Frozen Shoulder - Causes, Treatment & Exercises

Frozen shoulder BY Dina Othman Shokri  Objectives At the end of this lecture, the student will be able to: Define frozen shoulder Explain etiology ,pathophysiology, classification of frozen shoulder Understand the different stage of frozen shoulder with its clinic...

Frozen shoulder BY Dina Othman Shokri  Objectives At the end of this lecture, the student will be able to: Define frozen shoulder Explain etiology ,pathophysiology, classification of frozen shoulder Understand the different stage of frozen shoulder with its clinical manifestation Differentiate between frozen shoulder and other related pathological cases Know how to apply a successful patient management. Frozen Shoulder is an enigmatic condition characterized by painful, progressive, and disabling loss of active and passive glenohumeral joint range of motion in multiple planes (at least two directions most notably shoulder abduction and external rotation). Approximately 2% to 5% of adults between age 40 and 70 develop frozen shoulder with a greater occurrence in women and in individuals with thyroid disease or diabetes. There is no known genetic predisposition. The non-dominant arm is slightly more affected then the dominant arm. Once a patient has experienced an episode of frozen shoulder, the risk of recurrence on the contralateral side is 6%–17% within 5 years. Recurrence in the same shoulder is rare. Bilateral involvement occurs in 10% to 40% cases. It is also known as adhesive capsulitis which is a benign, self-limiting condition of unknown etiology, and that spontaneous resolution can be expected. This has not been consistent with our clinical experience. Even if it were true, this should not be a reason for failing to institute active treatment, because with appropriate therapy satisfactory results can be expected within no longer than 3 to 4 months. The only common exception is when a frozen shoulder is part of a sympathetic reflex dystrophy. These cases are often refractory to conservative management and may require supplementary measures such as sympathetic blocks or manipulation under anesthesia.  Pathophysiology The capsule that surrounds the shoulder joint thickens Becomes tight Forms scar tissue called adhesions The shoulder ligaments The shoulder joint is moved less, contributing become inflamed to the ‘frozen’ state. limit the movement of the shoulder Causing pain within the joint The pathophysiology of frozen shoulder is not completely clear. Patients with frozen shoulder had both chronic Inflammatory cells and fibroblast cells, indicating both an inflammatory process and fibrosis. Significant capsuloligamentous complex (CLC) fibrosis and contracture, Contracture of the rotator cuff interval (RCI) is prevalent in patients with frozen shoulder. The rotator cuff interval is a triangular space between the tendon of subscapularis and supraspinatus and the base of the coracoid process. It is roofed by the coracohumeral ligament. It contains the tendon of the long head of the biceps and the superior glenohumeral ligament. The interval acts as an anterior-superior hammock, restricting external rotation with the arm at the side and preventing inferior translation. Imbrication of the RCI resulted in a 50% loss of external rotation with the arm at the side. Capsular fibrosis at the shoulder, the anterior joint capsule becomes especially tight. Adhesion of the capsule to itself and to the neck of the humerus while the redundant folds of the capsule situated anteroinferiorly adhere to one another causes obliteration of the axillary racess, reduction in joint volume, minimal presence of synovial fluid, and restricted glenohumeral movement. The natural course takes 12–42 months before resolution.  Classification of frozen shoulder 1-Primary: if it occurs independent of other pathologies 2-Secondary: (associated with another condition). if it occurs after -Extrinsic pathology to the GH joint as trauma (humeral fracture)/ Surgery/ systemic (diabetes, thyroid problems) -Intrinsic pathology to the GH joint (rotator cuff tear, Biceps tendonitis). Classification according to irritability level  Phases of adhesive capsulitis Adhesive capsulitis progresses through three overlapping clinical phases: Acute/freezing/painful phase: Gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption. Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of glenohumeral motion in capsular pattern. Pain is apparent only at extremes of movement. Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion.  