Frozen Shoulder

Frozen Shoulder 

Painful, significant restriction of active and passive ROM at the shoulder

Most frequently in abduction and external rotation

Frozen shoulder theories

Subacromial bursitis, biceps tendon pathology, disuse, supracapsular nerve entrapment leading to muscle dysfunction, small rotator cuff tears
Joint capsule is primarily involved, with secondary involvement of the surrounding structures
Close association among frozen shoulder, referred neck pain, rotator cuff tears and impingement syndrome

Normally, the superior joint capsule attaches proximal to the greater tuberosity of the humerus and runs medially to the bony rim of the glenoidd fossa of the scapula
Inferior joint capsule hangs in the fold or pleat called the “auxiliary recess”
This fold is stretched out when the humerus is abduct
Contractures have been noted in the coracohumeral ligament, which may limit external rotation 
Idiopathic frozen shoulder may also be d/t hyperkyphosis causing an alteration off the scapulohumeral alignment, with consequent stress on the joint capsule
TrP in the subscapularis muscle restrict external rotation at the shoulder

Differentiating sources of shoulder pain and restricted abduction and external rotation

- Posterior dislocation
- Acromioclaviular joint sprain
- Tendinitis
- Glenohumeral osteoarthritis
- Cervical nerve root pathology
- Cervical facet joint irritation
- Reflex sympathetic dystrophy
- Referred shoulder pain

Acute aka Freezing phase

Gradual onset, unable to sleep on the affected side, pain is worse at night, inflammation is present in the capsule, stiffness is progressive

This stage may last 2 to 9 months

Objective information

AROM is restricted by pain in external rotation, abduction an internal rotation
PROM restrictions in external rotation, abduction and internal rotation d/t pain
Mxl guarding end feel may be noticed

Treatment plan

Reduce pain, Reduce sympathetic nervous system firing

Treat any compensating structures

Ice hydrotherapy (cryotherapy)with Prone position

Treatment begins on the unaffected side for relaxation. Effleurage, Petrissage (Palmar kneading, fingertip kneading, C-scooping)

If patient can take some pain, TrP and ischemic compression can be performed followed by effleurage

On affected side: Reduce hypertonicity, TrP, Maintain local circulation, Mobilize hypo mobile joint, Maintain ROM

Reduce inflammation, Reduce fascial restriction, treat any compensating structures, Reduce spasm

Self Care Plan

Self massage on affected shoulder

Passive pendulum exercise in pain free range

Refer patient to Physiotherapist or Acupuncturist

Subacute aka Frozen phase

Severe pain begins to diminish, Stiffness becomes the primary complaint, disuse atrophy of the deltoid and rotator cuff muscles may occur

This stage lasts 4 to 12 months

Treatment plan

Reduce hypertonicity and TrP

Maintain local circulation

Mobilize hypomobile joints

 Increase ROM

Reduce Fascial restrictions

Treat any compensating structures

Self Care Plan

Heat hydrotherapy on the affected shoulder

Active pendulum movement within pain free range

Self-stretches for upper trapezius and elevator scapula

Wall-walking exercise

Chronic aka thawing phase

Pain is localized to the lateral arm and continues to diminish

Motion and function gradually return

Full ROM is not always regained unfortunately

Treatment plan

Joint play for increasing the ROM in joint capsule with a focus on the anterior capsule

Interior and lateral joint play in grade 4 oscillation and grade 3 mobilization are employe

Self Care Plan

Continue self-care suggestions as above

Gradually progress the ROM and strength

Exercising in the pool may also be helpful

Treatment Frequency and Expected Outcome

Weekly for 6 weeks and then reassess Remedial exercise home care

Regaining full ROM may not be possible

Once sxs resolve, they rarely recur in the same shoulder

Prevention of Frozen shoulder is the best route following shoulder or thoracic surgery

Client should be encouraged to get the humerus moving as ASAP