Frozen Shoulder

The shoulder is made up of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The joint cavity is cushioned by articular cartilage covering the head of the humerus and face of the glenoid. The joint is stabilized by a ring of fibrous cartilage surrounding the glenoid called the labrum.

Four short muscles originate on the scapula and pass around the shoulder where their tendons fuse together to form the rotator cuff. Two bursae cushion and protect the rotator cuff from the bony arch of the acromion and allow smooth movement of the joint- subacromial bursa and subdeltoid bursa.

JOINTS OF THE SHOULDER
There are 3 joints of the shoulder-
Glenohumeral joint
Acromioclavicular joint
Sternoclavicular joint

CAPSULE OF THE SHOULDER JOINT LIGAMENTS OF THE SHOLDER JOINT

MOVEMENTS OF THE SHOULDER
1. Abduction: 150 degrees
2. Adduction: 150-0 degrees
3. Forward flexion: 180 degrees
4. Extension: 45-60 degrees
5. Rotation (test with elbow flexed to 90 degrees)
1. External Rotation: 90 degrees
2. Internal rotation: 70-90 degrees

DEFINITION OF FROZEN SHOULDER
Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, and grows together with abnormal bands of tissue, called adhesions, greatly restricting motion and causing chronic pain. A frozen shoulder is a shoulder joint with significant loss of its range of motion in all directions. The range of motion is limited not only when the patient attempts motion, but also when the doctor attempts to move the joint fully while the patient relaxes. Frozen shoulder is defined as a clinical syndrome characterised by painful restriction of both active and passive shoulder movements due to causes within the shoulder joint or remote (other parts of the body). • Frozen shoulder is the result of scarring, thickening, and shrinkage of the joint capsule. • RISK FACTORS

• Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10% to 20% of these individuals. Other medical problems associated with increased risk of frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson’s disease, and cardiac disease or surgery. •

CAUSES OF FROZEN SHOULDER
Most cases of frozen shoulder are idiopathic(Primary frozen shoulder), but some maybe associated with certain factors such as diabetes mellitus, spinal lesions, trauma or prolonged immobilisation of the shoulder for some other cause(Secondary frozen shoulder). Any injury to the shoulder can lead to frozen shoulder, including tendinitis, bursitis, and rotator cuff injury. Frozen shoulders occur more frequently in patients with diabetes, chronic inflammatory arthritis of the shoulder, or after chest or breast surgery. Long-term immobility of the shoulder joint can put people at risk to develop a frozen shoulder. It is recognised that frozen shoulder follows a definite sequence that occurs in three main stages. These have been described by Cyriax as follows: STAGE 1(stage of pain): patient complains of acute pain, decreased by movements, external rotation greatest followed by loss of abduction and then forward flexion. Internal rotation is least affected. This stage last for 10-36weeks. STAGE 2(stage of stiffness): Here, pain gradually decreases and the patient complains of stiff shoulder. Slight movements are present. STAGE 3(stage of recovery): patient will have no pain and movements will have recovered but will never be regained to normal. It lasts for 6months to 2years.

ASSESSMENT OF A PATIENT WITH FROZEN SHOULDER
DEMOGRAPHIC DATA
Name, age, gender, occupation, socio economic status
Chief complaints-patient complaints of pain in the shoulder and inability to move the shoulder after a certain range. HISTORY
Past history- h/o DM or HTN
Family history-h/o DM or HTN
Present history-cause of pain, onset of pain, duration of pain. OBSERVATION
Build of the patient- Endomorphic/ectomorphic / mesomorphic
Posture of the patient/Attitude of the limbs
Range of Motion- compare both the limbs ROM for any deviation in both Active and Passive movements.