Clinical presentation Onset of adhesive capsulitis is often insidious. Symptom severity and physical findings will vary depending on the disease stage at the time of examination. -Site of pain-Lateral brachial region, possibly referred distally into the C5 or C6 segment.This pain is usually aggravated by shoulder movement and alleviated by rest. Pain may be most intense at night and disrupt sleep. -Difficulty with activities of daily living is common, particularly with those that require reaching behind the back, overhead, or across the body (Apley’s Scratch test). As symptoms progress, patients have increasing difficulty finding comfortable arm positions. Apley’s Scratch test Hand to neck: Shoulder flexion + abduction + ER (Similar to ADLs such as combing hair, putting on a necklace) Hand to scapula: Shoulder extension + adduction + IR (Similar to ADLs such fitting a bra, putting on a jacket, getting into back pocket) Hand to opposite shoulder: Shoulder flexion + horizontal adduction -Limitations of active and passive glenohumeral joint ROM are common in multiple planes. Losses greater than 50% have been reported. The hallmark loss of motion follows a capsular pattern of restriction, which is a characteristic pattern of motion loss, secondary to capsular involvement in synovial joints. In the glenohumeral joint a capsular pattern of restriction is seen by a loss of lateral rotation that is most affected, followed by abduction, followed by a lesser limitation of medial rotation. -External rotation ROM with the arm at the side (neutral) is often significantly reduced in individuals with adhesive capsulitis. Other shoulder conditions that restrict external rotation in neutral (e.g., severe osteoarthritis, proximal humeral fracture, locked posterior dislocation, acute calcific bursitis/tendinitis) have specific radiographic features. Thus the diagnosis of adhesive capsulitis is often based on passive external rotation ROM loss in neutral in conjunction with normal radiographs. -Increases in scapulothoracic joint movement are common, presumably to compensate for lost glenohumeral motion. Scapular movement aberrations may be present, including a “shrug” sign. Shoulder Shrug Sign: During elevation of the glenohumeral joint in both the frontal and sagittal planes. Patients with adhesive capsulitis develop the characteristic “shrug sign” during glenohumeral joint elevation, where the scapula migrates upward prior to 60 degrees of abduction. Joint accessory mobility, In patients with adhesive capsulitis, the anterior and inferior capsule will be the most limited. Restriction of most joint-play movements, especially inferior glide. Fascial mobility assessment: It is likely that limitations in range of motion and the pain associated with frozen shoulder are not only related to capsular and ligamentous tightness, but also fascial restrictions, muscular tightness, and trigger points within the muscles. Shoulder strength may be impaired with adhesive capsulitis, particularly in the glenohumeral internal rotators and flexors.  Diagnosis It is often achieved by physical examination alone, but imaging studies can further confirm the diagnosis and rule out underlying pathology. Radiography rules out pathology to the osseous structures. Arthrography has been used to determine decreased glenohumeral joint volume associated with adhesive capsulitis. Magnetic resonance imaging (MRI) helps with the differential diagnosis by identifying soft tissue abnormalities of the rotator cuff and labrum. MRI has identified abnormalities of the capsule and RCI in patients with frozen shoulder. Ultrasonography, It has gained favor because it can help differentiating rotator cuff tendinopathy from frozen shoulder.  Differential diagnosis Osteoarthritis (OA). Both may have limited abduction and external rotation AROM, but with OA, PROM will not be limited. OA will also present with the most limitations with flexion whereas this is the least affected motion with adhesive capsulitis. Radiography can be used to rule out pathology of osseous structures. Rotator Cuff (RC) Pathologies. The primary way to distinguish RC pathologies from adhesive capsulitis is to examine the specific ROM restrictions. Adhesive capsulitis presents with restrictions in the capsular pattern while RC involvement typically does not. RC tendinopathy may present similarly to the first stage of adhesive capsulitis because there is limited loss of external rotation and strength tests may be normal. MRI and ultrasonography can be used to identify soft tissue abnormalities of the soft tissue and labrum. Posterior Dislocation. A posteriorly dislocated shoulder can present with shoulder pain and limited ROM, but, unlike adhesive capsulitis, it is related to a specific traumatic event. If the patient is unable to fully supinate the arm while flexing the shoulder, the clinician should suspect a posterior dislocation. Active Muscle Guarding" Hollmann et al. (2015) reported in their study that all of the patients suspected to have Frozen Shoulder showed a significant increase in range of motion under anesthesia, which confirms that some cases might have been falsely diagnosed with Frozen Shoulder and that the loss of range of motion cannot only explained by capsular contractions. To diffentiate between True And Pseudo Adhesive Capsulitis The coracoid pain test: Pain on pressure over the coracoid process, a pathognomonic sign of shoulder adhesive capsulitis. Appearance of pain by deep palpation on the coracoid area, which is located just above the anatomical area involved in the disease (RCI). On physical examination, digital pressure was carried out on the AC joint and the anterolateral subacromial area and coracoid area. Patients were instructed to record the severity of pain on a visual analogue scale (VAS) of 0 (no pain) to 10 points (most severe pain). The test was considered positive when the score was 3 points or higher on pressure in the coracoid area compared with the other two areas.  