What Is Frozen Shoulder Syndrome?
Frozen shoulder syndrome (also known as adhesive capsulitis in more sophisticated medical terms) is marked by pain, discomfort and limitation of movement across shoulder joint with “waxing waning” symptoms over time. It has been observed that the risk of developing adhesive capsulitis increases in certain medical or vascular conditions that limit the mobility of upper limb.
According to the detailed report of B. Reeves (2) published in Scandinavian Journal of Rheumatology, author studied the natural history of frozen shoulder syndrome in 49 patients. It is concluded that the progressive joint discomfort starts with a painful stage in which minimal movement of upper limb or shoulder joint evokes strong pain and discomfort. This is followed by a stiff stage which the pain experienced is minimal but the joint is stiff with impaired range of motion. Reeves suggested that the duration of stiff stage determines the duration of recovery stage– the third and final stage of frozen shoulder syndrome.
What Are The Causes Of Frozen Shoulder Syndrome?
Frozen shoulder syndrome is the inflammation of shoulder joint capsule that encase and embrace all the tendons, ligaments, muscles, bones of the ball and socket joint. Typically, any ongoing inflammatory process limits physical activity due to shoulder pain and discomfort. In the absence of any intervention, the connective tissue components begin to thicken as a result of ongoing inflammatory process leading to prolonged stiffness and limited range of motion.
It is not clearly known what causes frozen shoulder syndrome. However, it can be safely stated that certain medical, physiological and surgical conditions may increase the risk of developing frozen shoulder syndrome. Here are a few most common risk factors that are associated with the condition:
- Advanced age (over 45 years due to age related degenerative changes in the connective tissue components) and 70% of the cases are reported in females (3). Clinical data indicates that males develop a more distressing and disabling disease (3).
- History of recent limb injury or immobility (in the setting of the tearing of rotator cuff tendons, any vascular, orthopedic surgery involving upper limb or impaired limb motion due to stroke). 25% of all stroke patients develop adhesive capsulitis (5).
- Diabetes is one of the strongest risk factors that are associated with the pathogenesis of secondary frozen shoulder syndrome. According to a study conducted in 1986 (4), almost 19% of all the diabetics develop frozen shoulder with poorly managed blood sugar levels. Another report suggests the risk of developing this condition is 71% higher in diabetics as compared to general population.
- Certain metabolic or endocrinological disorders like hyper or hypothyroidism, untreated or poorly managed circulatory conditions and tuberculosis also increases the risk of developing frozen shoulder syndrome significantly.
What Are The Common Treatment Options For Frozen Shoulder Syndrome?
According to research published in the peer-reviewed Journal International Orthopaedics (1), author suggested that the primary causes, pathogenesis and main-stay treatment modalities for the management of symptomatic frozen shoulder syndrome vary significantly in clinical practices. In fact, some of these can be considered somewhat “controversial”.
Currently, most healthcare providers suggest the following treatments for frozen shoulder syndrome:
- Pain medication and corticosteroid injections
Pain medications are employed to manage acute symptoms of discomfort, disability and pain. Although non-steroidal anti-inflammatory drugs (NSAIDs) and other over the counter medications are usually helpful in managing the early symptoms and acute episodes of shoulder pain, the efficacy is generally limited in extensive fibrosis and acute inflammation. You can always speak to your healthcare provider for advice on pain relieving medications. In acute pain syndromes, intracapsular steroid injection aborts pain and acute swelling.
- Manipulation under anesthesia
This is performed under general anesthesia in most cases. The surgeon performs manual manipulation to loosen the stiff joints and fibrotic knots that are produced as a result of ongoing inflammatory processes.
Physiotherapy is mainly used in second and third stages of frozen shoulder syndrome (stiffness stage and recovery stage). Physical therapy exercises include soft tissue mobilization, joint mobilization and stretching exercises.
- Joint distension
Joint distension is helpful in improving range of motion when the joint capsule is stiff or fibrotic. For distension, surgeons usually introduce normal saline to stretch the capsule.
- Arthroscopic management
Arthroscopic management is the surgical therapy to manage frozen shoulder. In this procedure, surgeons identify and remove the scar tissues and other adhesive tissue that limits the free movement of joints, tendons and ligaments. Usually small surgical instruments are used to limit tissue trauma and resulting new scar formation.
Acupuncture therapies are helpful in relieving pain and discomfort by insertion of needles at specific pressure points. Generally the process is painless and overly effective (with no risk of side effects if procedure is performed under experienced hands).
6 Best Exercises For Treating Frozen Shoulder Syndrome
Shoulder exercises are generally recommended by healthcare providers to regain mobility and range of motion. Physical therapy maneuvers and exercises are especially effective in stiffness stage and recovery stage. Some of the best exercises for frozen shoulder syndrome suggested by healthcare providers are discuss below:
- Shoulder Abduction
Physical therapist suggests active-passive exercises to restore joint range of motion. A variety of pulley exercises are devised by Dr. Phil for such patients like shoulder abduction (6).
