FROZEN SHOULDER

INTRODUCTION:

Adhesive capsulitis (AC), often referred to as Frozen Shoulder, is characterized by initially painful and later progressively restricted active and passive glenohumeral (GH) joint range of motion with spontaneous complete or nearly-complete recovery over a varied period of time.

Common names for AC include:

• Frozen Shoulder
• Painful stiff shoulder
• Periarthritis

This inflammatory condition causes fibrosis of the GH joint capsule, is accompanied by gradually progressive stiffness and significant restriction of range of motion (typically external rotation).

In clinical practice it can be very challenging to differentiate early stages of AC from other shoulder pathology.

The brief video below gives a good summary of the condition.

ETIOLOGY:

• The etiology of frozen shoulder is, however, complex and multifactorial with both genetic and environmental factors playing an important role.
• Long held hypothesis based on arthroscopic and pathologic observations, that there is an inflammatory component within the axillary fold. This is followed by stiffness and adhesions, which results in fibrosis of the synovial lining, which is associated with the inflammation.

AC may be:

1. Primary - Onset is generally idiopathic (it comes on for no attributable reason)
2. Secondary - Results from a known cause, predisposing factor or surgical event.  A secondary frozen shoulder can be the result of several predisposing factors. For example, post surgery, post-stroke and post-injury. Where post-injury, there may be an altered movement pattern to protect the painful structures, which will in turn change the motor control of the shoulder, reducing the range of motion, and gradually stiffens up the joint.

• Three subcategories of secondary frozen shoulder include:
  1. Systemic (diabetes mellitus and other metabolic conditions);
  2. Extrinsic factors (cardiopulmonary disease, cervical disc, CVA, humerus fractures, Parkinson’s disease)
  3. Intrinsic factors (rotator cuff pathologies, biceps tendinopathy, calcific tendinopathy, AC joint arthritis). 

Adhesive capsulitis more prevalent

• In women, as approximately 70% of individuals who present with a frozen shoulder, are females.
• Among individuals 35-65 years old, with an occurrence rate of approximately 2-5% in the general population,  In China and Japan, it's called the 50 year old shoulder due to its prevalence at that age.
• Within the diabetic population, with an occurrence rate of 20% . 
• If an individual has had AC (5-34% chance of having it in the contralateral shoulder at some point as well). Simultaneous bilateral involvement has been found to occur in approximately 14% of cases.

RISK FACTORS:

• Diabetes mellitus (with a prevalence of up to 20%)
• Stroke
• Thyroid disorder
• Shoulder injury (FOOSH, direct impact, dislocation)
• Dupuytren disease
• Parkinson's
• Complex regional pain syndrome
• Avascular necrosis (rare, but can occur)
• Tuberculosis
• Shortness of breath, severe cough, any compromises to the quality of the breath
• Metastatic disease
• Rheumatisms
• Multiple joint involvement
• Fever, chills, severe (inexplicable) pain
• History of cancer (to the individual, or family)
• Any suspicion of a systemic pathology or condition.

HIGH-RISK POPULATION:

• Diabetics: There is a high incidence of adhesive capsulitis in diabetic patients (prevalence is as high as 10 to 22 percent of individuals with diabetes mellitus versus as 2 to 4 percent of the general population). These patients generally do not respond well to treatment, as well as non diabetic patients do.
• Hypothyroidism: Can have an influence because we can develop muscle aches and tenderness and stiffness with hypothyroidism.
• Metabolic syndrome: Metabolic syndrome is a cluster of conditions occurring together that increase the risk of, amongst other things, type two diabetes.

CLINICAL FEATURES:

Patients presenting with adhesive capsulitis will often report an insidious onset with a progressive increase in pain, and a gradual decrease in active and passive range of motion.

One of the main presenting factors is loss of external rotation (ER) in a dependent position with the arm down by the side.

Patients frequently have difficulty with grooming, performing overhead activities, dressing, and particularly fastening items behind the back. Adhesive capsulitis is considered to be a self-limiting disease with sources stating symptom resolution as early as 6 months up to 11 years. Unfortunately, symptoms may never fully subside in many patients.