Treatment Oral medications Corticosteroids injection Distension therapy: (hydrodilation).Distension therapy involves injecting large volumes of fluid (saline or local anaesthetic, with or without steroid) into the shoulder joint, with the aim of distending joint capsule. Physical Therapy Treatment Operative treatments: If the symptoms and motion are unresponsive to the previous treatment over time (3-6 months) and quality of life is compromised, a manipulation under anesthesia or surgical capsular release should be considered.  Physical therapy interventions Patient education: Prior to initiating treatment, patients should be educated on the natural history and chronicity of adhesive capsulitis. This can help patients prepare for a slow progression and allay some of their concerns. Patients should also be made aware of the importance of preserving or improving motion on a symptom-limited basis. Instruction in performing a consistent home exercise program (HEP) is important, because daily exercise is effective in relieving symptoms. Instruct the patient in home range of motion exercises. These are necessary to maintain gains made in treatment and to help increase movement. A major goal of the treatment program is to promote independence in mobilization procedures. Once about 120° abduction, 140° flexion, and 60° external rotation are achieved, many patients continue to make satisfactory improvement in range of motion by continuing on a supervised home exercise program. From the outset, though, it is difficult for most patients to make substantial gains in range of motion with home exercises alone; skillfully applied passive movement will significantly accelerate improvement in the early phases of treatment. This is probably because in the relatively acute stage, the reflex muscle spasm that accompanies active movement of the joint prevents patients from exerting an effective stretch to the joint capsule. They simply fight against their own muscles. The therapist skilled in the use of passive joint mobilization procedures can localize the stretch to specific portions of the joint capsule and carefully graduate the intensity of the stretch to avoid eliciting protective muscle contraction. A. Acute stage 1-Relief of pain and muscle guarding to allow early, gentle mobilization -Grade I or II joint-play oscillations. -Modalities: Ice or superficial heat, Hot packs can be applied before or during ROM exercises. Application of moist heat in conjunction with stretching has been shown to improve muscle extensibility. Ultrasound preceding or accompanying stretching procedures, iontophoresis, and phonophoresis, transcutaneous electrical Stimulation (TENS), low-power laser therapy. Deep heating through diathermy combined with stretching was shown to be more effective than superficial heating for treating frozen shoulder patients. A combination of extracorporeal shock wave therapy (ESWT) and electroacupuncture reduces pain and improves shoulder joint range of motion (ROM) for patients with frozen shoulder (adhesive capsulitis). 2. Maintenance of existing range of motion and efforts to gently begin increasing range of motion a. Grade I or II joint-play mobilization. At this stage it is often best to perform these with the patient lying prone and the arm hanging freely at the side of the plinth. Inferior glide is particularly comfortable for most patients and is usually most helpful in relieving muscle spasm. This is an important movement to perform because the spasm, which is usually present in the acute stage, causes the humerus to assume a superior position in the glenoid cavity, further interfering with normal joint mechanics. b. Initiation of active assisted range of motion exercises at home, such as automobilization techniques and wand and pendulum exercises. Pendulum or Codman exercise Range of motion exercises of low intensity and short duration can alter joint receptor input, reduce pain, and decrease muscle guarding. Stretches may be held from one to five seconds in a pain free range, 2 to 3 times a day. A pulley may be used to assist range of motion and stretch.  Internal rotation; Elevation and ER with Forward flexion; horizontal adduction; cane external rotation; pulleys for elevation extension 3. Isometric strengthening exercises, especially for the rotator cuff muscles. The “Shoulder Sling” exercise can be used to help re-train the initial setting phase of the rotator cuff when initiating abduction. The Shoulder Sling exercise for a “rotator cuff set” is considered analogous to a “quad set” exercise in the lower extremity. The elastic band creates an “upward and inward” vector of resistance that the patient must push against in a “down and out” vector. This movement simulates the initiation of abduction as well as the depression and stabilization functions of the rotator cuff, which occur prior to and during abduction. This exercise helps reduce early activation of the upper trapezius during abduction in patients demonstrating a shrug sign. “Shoulder Sling” exercise designed to facilitate “setting” of the rotator cuff. Place an elastic loop under the elbow and around the neck and opposite shoulder. Simultaneously depress your shoulder and initiate abduction against the band