Frozen Shoulder

Frozen Shoulder

Symptoms

Frozen shoulder has three stages, each of which has different symptoms. 
The 3 Stages are:

1. Freezing – characterised by pain around the shoulder initially, followed by a progressive loss of range of movement. Known as the RED phase due to the capsule colour if you undergo arthroscopic surgery.

2. Frozen – minimal pain, with no further loss or regain of range. Known as the PINK phase due to the capsule colour if you undergo arthroscopic surgery.

3. Thawing – gradual return of range of movement, some weakness due to disuse of the shoulder. Known as the WHITE phase due to the capsule colour if you undergo arthroscopic surgery.
Each stage can last on average 6 to 8 months if left untreated.

Diagnosed

Frozen shoulder can be diagnosed in the clinic from your clinical signs and symptoms. 
A clinical diagnosis of frozen shoulder can be determined by a thorough shoulder examination. Your physiotherapist will ask about what physical activities you are having difficulty performing. 

Common issues include:
Unable to reach above shoulder height
Unable to throw a ball
Unable to quickly reach for something
Unable to reach behind your back eg bra or tuck shirt
Unable to reach out to your side and behind. eg reach for seat belt
Unable to sleep on your side.

In some cases you may be referred for X-rays or MRI to rule out other causes of shoulder pain. X-rays are not able to diagnose frozen shoulder. MRI or preferably MRA can provide a definitive diagnosis. A double-contrast shoulder arthrography is the traditional diagnostic method, although this is usually not required if you have a skilled shoulder practitioner assessing you.
Frozen shoulder is commonly misdiagnosed or confused with rotator cuff injury by inexperienced shoulder practitioners. It is important to get an accurate diagnosis since the treatment and recovery vary considerably.

Physical Examination

Your physiotherapist will ask you to perform shoulder movements. Frozen shoulder has a distinct capsular pattern of stiffness:

Lateral Rotation > Flexion > Internal Rotation.

Normally, your rotator cuff strength will still be normal with the exception of pain inhibition. 
Frozen shoulders are commonly non-tender on palpation examination due to the pathology being quite deep. 
Quick movements are very painful with patients very keen to avoid any fast movements such as reaching or throwing and catching.

Who is Likely to Suffer from Frozen Shoulder?

Frozen shoulder is more likely to occur in people who are 35-50 years old. 
It can be primary, with no known cause, or secondary, associated with an underlying illness or injury.

There are a number of risk factors predisposing you to developing frozen shoulder. 
These include:
shoulder trauma,
surgery,
diabetes,
inflammatory conditions,
inactivity of the shoulder,
autoimmune disease,
cervical cancer, and 
hyperthyroidism.
Approximately 20% of people who have had a frozen shoulder will also develop frozen shoulder in their other shoulder in the future.

Treatment

Physiotherapy treatment for frozen shoulder depends on what stage you are in, and is tailored to your specific needs.

1. Freezing

Pain relieving techniques including gentle shoulder mobilisation, muscle releases, acupuncture, dry needling and kinesiology taping for pain-relief can assist during this painful inflammation phase. Intracapsular corticosteroid injection is considered when pain is unbearable.
It is important not to aggravate a frozen shoulder during this phase, which is unfortunately a side effect of an overzealous practitioner.

2. Frozen

Shoulder joint mobilisation and stretches, muscle release techniques, acupuncture, dry needling and exercises to regain range and strength are useful for a prompt return to function. Care must be taken not to introduce any exercises that are too aggressive. 
Overenthusiastic treatment can aggravate your capsular synovitis and subsequently pain. A quality shoulder physiotherapist will know how much is enough and how much is too much.

3. Thawing

Shoulder mobilization and stretches are your best chance of a prompt return to full shoulder movement. As your range of motion increases your physiotherapist will be able to provide you with strengthening exercises to control and maintain your newly found range of movement.

Frozen Shoulder Exercises (Rehabilitation Protocol):

Phase 1: Weeks 0-8

Goals
• Relieve pain
• Restore Motion
No restriction or immobilization.
Pain Control
• Medications
• NSAIDS- first line medication for pain control
• GH joint injection: corticosteroid/local anesthetic combination
• Oral steroid taper- for patients with refractive or symptomatic frozen shoulder.
• Therapeutic modalities
• Ice, ultrasound, HVGS
• Apply moist heat before therapy and ice pack at the end of session.

Motion: Frozen Shoulder Exercises

• Initially focus on forward flexion and internal and external rotation with the arm at the side, and the elbow at 90 degrees.
• Active ROM exercises.
• Active assisted ROM exercises.
• Passive ROM exercises.
• In home these Frozen Shoulder Exercises should be performed 3-5 times per day.
• A sustained stretch, of 15-30 seconds, at the end ROMs should be part of all ROM routines.

Phase 1: Weeks 8-16

Criteria for progression to Phase 2
• Improvement in shoulder discomfort.
• Improvement in shoulder motion.
• Satisfactory physical examination.

Goals
• Improve shoulder motion in all plane
• Improve strength and endurance of rotator cuff and scapular stabilizers

Pain Control by same means as used in 1st 8 weeks.

Motion: Frozen Shoulder Exercises
Perform active, active assisted and passive range of motion exercises to obtain around 140 degree of forward flexion, 45 degree of external rotation and internal rotation to twelfth thoracic spinous process.

Muscle strengthening
Start with rotator cuff strengthening exercises 3 times per week, 8-12 repetitions for three sets.

• Closed chain isometric strengthening with the elbow flexed to 90 degrees and the arm at the side. Perform internal rotation, external rotation, abduction and forward flexion.
• Progress to open chain strengthening exercises with theraband for same greoup of muscles.
• Progress to light weight dumbbell exercises for internal rotators, external rotators, abductors and forward flexors.
• Perform strengthening of scapular stabilizers. Deltoid strengthening.

Phase 3: 4 months and beyond

Criteria for progression to Phase 3
• Significant functional recovery of shoulder motion.
• Successful participation in activities of daily living.
• Resolution of painful shoulder.
• Satisfactory physical examination.

Goals
• Home maintenance frozen shoulder exercises.
• ROM exercises 2 times a day.
• Rotator cuff strengthening 3 times a week.
• Scapular stabilizer strengthening 3 times a week.

Please check with your Physical Therapist before starting with this frozen shoulder exercises.

Warning Signs:
• Loss of motion
• Continued Pain

Treatment of Complications:
• These patients may need to move back to earlier routines
• May require increased utilization of pain control modalities as outlined above
• If loss of motion is persistent and pain continues, patients may require surgical intervention Manipulation under anesthesia Arthroscopic release

Prevent

While the spontaneous onset frozen shoulder is of unknown origin, you can prevent frozen shoulder caused by disuse by avoiding long period of shoulder inactivity. eg post-surgery or shoulder injury.
If you do have a shoulder or arm injury, it is always advisable to seek the professional advice of someone such as your shoulder physiotherapist about exercises to help prevent a secondary frozen shoulder developing. This is especially important if you are in a high risk category.