The literature reports that 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 which may last anywhere from 2-9 months.
• Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of GH motion in capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last till about 12 months.
• Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion which can last anywhere from 5 to 24 months. Despite this, some studies suggest that it's a self limiting condition, and may last up to three years. Though other studies have shown that up to 40% of patients may have persistent symptoms and restriction of movement beyond three years. It is estimated that 15% may have persistent pain and long term disability. Effective treatments which shorten the duration of the symptoms and disability will have a significant value on reducing the morbidity.

ASSESSMENT:

Taking Patient History:

• Listen carefully to the patient’s past medical history (PMHx), this may well rule out red flags and guide the shoulder examination.
• History of presenting condition (Hx PC).
• Pain distribution and severity: Strong component of night pain, pain with rapid or unguarded movement, discomfort lying on the affected shoulder, pain easily aggravated by movement. Pain can be anywhere from the base of the skull, from down the arm into the hand.
• Aggravating activities - limited reaching, particularly during overhead (e.g., hanging clothes) or to-the-side (e.g., fasten one's seat belt) activities. Patients also suffer from restricted shoulder rotations, resulting in difficulties in personal hygiene, clothing and brushing their hair. Another common concomitant condition with frozen shoulder is neck pain, mostly derived from overuse of cervical muscles to compensate the loss of shoulder motion

ON OBSERVATION:

Scapular winging of the involved shoulder may be observed from the posterior and/or lateral views.

JOINT RANGE OF MOTION ASSESSMENT:

Cervical, thoracic, shoulder ROMs with OP as well as rib mobility should be performed. Reduced forward flexion, abduction, external rotation, and internal rotation range of motion are key clinical signs of adhesive capsulitis.

• Scapular substitution frequently accompanies active shoulder motion

Shoulder Flex/ABd/ER/IR

• The method of measuring ER and IR ROM in patients with suspected adhesive capsulitis varies in the literature
• Patients with adhesive capsulitis commonly present with ROM restrictions in a capsular pattern. A capsular pattern is a proportional motion restriction unique to every joint that indicates irritation of the entire joint. The shoulder joint has a capsular pattern where external rotation is more limited than abduction which is more limited than internal rotation  (ER limitations > ABD limitations > IR limitations). In the case of adhesive capsulitis, ER is significantly limited when compared to IR and ABD, while ABD and IR were not seen to be different.

ACCESSORY MOVEMENTS:

Glenohumeral joint:

• Anterior 
• Inferior
• Posterior
• Posterior capsule stretch

A reminder of the arthro-kinematics of the shoulder joint. A review of coupled movements:

• Flexion / internal (medial) rotation / horizontal flexion = anterior superior translation of the humeral head.
• Extension and external (lateral) rotation / abduction and external (lateral) rotation = posterior translation of the humeral head.

In patients with adhesive capsulitis, the anterior and inferior capsule will be the most limited but joint mobility will be restricted in all directions.

ASSES GH LIGAMENTS:

• Inferior GH ligament: The "Hammock" at the bottom of the joint. It has an anterior band, a posterior band and a less taught section in the middle (the pouch). The anterior band stabilizes the joint in ABDuction and external (lateral) rotation. As the arm moves into ABDuction and external (lateral) rotation, the anterior band will move up, across the front of the joint, providing an anterior stabilization (clinically relevant for throwing movements).
• Middle GH ligament: Stabilizes the GH joint in ADDuction plus external rotation and in ABDuction and external rotation (roughly 45 degrees of ABDuction).
• Superior GH ligament: Stabilizes the GH joint in ADDuction. Limits external (lateral) rotation and inferior translation of the humeral head.
• Coracohumeral ligament: Limits extension through it's anterior portion. Limits flexion through the posterior portion. Also limits inferior and posterior humeral head translation.

When assessing the joint capsule, you are assessing the available freedom of movement, or accessory movement at the joint. At 60° of Abduction, it have equal tension across all GH ligaments. This position will give an overall indication of global stiffness of the GH joint. It must be to compare to the contralateral shoulder as well.

MANUAL MUSCLE POWER TESTING:

Shoulder external rotation (ER)/ Internal rotation (IR)/abduction (ABd) (seated) should be performed.

• Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd relative to the asymptomatic side.
• Patients may also present with significant muscle guarding. Be aware of the stage of Adhesive Capsulitis you suspect your patient to be in, before subjecting them to muscle testing (manual muscle testing or with an isokinetic dynamometer).