resistance, pushing your elbow in a “down and out” motion. Do not actually move the arm away from the body. 4. Postural correction and prevention of excessive kyphosis and shoulder- girdle protraction. When appropriate, provide instruction in postural awareness for the upper trunk and shoulder girdles such that the patient learns to differentiate proprioceptively between a kyphotic, protracted posture and a relatively upright, retracted position. Rigid and Kinesiological Taping. Taping may be helpful in reducing pain and providing tactile cues through proprioceptive and afferent mechanisms. Because adhesive capsulitis patients often exhibit poor posture and scapular mechanics, KT may provide postural cues and assist with promoting proper scapular motion Kinesiological Taping Technique: Postural Spider In more acute cases of frozen shoulder, the patient's major complaint is often the inability to get a good night's sleep: each time he or she rolls onto the involved side, he or she is awakened by pain. The resultant fatigue adds to the patient's general debilitation. Fortunately, with appropriate management this is usually the first aspect of the problem to resolve. In fact, subjective improvement, in the form of significant reduction in night pain, will usually precede any evidence of objective improvement, such as increased range of motion. In our experience, one or two sessions of gentle joint-play oscillations, especially into inferior glide, preceded by superficial heat or ice, are often enough to alleviate nocturnal symptoms. This leads us to speculate whether the night pain may be related more to the fact that the joint is compressed in a position in which the humerus is held into a cephalad malalignment by muscle spasm, rather than being the result of compression of an inflamed joint capsule. At any rate, relaxation of the associated muscle spasm seems to be one of the more important measures in reducing pain in the acute phase. Some people find that placing a cushion or rolled towel under the armpit and gently squeezing it can ease pain. If your shoulder is painful to lie on, the following positions may reduce the discomfort: -Lie on your good side with a pillow under your neck. Use a folded pillow to support your painful arm in front of your body. Another pillow behind your back can stop you rolling back onto your painful side. -If you prefer to sleep on your back, use one or two pillows under your painful arm to support it off the bed. B. Chronic stage -Increase the extensibility of the joint capsule, with special attention to the anteroinferior aspect of the capsule. 1. Continue the modalities 2. Specific joint mobilizations, with emphasis on the anteroinferior capsular stretch. Clinicians attempting to regain shoulder external rotation should perform stretching and joint mobilization techniques that target the rotator interval and coracohumeral ligament. Positional stretching of the coracohumeral ligament in the initial phase of adhesive capsulitis. The stretches performed focused on providing positional low load and prolonged stretch to the CHL and the area of the rotator interval capsule following anatomical fiber orientation. The rationale behind this was to produce tissue remodeling through gentle and prolonged tensile stress on the restricting tissues.  Stretch the rotator cuff interval. The patient’s hand remains fixed and the elbow is moved toward the table. 3-High grade mobilization techniques (HGMT) have been shown to be helpful for improving range of motion in patients with adhesive capsulitis for at least three months. Inferior and posterior gliding mobilizations for the proximal humerus tend to be less irritating and more effective than stretching to increase external rotation or anterior gliding mobilizations in patients with adhesive capsulitis. A-Posterior glide mobilization was determined to be more effective than anterior glide for improving external rotation range of motion in patients with adhesive capsulitis. Traditionally physical therapists have used an anterior glide of the humeral head on the glenoid technique to improve external rotation range of motion a choice based on ‘convex on concave’ concept of joint surface motion. In contrast Roubal et al. used a posteriorly directed glide manipulation based on the ‘Capsular constraint mechanism’ to restore external as well as internal rotation range of motion. Norotny et al found that the tension in the capsular tissue rather than joint surface geometry controls the translatory movements of the humeral head. The capsule plays an important role in dictating the humeral head translation possibly in the opposite direction to the expected effect of joint geometry if restricted. b-Specific joint mobilization techniques are believed to selectively stress certain parts of the joint capsule; for example, an inferior glide with the arm at the side, while in external rotation, would stress the RCI. Inferior glide with the arm at the side and in external rotation. C-Joint mobilization techniques may be combined with hold-relax stretching methods to maximize relaxation. An example is performing a submaximal isometric contraction of the internal rotators, preceding an anterior glide. D-End range mobilization and mobilization