Frozen shoulder ; causes, treatment, physiotherapy managment

  In this article we will discuss the most common cause of shoulder pain in adults which is more common in diabetic patients. Here is the complete guide of Frozen shoulder , frozen shoulder symptoms , causes and a brief guide for physiotherapy managment of  patients with frozen shoulder.

diopathic frozen shoulder

This disorder, which is also called adhesive capsulitis or periarthritis, is characterized by the development of dense adhesions, capsular thickening, and capsular restrictions, especially in the dependent folds of the capsule, rather than arthritic changes in the cartilage and bone, as seen with rheumatoid arthritis or osteoarthritis. The onset is insidious and usually occurs between the ages of 40 and 60 years; there is no known cause (primary frozen shoulder), although problems already mentioned in which there is a period of pain and/or restricted motion, such as with rheumatoid arthritis, osteoarthritis, trauma, or immobilization, may lead to a frozen shoulder (secondary frozen shoulder). With primary frozen shoulder, the pathogenesis may be a provoking chronic inflammation in musculotendinous or synovial tissue such as the rotator cuff, biceps tendon, or joint capsule.

Consistent with this is a faulty posture and muscle imbalance predisposing the suprahumeral space to impingement and overuse syndromes.


Clinical Signs and Symptoms

Glenohumeral joint arthritis

The following characteristics are associated with glenohumeral (GH) joint pathologies that lead to hypomobility.

Acute phase

 Pain and muscle guarding limit motion, usually external rotation and abduction. Pain is frequently experienced radiating below the elbow and may disturb sleep. Joint swelling is not detected owing to the depth of the capsule, although tenderness can be elicited by palpating in the fornix immediately below the edge of the acromion process between the attachments of the anterior and middle deltoid.

Subacute phase

 Capsular tightness begins to develop. Limited motion is detected, consistent with a capsular pattern (external rotation and abduction are most limited, and internal rotation and flexion are least limited). Often, the patient feels pain as the end of the limited range is reached. Joint-play testing reveals limited joint play. If the patient can be treated as the acute condition begins to subside by gradually increasing shoulder motion and activity, the complication of joint and soft tissue contractures can usually be minimized.

Chronic phase

 Progressive restriction of the GH joint capsule magnifies the signs of limited motion in a capsular pattern and decreased joint play. There is significant loss of function with an inability to reach overhead, outward, or behind the back.


Idiopathic frozen shoulder

 This clinical entity follows a

classic pattern*.


 Characterized by intense pain even at rest

and limitation of motion by 2 to 3 weeks after onset.

These acute symptoms may last 10 to 36 weeks.“Frozen.” Characterized by pain only with movement,significant adhesions, and limited GH motions, with substitute motions in the scapula. Atrophy of the deltoid, rotator cuff, biceps, and triceps brachii muscles occurs.

This stage lasts 4 to 12 months.


 Characterized by no pain and no synovitis but significant capsular restrictions from adhesions. This stage lasts 2 to 24 months or longer. Some patients never regain normal ROM. Some references indicate that spontaneous recovery occurs, on average, 2 years from onset,66 although others have reported long-term limitations without spontaneous recovery.  Inappropriately aggressive therapy at the wrong time may prolong the symptoms.15 Management guidelines are the same as for acute (maximum protection during the freezing stage), subacute (controlled motion during the frozen stage), and chronic (return to function during the thawing state) joint pathology described in this section.


Common Impairments

Night pain and disturbed sleep during acute flares. Pain on motion and often at rest during acute flares

Mobility: decreased joint play and ROM, usually limiting

external rotation and abduction with some limitation

of internal rotation and elevation in flexion

Posture: possible faulty postural compensations with

protracted and anteriorly tipped scapula, rounded shoulders,

and elevated and protected shoulder

Decreased arm swing during gait

Muscle performance:

 general muscle weakness and poor

endurance in the glenohumeral muscles with overuse of

the scapular muscles leading to pain in the trapezius and

posterior cervical muscles

Guarded shoulder motions with substitute scapular


Common Functional Limitations/Disabilities:

Inability to reach overhead, behind head, out to the side, and behind back; thus, having difficulty dressing (such as putting on a jacket or coat or women fastening undergarments

behind their back)

reaching hand into back pocket of pants (to retrieve wallet)

 reaching out a car window (to use an ATM machine)

 self-grooming (such as combing hair, brushing teeth, washing face), and bringing eating utensils to the mouth

Difficulty lifting weighted objects, such as dishes into a cupboard

Limited ability to sustain repetitive activities



Glenohumeral Joint Hypomobility:

Management—Protection Phase


Control Pain, Edema, and Muscle Guarding

The joint may be immobilized in a sling to provide rest and minimize pain. Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation techniques are initiated as soon as the patient tolerates movement in order to minimize adhesion formation.