SPECIAL TESTS:

Shoulder Shrug Sign (inability to lift the arm to 90° abduction without elevating the whole scapula or shoulder girdle)  Previously was associated with rotator cuff disease, but more commonly was associated with glenohumeral arthritis, adhesive capsulitis, and massive cuff tears.

Yang et al. investigated the reliability of 3 function related tests in patients with shoulder pathologies via a non-experimental study 

Shoulder flexion + abduction + ERHand to neck

• 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 scapula

• Shoulder flexion + horizontal ADDuction (The Scarf Test - cross body adduction).

These tests require appropriate elbow, scapulothoracic, and thoracic mobility and these areas should be cleared of pathology first. If a patient is unable to complete the motion, other structures outside of the shoulder joint may be the limiting factor.

Reliability of the three tests was excellent and correlation between them was moderate. 

These functional measures appear to be helpful for their objectivity in measuring shoulder dysfunction. However, even though the tests mimic fundamental ADL movements, the direct relationship between these tests and activities of daily living cannot be assumed.

PHYSIOTHERAPY MANAGEMENT:

The definitive treatment for adhesive capsulitis remains unclear even though multiple interventions have been studied. For most patients, enrolling in a physical therapy program is the key to recovery. Also, a meta-analysis carried out by Tedla & Sangadala in 2019 concluded that PNF is very effective in decreasing pain, increasing ROM, improving function, and reducing disability.

EDUCATION:

For the treatment of adhesive capsulitis, patient education is essential in helping to reduce frustration and encourage compliance. It is important to emphasize that although full range of motion may never be recovered, the condition will spontaneously resolve and stiffness will greatly reduce with time. It is also helpful to give quality instructions to the patient and create an appropriate home exercise program (HEP) that is easy to comply with as daily exercise is critical in relieving symptoms. The below video gives a good outline of a HEP for the 3 phases of AC.

TECHNIQUES:

FIRST PHASE:

Pain relief and the exclusion of other potential causes of the frozen shoulder is the focus during this phase.

Very gentle shoulder mobilisation, muscle releases, acupuncture, dry needling and kinesiology taping for pain-relief can assist during this painful inflammation phase.  The application of a TENS machine was shown reduce pain and increase range of motion.

Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in conjunction with stretching can help to improve muscle extensibility and range of motion by reducing muscle viscosity and neuromuscular mediated relaxation. In a randomised study by Bal et al., patients improved with combined therapy which involved hot and cold packs applied before and after shoulder exercises were performed. However, Jewell et al, claimed that ultrasound, massage, iontophoresis and phonophoresis reduced the chances of positive outcomes. Green et al. suggested that there is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis.

As alluded to, treatment should be customized to each individual based on the stage of the condition.

Pain relief should be the focus of the initial phase, also known as the painful, freezing Phase. During this time, any activities that cause pain should be avoided. Better results have been found in patients who performed simple pain free exercise, rather than intensive physical therapy  In patients with high irritability, 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, depending on the patient’s ability to tolerate the exercise. Core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately 40 degrees of abduction in the plane of the scapula, and active assisted range of motion in extension, horizontal adduction, and internal rotation.

Although performed on a single patient only, Ruiz et al performed positional stretching of the coracohumeral ligament in the initial phase of adhesive capsulitis. The patient's Disabilities of Arm Shoulder and Hand (DASH) scores improved from 65 to 36 and Shoulder Pain and Disability Index (SPADI) scores improved from 72 to 8 and passive external rotation increased from 20 to 71 degrees. 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 fibre orientation. The rationale behind this was to produce tissue re-modelling through gentle and prolonged tensile stress on the restricting tissues. While a cause and effect relationship cannot be inferred from a single case, this report may help with further investigation regarding therapeutic strategies to improve function and reduce loss of range of motion in the shoulder and the role that the CHL plays in this.

In the case of adhesive capsulitis, physical therapy can also be a complement to other therapies (such as steroid injections as discussed previously), especially to improve the range of motion of the shoulder. Bal et al suggested that concomitant exercises to steroid injections should include isometric strengthening in all ranges once motion returned to 90% of normal ranges, theraband exercises in all planes, scapular stabilization exercises, and later, advanced muscular strengthening with dumbbells.)

