Frozen Shoulder

By : Kanchan Sharma
Frozen Shoulder, often referred to as Adhesive capsulitis (AC) is characterized by initially inflammation of joint capsule which causes pain
and later progressively restricts active and passive glenohumeral (GH) joint range of motion.

  Muscle involved in frozen shoulder:

• Supraspinatus: Abduction at shoulder ( Initial 15° of motion)
•  Infraspinatus: External rotation + Extension of shoulder.
•  Tere minor: External rotation + Extension of shoulder.
•  Subscapularis : Internal rotation
 
 Understanding the capsule - Proprioceptive Role:

• The capsule is not simply a passive structure which holds everything

"together" with a couple of identified thickenings (ligaments). It is also
a major proprioceptive end organ. Also, the tendons of the rotator cuff
muscles insert into the capsule.
 
• If the capsule becomes tight, it will have an effect on the proprioception
system as this will stimulate the localized mechanoreceptors and
increase the feed forward mechanism within the joint, which could in
turn increase capsular tightness. This could cause a continuous loop of
tightening the capsule, stimulating the mechanoreceptors, increasing
the local stabilizing muscles (such as the rotator cuff), which will
ultimately increase the tension around the joint. It is highly suspected
the frozen shoulder has a strong neurological component.
Pathology:
Etiology :
 Risk Factors & Red Flags:

•Diabetes mellitus
•Stroke
•Thyroid disorder
•Shoulder injury (FOOSH, direct impact, dislocation)
•Dupuytren disease
•Parkinson's
•Complex regional pain syndrome.
•Tuberculosis
•Rheumatisms
Multiple joint involvement
•

Characteristics/Clinical Presentation:
 
Progressive increase in pain, and a gradual decrease in active and passive range of motion.
Loss of External rotation
 
Stages of Frozen Shoulder:
•Acute/freezing/painful phase:

Gradual onset of shoulder pain at rest with sharp pain at

extremes of motion, and pain at night with sleep interruption
which may last anywhere from 2-9 months.

•Adhesive/frozen/stiffening phase: Pain starts to subside,

progressive loss of GH motion in capsular pattern. Pain is
apparent only at extremes of movement. This phase may
occur at around 4 months and last till about 12 months.

•Resolution/thawing phase: Spontaneous, progressive

improvement in functional range of motion which can last
anywhere from 5 to 24 months.
 Assessment :
 
•Subjective Assessment:
 
•Patient History- 
•Aggravating activities - limited reaching, particularly during overhead (e.g., hanging clothes) or to-the-
side (e.g., fasten one's seat belt) activities.

•Screening: 
•A full Upper quarter examination should be performed to rule out cervical spine involvement or any
neurological pathology.
 
•Range of Movement Assessment - (Active/Passive)
 
•Reduced forward flexion, abduction, external rotation, and internal rotation range of motion are key
clinical signs of frozen shoulder.
 
•The shoulder joint has a capsular pattern where external rotation is more limited than abduction
which is more limited than internal rotation (ER limitations > ABD limitations > IR limitations).
 .
 

•Shoulder Shrug Sign: Inability to lift the arm to 90° abduction

without elevating the whole scapula or shoulder girdle.

•Hand to neck: Shoulder flexion + abduction + ER

Similar to ADLs such as combing hair, putting on a necklace.
 
•Hand to scapula: Shoulder extension + adduction + IR
Similar to ADLs such as fitting a bra, putting on a jacket, getting
into a back pocket.

•Hand to opposite scapula: Shoulder flexion + horizontal

Adduction (The Scarf Test - cross body adduction).
Special tests:
 Physiotherapy management:
• Phase I: Weeks 0–8 :
 
• Goals:
 
• Relieve pain.
• Restore motion.
• Restrictions –None
• Immobilization- None.
 
• Medications:

• NSAIDs , GH joint injection: corticosteroid/local, anesthetic combination and Oral steroid

taper.
 
• Therapeutic modalities: Ice, ultrasound, HVGS.
• Moist heat before therapy, ice at end of session
 Continue…
• Motion: (Shoulder Goals):
 
• Controlled, aggressive ROM exercises.
• Focus is on stretching at ROM limits.
• No restrictions on range, but therapist and patient have to communicate to
avoid injuries.
 
• Exercises :
 
• Initially focus on forward flexion and external and internal rotation with the
arm at the side and the elbow at 90 degrees.
• Active ROM exercises, Active-assisted ROM exercises and Passive ROM
exercises.
• A sustained stretch, of 15 to 30 seconds, at the end ROMs should be part of all
ROM routines. 
 Phase II: Weeks 8–16 :

• Goals:
• Improve shoulder motion in all planes.
• Improve strength and endurance of rotator cuff and scapular
stabilizers.
• Motion: Shoulder Goals:
• 140 degrees of flexion.
• 45 degrees of external rotation.
• Internal rotation to twelfth thoracic spinous process.  
• Exercises:
• Active ROM exercises, Active-assisted ROM exercises and
Passive ROM exercises.
 Muscle Strengthening:
 
• Rotator cuff strengthening
• Closed chain isometric strengthening with the elbow flexed to 90 degrees.
• Progress to open chain strengthening with Theraband.
• Exercises performed with the elbow flexed to 90 degrees.
• .Exercises are performed through an arc of 45 degrees in each of the five
planes of motion.
• Progression to the next band occurs usually in 2- to 3-week intervals..
•  Theraband exercises permit concentric and eccentric strengthening of the
shoulder muscles and are a form of isotonic exercises (characterized by
variable speed and fixed resistance).
• Internal rotation • External rotation. • Abduction. • Flexion.
• Progress to light isotonic dumbbell exercises.
• Strengthening of scapular stabilizers, Deltoid strengthening.
Scapular Strengthening Exercise
Phase III: Months 4 and Beyond Criteria for Progression to
Phase IV :

• Significant functional recovery of shoulder motion.

• Successful participation in activities of daily living.
• Resolution of painful shoulder.
• Satisfactory physical examination.

Goals:

• Home maintenance exercise program.

• ROM exercises two times a day.
• Rotator cuff strengthening three times a week.
• Scapular stabilizer strengthening three times a week.

Maximum improvement by 6 to 9 months after initiation of

treatment program.
Thank you