MOVEMENTS RIGHT LEFT Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
PALPATION/PERCUSSION
No focal point of tenderness.
TEST AND EXAMINATION

Active test of ROM with slight overpressure at the terminal point of each movement. This test will reveal definite capsular restriction of the glenohumeral joint. The movements principally involved are external rotation and abduction. No apparent muscular weakness will be present in the available ROM, but overpressure at the end of the range will elicit pain. Active resisted test of ROM. At the initial range usually there is no pain, however, considerable resistance maybe painful. Passive test of ROM. With patient in supine position it is important to confirm the capsular pattern of restriction of the joint and the diagnosis of adhesive capsulitis. Laboratory and Radiographic tests:

Blood test: Blood tests can help the doctor look for other medical complaints that may be causing shoulder pain e.g. diabetes, underlying arthritis. X-ray: of neck to check for arthritis or spondylosis in the joints. X-ray of shoulder itself might show calcium in the muscles or arthritis of the shoulder. If special die is injected prior to the x-ray or scan then the test is known as an “arthrogram”. Ultrasound scan: An ultrasound scan is a very useful test for assessing a patient with shoulder pain. These scans are excellent at examining the muscles and tendons around the shoulder and will allow the doctor to detect an inflamed or torn muscle. MRI Scan: useful for identifying pathology in soft tissues around shoulder joint.

MANAGEMENT OF PATIENT WITH FROZEN SHOULDER
Management of this disorder focuses on restoring joint movement and reducing shoulder pain. Conservative management
Medications- Injection with steroids (NSAIDS) e.g. methylprednisolone, cortisone. Treatment may be needed for several months. Injections are usually given under radiological guidance, with either fluoroscopy, ultrasound or Computed Tomography (CT). Radiological guidance is utilized so that the needle is safely and accurately guided into the shoulder joint. Surgical-aimed at stretching or releasing the contracted joint capsule of the shoulder Arthroscopy-to cut the adhesions (capsular release) may be indicated in prolonged and severe cases. Manipulation under anaesthesia involves putting the patient to sleep and “manipulating” or forcing the shoulder to move. This process causes the capsule to stretch or tear. Nutrition

PHYSIOTHERAPY MANAGEMENT OF FROZEN SHOULDER
Physiotherapy in FS

Restorative methods Preventive methods Relaxation, mobilisation methods Early detection and thermotherapy Early mobilisation By physiotherapist By patient himself Avoid quacks Passive mobilisation Home regime

Health education
STAGE 1- In this stage long acting once a day NSAIDs are usually preferred as this condition usually runs a long course (10-36weeks). Intra-articular steroids may be helpful STAGE 2 and 3- Shoulder mobilisation and strengthening of muscles needed to bring about these movements. SHOULDER MOBILISATION TECHNIQUES

Efforts are targeted at softening this capsule by passive mobilisation. Role of the physiotherapists
Thermotherapy- before resorting to thermotherapy, the thick and contracted capsules can be relaxed and made more stretchable by deep heating using ultrasound or other modalities. The heating is carried out all around the shoulder with a special focus on the antero-inferior border of the axilla where the basic defect is said to exist. Passive mobilisation techniques- after thermotherapy the following is done In the forward stoop position. In this position the physiotherapist stabilizes the shoulder joint with one hand and grasps the wrist with the other hand. A slow rhythmic circumduction movement is carried out upto the limit of pain. In the supine position. Here patient is supine and the shoulder is in the position of maximum abduction, neutral rotation with the elbow in 90degree of flexion. The physiotherapists now grasps the arm with his hand and applying longitudinal traction along the axis of the humerus, he carries out an antero-posterior glide and an abduction and adduction glide in a slow rhythmic manner. Role of patient

The following measures are suggested to the patient to be carried out at home at frequent intervals: Pendulum Exercises- in a forward stoop position, with one hand resting on the table or chair, the patient gradually swings his arm like a pendulum and later carries out a circumduction movement. Shoulder elevation- with the normal hand supporting the affected one, the shoulder is gradually lifted up in a position of flexion, abduction and external rotation. Hand to back position- Here the patient carries the affected arm backwards with the shoulder in a position of extension, adduction and internal rotation with the elbow in 90degree flexion. Self stretch- Using the normal arm the patient is instructed to stretch limb gradually and periodically. Other measures

a) Shoulder wheel exercises
b) Pulley exercises
c) Wall climbing exercises/finger ladder
PREVENTIVE MEASURES
1. Early detections
2. high risk patients

