Frozen Shoulder: It Can Strike Out Of Nowhere
Posted on May 22, 2007 and filed under ShoulderWhat You Need To Know About This Painful And Common Condition
It’s Monday morning. Still sleepy, Jenny rolls over and hits the snooze button on her alarm clock. As she does this, she notices a slight amount of pain in her left shoulder. Unconcerned, she goes about her normal daily routine. Throughout the day, she notices that she is not using her left arm as much as usual. As time goes on, she notices the pain getting worse. One night while preparing dinner, she reaches up to grab some dishes out of her cupboard. However, she realizes she cannot lift her arm all the way up and the pain is worse than ever. A few more days go by and her condition worsens. She eventually calls her physician to receive medical treatment. Her physician gives her a diagnosis of “Frozen Shoulder” and refers her to a physical therapist for further treatment.
What Is Frozen Shoulder?
Jenny’s story above is an example of a condition called “Frozen Shoulder”. At any one time, we’ll be treating a few people who are suffering from this condition. In fact, a lot of people don’t realize how common it is.
The medical term for Frozen Shoulder is Adhesive Capsulitis. This is a term commonly used to refer to a shoulder condition consisting of decreased range of motion and increased pain. The purpose of this article is to review causes, pathology and signs, symptoms, impairments and functional limitations associated with Adhesive Capsulitis. Adhesive Capsulitis is defined by the loss of extensibility (muscle and the surrounding soft tissue ability to stretch). The joint capsule can also become inflamed which creates pain and limits range of motion. Usually, people experience pain on the outside of the shoulder, followed by a reduction in range of motion. This happens because the person becomes reluctant to move the joint or arm. In time, the pain can go away. However, this doesn’t mean the person is “out of the woods” yet. The limited joint mobility will continue. This changes the way the muscles in the shoulder activate/contract, and commonly produces a “hiking” condition of the shoulder. What is “hiking”? The answer is simple. Hiking means you go to lift your arm up, and instead of lifting just your arm, your entire shoulder moves up! The decreased muscle activity and shoulder hiking together can create shoulder impingement (which we talked about a few issues ago). This means the pain, swelling and inflammation gets worse. It becomes a snowball effect. Frozen Shoulder can last from one to three years in duration. Yes, THAT long. It can also be broken up into three stages based on clinical findings:
Stage 1: The Freezing Stage
Here, people experience increased shoulder pain and decreased use and flexibility due to changes in the soft tissue of the joint.
Stage 2: The Frozen Stage
In the frozen stage, people have decreased pain and intensity, BUT also have decreased range of motion when they move their shoulder in certain directions. In the frozen stage, they also might have impairments leading to shoulder “hiking” as well as altered shoulder movements.
Stage 3: The Thawing Stage
This stage is characterized by pain - but most people only experience pain while moving or stretching in a particular direction. Some people may start to return to normal shoulder movements or biomechanics and normal function.
Now, looking at this progression, you might think to yourself, “well, it sounds like this condition actually corrects itself”. Not exactly. Looking back at the freezing stage, most people have fairly normal shoulder movement and muscle function. But this is also the stage where the pain starts. Once the pain sets in, you may experience more and more muscle guarding. Muscle guarding is a way for someone to protect their injured body part. It’s a natural response to pain or injury. Many patients don’t even realize they’re doing this. The problem is that muscle guardin and inflammation leads to decreased function and weakness of the rotator cuff muscle group. You stop using the muscle because of the pain and inflammation which causes muscle inhibition and results in the muscle “shutting down”. As the pain intensifies, the ability to move the shoulder decreases.
The Snowball Effect
Once people reach the frozen stage, limited flexibility is at its maximum. This loss of movement occurs because of the inability to elongate the soft tissue around the shoulder, which alters the normal shoulder movement. So in a nutshell, here’s what happens: First, pain occurs. Pain leads to decreased use. Then decreased use leads to limited range of motion. And so on. It’s a snowball effect.
Different Types of Frozen Shoulder
Let’s talk a little bit about the different types of frozen shoulder we see at Physical Therapy Specialists. First of all, Frozen Shoulder is either Primary or Secondary.
Primary Frozen Shoulder
This is a spontaneous Frozen Shoulder and it may occur without a specific cause. The patient notices their shoulder being a little bit “sore”, which results in decreased movement and use. As time goes on, the pain intensifies and flexibility becomes more limited. At this point, the person normally seeks medical attention. Jenny’s story at the beginning of this article is a great example of Primary Frozen Shoulder.
Secondary Frozen Shoulder
This is where Frozen Shoulder is the result of surgery or a shoulder injury. This can either be a rotator cuff injury; shoulder tendonitis, impingement syndrome or any other injury involves the shoulder. The actual injury doesn’t directly cause the condition. What happens is that the injury creates a situation where the patient doesn’t use his or her arm secondary to the pain they are experiencing. Lack of use, immobilization and lack of stretching results in limited range of motion.
Who Does Frozen Shoulder Strike?
Normally frozen shoulder occurs in people between 40 and 60 years of age and it effects women much more common than men.
Therapy
There are a few general things that we do to help this condition including, manual therapies, therapeutic exercise and therapeutic modalities.
Therapeutic Exercise:
Before treatment is initiated,the patient undergoes a thorough evaluation. We’re looking for a couple of things. First, how much pain is there? Are the exercises going to aggravate the pain and make the condition worse? Is the patient going to respond to exercise? If severe pain is present before resistance is applied, the condition is considered to be “irritable” and the intervention should not be as aggressive. If the pain is present after resistance is applied, the patient is not considered “irritable” and exercise can be more aggressive in nature. Once that is established, the intensity level and amount of exercise can be planned. Normally, exercise techniques include passive range of motion, active range of motion, active assisted range of motion, isotonics, isometrics, and progressive resistance exercises. I know many of these terms may not make sense to you, so email me with questions or ask me in person!
Manual Therapy
This includes mobilization of the soft tissue and/or the shoulder joint. These techniques can be used to reduce pain, edema (swelling and water retention), inflammation, and joint restriction, while increasing range of motion and tissue extensibility.
Therapeutic Modalities
Therapeutic modalities are helpful in rehabilitating patients with frozen shoulder. In the early stages, we use anti-inflammatory and pain medications to reduce its severity. During the latter stages, the use of physical agents can be used to increase tissue extensibility and reduce the effects of treatment irritation. Modalities commonly used with frozen shoulder patients include; therapeutic ultrasound, various forms of electrical stimulation and ice and heat. Physical therapy can be extremely effective in restoring range of motion, flexibility, strength and most importantly, function, to patients who have been diagnosed with frozen shoulder. Physical therapy can play an important role in reducing the severity, duration and functional limitations for those who suffer from this condition.
At Physical Therapy Specialists, we use therapeutic exercise, manual therapy techniques and therapeutic modalities along with critical thinking to insure optimal outcomes for our patients. If you have any questions about this article, or think you (or a patient of yours) may be suffering from frozen shoulder, please contact me at: (714) 528-9400.