frozen shoulder

FROZEN SHOULDER

By: Denise Dela Cruz

What is Frozen Shoulder?

It is a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain.

The Glenohumeral joint

It is a ball and socket joint with 3 degrees of freedom and has little bony stability.

The hemispheric-shaped head of humerus rests on the small, shallow, inclined plane of the glenoid cavity.

Surrounding the rim of the glenoid is a cartilaginous labrum, or lip.

The loose thin joint capsule covers the joint from the neck of the glenoid to the anatomic neck of

humerus.

FROZEN SHOULDER

A common chronic affectation characterized by pain and limitation of shoulder motion that slowly becomes worse over a period of 3-12 mos. And then, for reasons that are not clear,follows a course of gradual improvement to a normal or near –normal state.

It is seen most frequently in patients over the age of 40 years and is more common in women than men.

The disorder has also been called: periarthritis, obliteraive bursitis, and diffuse rotator cuff tendinitis.

Pathology

Edema, fibrosis, and round cell infiltration in the joint capsule—indicates a low-grade inflammatory process.

The synovial recesses may become adherent; such adhesions obliterate parts of the joint cavity and sharply limit joint motion.

The periarticular tissues lose elasticity and become shortened and fibrotic, thereby firmly fixing the humeral head in the glenoid cavity.

Muscle atrophy becomes pronounced.

Clinical Picture

May have insidious onset, may follow direct or indirect trauma, or may be a sequel to injuries of the distal part of the limb.

May also follow CVA or come about as the result of referred shoulder pain from cardiac or cervical nerve root affectations.

It frequently follows supraspinatus tendinitis, subacromial bursitis and other shoulder pathology.

The pain is accentuated by attempts at scapulohumeral joint motion, particularly abduction, ER, and extension.

The shoulder pain is usually diffuse but may radiate to the anterolateral aspect of the shoulder region, biceps muscle belly, flexor surface of the forearm and inferior angle of the scapula.

Tenderness may be elicited over the intertubercular sulcus and the tendon of the biceps muscle and diffusely about the joint capsule.

The main physical finding in frozen shoulder is decreased active and passive mobility in the scapulohumeral joint.

Restriction involves ER and abduction; stiffness may progress to almost complete loss of scapulohumeral motion.

Stages of Frozen Shoulder

“Freezing”- characterized by intense pain even at rest and LOM by 2-3 weeks after onset. These symptoms may last 10-36 weeks.

“Frozen”-characterized by pain only with movement, significant adhesions, and limited GH motions, with substitute motions in the scapula. Atrophy of deltoid,rotator cuff,biceps and triceps brachii ocuurs. This stage lasts 4-12 months.

“Thawing”- characterized by no pain and synovitis but significant capsular restrictions from adhesions. This stage lasts 2 to 24 mos. Or longer. Some patients never regain normal ROM.

Common Impairments

Night pain and disturbed sleep during acute flares.

Pain on motion and often at rest during acute flares.

Mobility: dec. jt. Play and ROM, usually ER and abduction with some limitations on IR and elevation in flexion.

Posture: possible faulty postural compensations with protracted and anteriorly tipped scapula, rounded shoulders and elevated protected shoulder.

Decreased arm swing during gait. MS. Performance: general ms weakness

and poor endurance in the glenohumeral muscles with overuse of the scapular muscles leading to pain in the trapz and posterior cervical muscles.

Guarded shoulder motions with scapular motions.

Common Fuxnal Limitations/Disabilities Inability to reach overhead, out to the side,

and behind the back; thus, having difficulty in 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 (combing of hair,brushing teeth, washing face) and bringing utensils to the mouth

Difficulty in lifting weighted objects, such as dishes into cupboard

Limited ability to sustain repetitive activities.

Diagnosis

An Arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.

Special Tests

Apley’s Scratch Test– Procedure: The seated patient is asked to touch

the contralateral superior medial corner of the scapula with the index finger.

Crank Test– Procedure: The examinerabducts the arm to 90°

and laterally rotates the patient's shoulder slowly.

Rockwood Test– The examiner stands behind the seated

patient. With the arm at the patient's side, the examiner laterally rotates the shoulder. The arm is abducted to 45°, and passive lateral rotation is repeated. The same procedure is repeated at 90° and 120°

Treatment

Pharmacotherapy– Anti-Inflammatory– Corticosteroids– Saline solution preceded by local

anesthetic and followed by hydroscortisone

Surgical– Acromioplasty– partial resection of

acromion or resection of AC joint, if involved.

Phyiscal Therapy

>>PROTECTION PHASEFor control of pain, Edema and

Muscle guarding– Immobilization – Intermittent periods of passive and

assisted motions within pain free ROM and gentle joint oscillation techniques are initiated as soon as the px tolerates the movement in order to minimize adhesion formation.

Maintain Soft Tissue and Joint Integrity and Mobility– PROM on all planes, if pain decreases

proceed to AROM 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. Teach the px to avoid faulty posture such as scapular elevation or a slumped posture.

– Passive joint distraction and glides, grade I and II with the jt. Placed in a pain free position.

– Pendulum (codman’s) exercises- are techniques that use the effect of gravity to distract the humerus from the glenoid fossa. No weight is used during this phase of tx.

– Gentle muscle setting to all muscle groups of the shoulder. 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– Hand exercises using squeeze ball to

prevent RSD.– ROM of elbow, forearm, wrist and fingers

several times while the shoulder is immobilized. If tolerated, active or gentle resistive ROM is preferred to PROM 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.

>> CONTROLLED MOTION PHASEControl pain, Edema, and Joint

Effusion.– Fuxnal activities– ROM is progressed up to the point of

pain, including all shoulder and scapular motions. The px is instructed in the use of self-assistive ROM techniques such as wand exercises or hand slides.

Progressively increase Joint and Soft tissue Mobility– PJM stretch grades III and IV

oscilation, using techniques that focus on the restricting capsular tissue at the end of available ROM to increase joint capsule mobility.

– Pendulum exercises with weights on the hand to cause a grade III distraction force.

– Self mobilization techniques: caudal, anterior and posterior glide.

– Manual stretching to increase mobility in shortened muscles and connective tissue

– Self-stretching, if px tolerates stretching.

Inhibit Muscle spasm and correct faulty mechanics– PJM grades I or II to help decrease

ms spasm.– Sustained caudal glide jt.

Techniques to reposition the humeral head in the glenoid fossa.

– Protected weight bearing, such as leaning hands against the wall, to stimulate co-contraction of rotator cuff and scapular stabilizing ms. (wt. bearing causes jt. compression, the benefits of jt. Intermittent jt. Compression stimulates synovial fluid motion).

– External rotation exercises to help depress the humeral head.

Improve Joint tracking– Shoulder MWM for painful

restriction of shoulder ER.

– MWM to improve IR

Progressively increase flexibility and stretch– Stretching and strengthening exercises

(active). Emphasis is on correct mechanics, safe progressions, and exercise strategy to return to function.

– If capsular tissue is still restricting ROM, vigorous manual stretching ang jt. Mob techniques are applied.

References

Handbook of Orthopaedic Surgery (Brashear)

Therapeutic Exercise (Kisner)Clinical Kinesiology

(Brunnstrom)

THANK YOU!!