MOBILIZATION TECHNIQUES FOR SHOULDER JOINT WITH ADHESIVE CAPSULITIS Mobilization is a therapeutic movement of the joint. It’s a back-and-forth oscillating movement done within the available joint range of motion. And it’s done by the physical therapist at a speed the patient can control. They are passive, skilled manual therapy techniques applied to joints and related soft tissues at varying speeds and amplitude using physiologic or accessory motions for therapeutic purpose. USES-Mobilization can be used to stretch the shoulder capsule and soft tissues. GOAL-The goal is to restore normal joint motion and rhythm. INDICATIONS

Pain, muscle guarding and spasm
Reverse joint hypomobility
positional faults/subluxation
Progressive limitations
Functional immobility
CONTRAINDICATIONS
Hypermobility
Joint effusion
Inflammation

Mid-range mobilization (MRM), end-range mobilization (ERM), and mobilization with movement (MWM) techniques have been advocated by Maitland, Kaltenborn and Mulligan. MRM-With the subject in a relaxed supine position, the humerus was moved to the resting position (40° of abduction). While the humerus was held in this position, 10 to 15 repetitions of the mobilization techniques were applied. ERM-The intent of ERM was not only to restore joint play but also to stretch contracted periarticular structures. The physical therapist examined the subject’s ROM to obtain information about the end-range position and the end-feel of the glenohumeral joint. Then, the therapist’s hands were placed close to the glenohumeral joint, and the humerus was brought into a position of maximal range in different directions. Ten to 15 repetitions of intensive mobilization techniques, varying the plane of elevation or varying the degree of rotation in the end-range position, were applied.

MWM-This technique combines a sustained application of a manual technique “gliding” force to a joint with concurrent physiologic (osteo-kinematic) motion of the joint, either actively performed by the subject or passively performed by the therapist. The manual force, or mobilization, is theoretically intended to cause repositioning of bone positional faults. The intent of MWM is to restore pain-free motion at joints that have painful limitation of range of movement. With the subject in a relaxed sitting position, a belt was placed around the head of the humerus to glide the humerus head appropriately, as the therapist’s hand was used over the appropriate aspect of the head of the humerus. A counter pressure also was applied to the scapula with the therapist’s other hand. The glide was sustained during slow active shoulder movements to the end of the pain-free range and released after return to the starting position. Three sets of 10 repetitions were applied, with 1 minute between sets.

TISSUE RESISTANT ANATOMIC LIMIT Diagrammatic representation of graded oscillation techniques (adapted from Maitland) Grade I. Small amplitude rhythmic oscillations at the beginning of range. Grade II. Large amplitude rhythmic oscillations within the range, not reaching limit. Grade III. Large amplitude rhythmic oscillations upto the limit of available motion and stressed into tissue resistance. Grade IV. Small amplitude rhythmic oscillations at the limit of available motion and stressed into tissue resistance. Grade V. Small amplitude high velocity thrust technique to snap adhesions at the limit of available motion.

TISSUE RESISTANCE ANATOMIC LIMIT Diagrammatic representation of sustained translatory joint play techniques (adapted from Kaltenborn) Grade I. (loosen) small amplitude distraction is applied where no stress is placed on the capsule. Grade II. (Tighten) enough distraction or glide is applied to tighten the tissues around the joint. Grade III. (Stretch) distraction or glide is applied with amplitude large enough to place a stretch on the joint capsule and on surrounding periarticular structures.

BIBLIOGRAPHY

Essentials of Orthopaedics for Physiotherapists-John Ebenezer Therapeutic Exercise- Carolyn Kisner and Lynn Allen Colby
Internet