SECOND PHASE:

Gentle and specific shoulder joint mobilization and stretches, muscle release techniques, acupuncture, dry needling and exercises to regain its range and strength are used for a prompt return to function. Care must be taken not to introduce any exercises that are too aggressive. In particular, mobilization with movement (MWM) style techniques appears the most effective and more effective than stretching exercises alone. MWM's are specific-techniques performed by suitably-trained shoulder physiotherapists.

A prospective study by Griggs et al, demonstrated success of a non-operative treatment through a four-direction shoulder stretching exercise programme in which 90% of the patients reported a satisfactory outcome. During the second phase of treatment, movement with mobilization and end range mobilizations are recommended. Mobilization with movement can also correct scapulohumeral rhythm significantly better than end range mobilization. The goal for end range mobilization is not only to restore joint range, but also to stretch contracted peri-articular structures, whereas mobilization with movement aims to restore pain free motion to the joints that had antalgic limitation of range of motion.

Gaspar and Willis. demonstrated that physical therapy paired with dynamic splinting had better outcomes compared to physical therapy alone or dynamic splinting alone. The patients in this group of combined treatments received physical therapy twice a week and a Shoulder Dyna splint System (SDS) for daily end range stretching. The combination of physical therapy with dynamic splinting had significant improvements in active, external rotation in patients with adhesive capsulitis.

THIRD PHASE:

Provide with exercise progressions including strengthening exercises to control and maintain increased range of movement.

Physiotherapy is most effective during this thawing phase.Progressed primarily by increasing stretch frequency and duration, whilst maintaining the same intensity, as tolerated by the patient. The stretch can be held for longer periods and the sessions per day can be increased. As the patient’s irritability level reduces, more intense stretching and exercises using a device, such as a pulley, can be performed to influence tissue re-modelling. 

Exercises:

Mechanical changes that occur as a result of mobilizations may include the break- up of adhesions, realignment of collagen, or increased fiber glide when specific movements stress certain parts of the capsular tissue. These techniques are intended to increase joint mobility by inducing changes in synovial fluid formation. 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. In a study by Vermeulen et al., patients were given inferior, posterior, and anterior glides as well as a distraction to the humeral head. These techniques were performed at greater elevation and abduction angles if glenohumeral joint range of motion increased during treatment. Patients who received HGMT received these mobilization at Maitland Grades III and IV according to the subjects' tolerance with the intention of treating the stiffness. Patients were allowed to report a dull ache as long as it did not alter the execution of the mobilizations or persist for more than four hours after treatment. However, patients who received low-grade mobilization techniques (LGMT) at Mailtand Grades I or II reported no pain. Statistically significant greater change scores were found in the HGMT group for passive abduction (at 3 and 12 months) and for active and passive external rotation (at 12 months) when compared with the low-grade mobilization techniques. High grade mobilization techniques appear to be more effective for increasing joint mobility and reducing disability. Further studies are needed, however, to investigate whether HGMTs applied during earlier stages of adhesive capsulitis are as effective.

Johnson et al. reported that joint mobilizations, in particular posterior glenohumeral glides, can help decrease deficits in external rotation, more so than anterior glenohumeral glides. Both techniques had a significant decrease in pain, but there was greater improvement in external rotation range of motion with the posterior mobilisation treatment. End range mobilisation is also more effective than mid-range mobilisation in increasing motion and functional mobility. Overall, there are significant beneficial effects of joint mobilisation and exercise for patients with adhesive capsulitis.

stretching:

Research regarding connective tissue stretch duration and intensity has produced 3 findings. Firstly, that high intensity, short duration stretching aids the elastic response, whilst low intensity, prolonged duration stretching aids the plastic response. Secondly, a direct correlation exists between the resulting proportion of plastic, permanent elongation and the duration of a stretch. Lastly, a direct correlation exists between the degree of either trauma or weakening of the stretched tissues and the intensity of a stretch. McClure et al, stated that the maximum TERT (Total End Range Time) or the total amount of time the joint is held at near end range position, will be different for each person and is often affected by personal circumstances such as their job or other responsibilities that may prevent a patient from increasing TERT.