with motion (Mulligan) have been shown to be slightly more effective than mid- range mobilization in increasing mobility and functional ability in patients who have had adhesive capsulitis symptoms for at least 3 months. Patients who are too irritable for end-range mobilization may still benefit from mid-range mobilization. E-Scapular mobilization: Scapular upward rotation, posterior tilt, superior tilt, and external rotation have been identified as patterns of dysfunction in patients frozen shoulder syndrome. Scapular motion Scapular mobilization F- Myofascial release: Myofascial trigger points, focal areas of increased tension within a muscle, may be present in the musculature around the shoulder complex in patients with adhesive capsulitis. the subscapularis muscle in particular is referred to as the “Frozen Shoulder” muscle because trigger points in the subscapularis cause limitations in shoulder elevation and external rotation. The Spray and Stretch technique for the subscapularis and latissimus dorsi muscle may be effective at reducing trigger point irritation, pain, and helping to gradually lengthen tight muscles. G-Soft tissue mobilization and deep friction massage may benefit adhesive capsulitis patients. instrument assisted soft tissue mobilization (IASTM) as used in such interventions as Graston Technique®, ASTYM®, or guasha has become increasingly popular in physical therapy practice. IASTM reportedly provides strong afferent stimulation and reorganization of collagen, as well as in increase in microcirculation. The inferior glenohumeral capsule and pectoral fascia are often restricted, as well as the insertion of the latissimus dorsi and subscapularis. IASTM may help improve fibroblast proliferation. and promote normal collagen alignment Instrument-assisted Graston Technique® for treatment of the pectoral fascia. To increase passive motion by Stretching Continuous passive motion or dynamic splinting are thought to help elongate collagen fibers. Because adhesive capsulitis involves fibrotic changes to the capsuloligamentous structures, Stretching exercises. Research regarding connective tissue stretch duration and intensity has showed that high intensity, short duration stretching aids the elastic response, whilst low intensity, prolonged duration stretching aids the plastic response. The concept of total end- range time (TERT) has also been described in the treatment of patients with adhesive capsulitis, suggesting maintenance of a stretch in the maximally lengthened range of motion for a total of 60 minutes per day. The total end range time (TERT) is the total amount of time the joint is held at or near end-range position. TERT is calculated by multiplying the frequency and duration of the time spent at end range daily, and is a useful way of measuring the dose of tissue stress. N.B. Dose is based upon the patient’s irritability classification. In patients with high irritability, low-intensity and short duration (Stretches may be held from 1 to 5 seconds at the relatively pain-free range, 2 to 3 times a day). During the adhesive phase, the focus of treatment should be shifted towards more aggressive stretching exercises in order to improve range of motion. The patient should perform low load, prolonged stretches in order to produce plastic elongation of tissues and avoid high load, brief stretches, which would produce high tensile resistance. Traditional ROM exercises are considered lower forms of tensile stress, while the highest tensile stress doses are achieved by low load prolonged stretching (LLPS).  Spencer Technique The Spencer technique is an osteopathic manipulative technique that dates back to 1916. It consists of a series of shoulder manual treatments. Indication Spencer technique is effective in reducing pain, improving shoulder ROM, and decreasing functional impairment in patients with frozen shoulder. Steps of Technique Step 1: Shoulder extension with elbow flexion Step 2: Shoulder flexion with elbow extension Step 3: Circumduction with compression Step 4: Circumduction with distraction Step 5: Shoulder abduction and adduction ,external rotation with elbow flexion Step 6: Shoulder abduction and internal rotation with elbow flexion Step 7:Distraction also called distraction in abduction with arm extended (inferior glide with scooping movement) to stretching tissue and pumping fluids. Strengthening Exercises Strengthening and aggressive functional activity should be avoided when high and moderate irritability is present, and introduced gradually when individuals have low irritability; however, regaining motion should always be emphasized. Thera band exercises in all planes. Scapular stabilization exercises, and later, advanced muscular strengthening with dumbbells. Resistive exercises typically include strengthening of the scapular stabilizers and rotator cuff, when range of motion has progressed enough for strengthening to be an appropriate intervention.  Closed kinetic chain and proprioceptive exercise Which is very critical to maintain the gained range, improve joint awareness, muscle co-contraction and improves capsular mobility. Shoulder Stabilization Exercises can be done by ball exercise, body weight supported on wall, plinth or mat, light dumbbells and manually.