stages: freezing, frozen, and thawing. The exact cause of frozen shoulder is unknown, but certain factors can increase the risk, such as age, gender (more common in women), certain medical conditions (diabetes, thyroid disorders), and previous shoulder injuries or surgeries.

When diagnosing frozen shoulder, healthcare professionals consider the patient's symptoms, medical history, and physical examination. Imaging tests may be performed to rule out other conditions. Differential diagnosis is important to distinguish frozen shoulder from other shoulder-related conditions such as rotator cuff tendinitis or tears, shoulder impingement syndrome, and glenohumeral osteoarthritis.

Treatment for frozen shoulder aims to reduce pain, improve shoulder mobility, and restore function. It typically includes nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management, physical therapy involving stretching and strengthening exercises, corticosteroid injections, hydrodilatation, and in severe cases, manipulation under anesthesia or surgery.

Physiotherapy is an important component of frozen shoulder treatment. It focuses on exercises to improve range of motion, stretching, strengthening, manual therapy techniques, and modalities for pain relief. Home exercise programs and education on proper posture and body mechanics are also provided.

While prevention of frozen shoulder is not always possible, maintaining shoulder mobility, avoiding prolonged immobilization, practicing good posture, gradually increasing activity levels, and managing underlying health conditions can help reduce the risk. Early treatment of shoulder injuries is also important.

Overall, a comprehensive approach involving medical management, physiotherapy, and lifestyle modifications can help alleviate symptoms, improve shoulder function, and enhance quality of life for individuals with frozen shoulder. It is important to consult with a healthcare professional for an accurate diagnosis and personalized treatment plan.