MEDICAL MANAGEMENT:

Although Adhesive Capsulitis is a self-limiting condition, it can take up to two to three years for symptoms to resolve and some patients may never fully regain full motion. Treatment for pain, loss of motion, and limited function rather than take the wait-and-see approach is therefore important. Various interventions have been researched that address the treatment of the synovitis and inflammation and modify the capsular contractions such as oral medications, corticosteroid injections, distension, manipulation, and surgery. Even though many of these treatments have shown significant benefits over no intervention at all, definitive management regimens remain unclear. It is suggested that the primary treatment for adhesive capsulitis should be based around physical therapy and anti-inflammatory measures, these outcomes, however, are not always superior to other interventions.

MANIPULATION UNDER ANESTHESIA:

Manipulation under anesthesia involves a controlled and forced, end range positioning of the humerus relative to the glenoid in physiologic planes of motion (flexion, abduction, rotation) in patients with an anesthetic block to the brachial plexus. The block allows the shoulder muscles to completely relax so that the force may actually reach the capsulo ligamentous structures. Traditionally, long lever arms were used, but now short lever arm techniques are utilized to minimize potential risks. Although success rates are high, ranging from 75-100%, manipulations are considered a last resort and are not indicated unless symptoms persist in spite of adequate conservative treatment for six months. This is due to the numerous risks and complications such as: dislocation, glenoid, scapular, or humeral fracture, nerve palsy, rotator cuff tear, hemarthrosis, labral tears, and traction injuries of the brachial plexus or a peripheral nerve. However, it has been shown that manipulations are the most reliable way to improve range of motion and reduce pain and disability in patients resistant to physical therapy and these complications can be minimized with proper techniques and precautions. A good prognosis is often indicated if an audible and palpable release of the tissue occurs during the manipulation.

An extensive post-manipulation programme begins immediately after release of the capsule. They are often prescribed active assisted range of motion exercises that should be performed every two hours during waking hours, for the next 24 hours. Patients are also instructed to ice their shoulder for 20 minutes every two hours with their hand resting behind their head. Post manipulation programs are designed to maintain gains in shoulder mobility and should specifically address each individual's impairments.

ARTHROSCOPIC PROCEDURE:

Arthroscopic capsular release is the preferred method over open release in patients with painful, disabling adhesive capsulitis that is unresponsive to at least 6 months of non-operative treatment.

The purpose of this surgical intervention is a capsular release, where they cut and remove the thickened, swollen, inflamed capsule as well as to help restore normal movement of the joint.

It has been found to be a reliable and effective method for restoring range of motion and is especially recommended for diabetics and in post-operative or post-fracture adhesive capsulitis patients. It has become the most popular method of treating non-responsive adhesive capsulitis despite the lack of higher level trials comparing it to MUA. This is because it allows a more controlled and selective release of the contracted capsule compared to manipulation which ruptures the capsuloligamentous structures and avoids the complications associated with MUA. Debate exists over which structures should be arthroscopically released with the rotator cuff and coracohumeral ligament being the most common structures released. 

Recommendations:

• If patient is unresponsive to at least 6 months of conservative treatment, arthroscopic capsular release alone or in conjunction with manipulation, has been shown to be effective in restoring range of motion.
• Avoids complications associated with manipulation under anesthesia and is recommended in diabetics and post-operative or post-fracture adhesive capsulitis patients.

Contraindications to manipulation under anesthesia include: history of fracture or dislocations, moderate bone loss, or an inability to follow through with post procedure care. Although manipulation under anesthesia has been shown to be effective in improving function and motion in patients with adhesive capsulitis, more randomized controlled trials comparing this treatment to competing treatments before widespread use are needed.

POST SURGICAL MEASURES:

Post surgery, whatever surgical technique was employed, clinicians need to consider the integrity of the local nerves. They could be disturbed by the arthroscopy as well, because there are many local nerves surrounding the shoulder joint (in close proximity to where the arthroscopy portals are located).

Also, the shoulder will not have been overly mobile for months (possibly years). Following surgery, there could be a sudden restoration of movement, which could in turn irritate the nerves.

The main nerves of concern are:

• Radial
• Ulnar
• Median
• Axillary
• Suprascapular
• Musculocutaneous
• Long thoracic
• Also possibly the brachial plexus as a whole
• The evaluation of the cervical spine and nerve root mobility should also be a priority post-surgery.

THOSE ABOVE ARE COLLECTED FROM SOME BOOKS AND WEBSITES..

THANK YOU,

 SRIKUMARAN PHYSIOTHERAPY CLINIC & FITNESS CENTER