- Attach a pulley to a door (as high and as secure as possible).
- Use a chair or stool with your back facing the door and grasp the two ends of the pulley with your both hands.
- Now extend your injured arm using pulley handle as fulcrum to the side of your body while using the non-injured arm as your overhead support.
- Now pull down the non-injured arm to the side of your body while extending and lifting the injured arm overhead.
- Repeat the exercise for 10 minutes twice a day.
This exercise is helpful in restoring full range of motion with minimal pain and discomfort.
- Shoulder External Rotation
The basic principle of all shoulder exercises in adhesive capsulitis or frozen shoulder syndrome is to improve the range of motion by allowing passive movements with minimal discomfort. Moreover, since the weight of upper body is supported by the pulleys, the movements are less stressful for the body that helps in directing all the force towards the joint components.
- For this exercise, secure the pulley around the door knob and extend your elbows while keeping your forearms parallel to the ground level.
- With gentle traction on injured arm, stretch your non-injured arm and rotate the pulley strings between two arms alternately.
The benefit of this exercise is loosening of ligaments that control rotatory motion of shoulder joint.
- Shoulder Flexion
It is very important to perform all the shoulder stretching exercises with your elbows fully extended. This exercise involves securing a pulley on top of a door or with a hook on wall.
- Once pulley is secure, stand straight with your back supported by the wall.
- Now using pulley handle, lift your normal arm in the air in full-extended motion, while your injured arm is stretched by the side of your body (shoulder joint is flexed in this position).
- Hold the position for a few seconds and extend your injured arm overhead while your normal arm is stretched by the side of your body.
- Repeat the exercise for a few minutes every day at periodic intervals.
This exercise helps in decreasing stiffness by promoting joint activity in vertical motion.
- Arm Circles
Arm circle is a common fitness exercise that is often advised to athletes to improve their overall range of motion. Instructions are simple and benefits are immense and almost immediate.
- Lie down on a flat horizontal surface like a table on your right side.
- Place your left hand on your left shoulder and try to make small circles in the air.
- Start off by making small circles and gradually increase the size and circumference of the circle by using elbow joint as the center point of focus.
- After making at least 20 clockwise circles, make 20 counter- clockwise circles.
- Repeat the activity with right side.
The most wonderful benefit of this exercise is increased flow of blood across the joint capsule and tissues that increase the pace of healing.
- Back Clasp
Black clasp is another exercise that primarily aims at improving the flexibility of shoulder muscles and joint ligaments. It ensures pain-free movements and to restore full range of motion.
- Stand straight with your legs wide apart.
- Next step is to use your hands and clasp on your back.
- Stabilize your arm and slowly raise the arms over your head.
- Stop the arm movement at the point of maximum resistance and hold your position for 30 seconds.
- Start from the base-level again and you will see that slowly your range of motion has increased by the time you are done with the exercise (at least for 5 to 8 minutes thrice a day).
- Wall Climbing
Wall climbing is an exercise or recreational activity that allows your shoulders to work in synchronous motion with the rest of your upper limb components. Since it is also a recreational activity, you may be able to work up your joint apparatus for a longer period of time without conscious perception.
- Stand straight with your legs wide apart.
- Now use your fingers to crawl or climb the wall and as you move up, stop and hold the position at every 6 inch to feel the grip.
- Discontinue when you begin to feel pain.
Generally, frozen shoulder syndrome is a fairly common condition that may be reported in the setting of chronic sports related injuries or following moderate trauma to shoulder capsule. In most situations, exercises are much more helpful than surgical manipulations and procedures (due to clear risk of scarring). In addition, it also helps in achieving speedy recovery and pain-free movements across shoulder joints.
According to the statistical rate calculated by Levine and colleagues (7), by performing non- operative physical therapy maneuvers or stretching exercise, the success rate is up to 90% within a short period of 4 months.
1. Sharma, R. K., Bajekal, R. A., & Bhan, S. (1993). Frozen shoulder syndrome. International orthopaedics, 17(5), 275-278.
2. Reeves, B. (1975). The natural history of the frozen shoulder syndrome. Scandinavian journal of rheumatology, 4(4), 193-196.
3. Sheridan, M.A. and J.A. Hannafin, Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am, 2006. 37(4): p. 531-9.
4. Pal, B., et al., Limitation of joint mobility and shoulder capsulitis in insulin- and non-insulin-dependent diabetes mellitus. Br J Rheumatol, 1986. 25(2): p. 147-51.
5. Bruckner, F.E. and C.J. Nye, A prospective study of adhesive capsulitis of the shoulder (“frozen shoulder’) in a high risk population. Q J Med, 1981. 50(198): p. 191-204.
6. Page, P. Frozen Shoulder Syndrome.
7. Levine, W.N., et al., Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg, 2007. 16(5): p. 569-73.