Maintain Soft Tissue and Joint

Integrity and Mobility

Passive range of motion (PROM) in all ranges of pain free motion. As pain decreases, the patient is progressed to active ROM with or without assistance using activities such as rolling a small ball or sliding a rag on a smooth table top in flexion, abduction, and circular motions. Be sure the patient is taught proper mechanics and avoids faulty patterns, such as scapular elevation or a slumped posture. Passive joint distraction and glides, grade I and II with the joint placed in a pain-free position.

Pendulum (Codman’s) exercises are techniques that use the effects of gravity to distract the humerus from the glenoid fossa.They help relieve pain through gentle traction and oscillating movements (grade II) and provide early motion of joint structures and synovial fluid.

No weight is used during this phase of treatment


P R E C A U T I O N :

 If there is increased pain or irritability in the joint after use of these techniques, either the dosage was too strong or the techniques should not be used at this time.

C O N T R A I N D I C A T I O N :

 Stretching (grade III) techniques

If there are mechanical restrictions causing limited motion, appropriate stretching can be initiated only after the inflammation subsides. Gentle muscle setting to all muscle groups of the shoulder, including scapular and elbow muscles because of their close association with the shoulder. Instructions are given to the patient to gently contract a group of muscles

while slight resistance is applied—just enough to stimulate a muscle contraction. It should not provoke pain. The emphasis is on rhythmic contracting and relaxing of the muscles to help stimulate blood flow and prevent circulatory stasis.

Maintain Integrity and Function of Associated Areas

Reflex sympathetic dystrophy (complex regional pain syndrome type I) is a potential complication after shoulder injury or immobility. Therefore special attention is given to the hand with additional exercises, such as having the patient repetitively squeeze a ball or other soft object. The patient is advised of the importance of keeping the joints distal to the injured site as active and mobile as possible. The patient or family member is taught to perform ROM exercises of the elbow, forearm, wrist, and fingers several times each day while the shoulder is immobilized. If tolerated, active or gentle resistive ROM is preferred to passive ROM for a greater effect on circulation and muscle integrity. If edema is noted in the hand, instruct the patient to elevate the hand, whenever possible, above the level of the heart.


Control Pain, Edema, and Joint Effusion

Functional activities

 It is important to carefully monitor increasing activities. If the joint was splinted, the amount of time the shoulder is free to move each day is progressively increased.

Range of motion

ROM is progressed up to the point of pain, including all shoulder and scapular motions. The patient is instructed in the use of self-assistive ROM techniques, such as the wand exercises or hand slides on table


Progressively Increase Joint and Soft Tissue Mobility

Passive joint mobilization techniques

 Stretch grades (grade III sustained or grade III and IV oscillation) using techniques that focus on the restricting capsular tissue at the end of the available ROM are used to increase joint capsule mobility include rotating the humerus and then applying either a grade III distraction or a grade III glide to stretch the restrictive capsular tissue or adhesions Use a grade I distraction with all gliding techniques. If the joint is highly irritable and gliding in the direction of restriction is not tolerated, glide in the opposite direction. As pain and irritability decrease, begin to glide in the direction of restriction Pendulum exercises can also be used for joint stretching by adding a cuff weight to the wrist or a weight to the hand to cause a grade III joint distraction force. To direct the stretch force to the glenohumeral joint, stabilize the scapula against the thorax manually or with a belt.


Self-mobilization techniques


The following self-mobilization techniques may be used for a home program.


 Patient position and procedure: Sitting on a firm surface and grasping the fingers under the

edge. The patient then leans the trunk away from the stabilized arm .


 Patient position and procedure: Sitting with both arms behind the body or lying supine

supported on a solid surface. The patient then leans the body weight between the arms .


 Patient position and procedure:

Prone, propped up on both elbows. The body weight shifts downward between the arms

Manual stretching

Manual stretching techniques are used to increase mobility in shortened muscles and related

connective tissue.

Self-stretching exercises

 As the joint reaction becomes predictable and the patient begins to tolerate stretching,

self-stretching techniques are taught.

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