Frozen Shoulder

What is frozen shoulder?

Frozen shoulder, or adhesive capsulitis, is a painful condition that afflicts this important joint. Suffering patients complain of joint stiffness, pain and limited movement. The causes of origin have not yet been completely clarified and the pathology often arises without any apparent cause.

The frozen shoulder affects the capsule that surrounds the joint of the same name, thickening and healing the tissues that make it up.

The joint capsule is a sleeve of dense connective tissue that wraps around the joint supporting and stabilizing the two bony heads that form it.

In normal conditions the shoulder joint, thanks to its particular anatomical shape, allows for a wide range of movements. When a patient develops the frozen shoulder but, inexplicably, the capsule that surrounds it becomes rigid and forms adhesions. The loss of elasticity and the compromise of some anatomical structures with which it makes contact causes pain and limitation of the typical movements of the disease.

In particular, when suffering from frozen shoulder the possibility of both active and passive movement decreases. In other words, this limitation is present both when the patient tries to actively move the arm, and when it is moved by the doctor or therapist. The decrease in passive movement is one of the characteristics that distinguishes the frozen shoulder from other pathologies affecting this joint, such as the lesion of the rotator cuff. The painful symptoms of the shoulder are, in fact, often confused with other pathologies such as calcific tendinopathy, rupture of the rotator cuff, arthritis or tendinitis. Another characteristic of this pathology is that the joint limitation is recorded on all planes of movement and above all in external rotation.

Causes

As we have seen, most cases of frozen shoulder arise without any apparent cause. Sometimes the pathology develops following a traumatic injury to the shoulder (dislocation, fracture, contusion, etc.), even if this is not a widespread circumstance. From the anamnesis of patients suffering from this pathology, however, predisposing risk factors emerge. These include:

• age: the frozen shoulder occurs more frequently in subjects aged between 40 and 60 years.
• Sex: adhesive capsulitis affects women the most, having a double / triple risk compared to men
• Diabetes and thyroid dysfunction: patients with these diseases are more at risk than the healthy population. In particular, about 10-20% of patients with type II diabetes and 35-40% of type I diabetics also suffer from frozen shoulder.
• Other systemic diseases (cardiovascular, Parckinson's disease, hypercholesterolemia, arthritis, etc.). have been related to an increased risk of developing frozen shoulder.
• Past history of shoulder pain and immobility: patients who suffer a shoulder injury develop the frozen shoulder more frequently, especially if a long period of immobilization has been followed after the injury, not followed by an adequate rehabilitation program
• Prolonged use of some drugs

Symptoms

To learn more: Frozen Shoulder Symptoms

A frozen shoulder causes a typical set of symptoms that can lead the physician to diagnose the disease even after a clinical examination. The most important symptom is the limitation of movement associated with pain. However, as we have seen, this symptomatology is common to other diseases that affect the shoulder. Also for this reason it is very important to consult a doctor when one or more of the following symptoms appear:

• limitation of shoulder movement: strangely this disease affects the shoulder of the non-dominant limb more easily; sometimes it affects both shoulders simultaneously (in only 10% of cases).
• Shoulder pain: it is a pain usually acute and quite intense, sometimes associated with swelling and localized especially in the upper external part of the shoulder.
• Pain and inability to perform normal daily gestures such as shaving, lacing the bra or brushing your hair
• Pain that intensifies during night rest, especially if you fall asleep leaning on your side and on your aching shoulder.

The symptomatology and the evolution of the pathology can be classified into three distinct phases:

• Cooling phase: it is the initial and most painful phase of the pathology; the pain is increasing over time and as this gets worse the patient tends to limit his use more and more. In this phase the movements are limited but the shoulder still retains much of its mobility, gradually losing it; this phase generally lasts 6-12 weeks
• Freezing phase: there is an increase in joint stiffness while the pain tends to relieve itself; this phase can last 4-6 months
• Thawing phase: it is characterized by a gradual improvement of the condition that can last even more than a year

Diagnosis

The study of the symptomatology combined with the patient's medical history and some specific tests normally allows the clinical diagnosis of the pathology. However, your doctor may decide to carry out further diagnostic tests (such as X-rays) to make sure there are no further specific lesions or signs of arthrosis. MRI is hardly used, which is the most sensitive exam in evaluating other types of pathologies such as the rotator cuff lesion. Other tests, such as blood tests, can be performed to assess the presence of predisposing diseases such as hypercholesterolemia, diabetes and thyroid dysfunction.

Treatment and rehabilitation

Painful shoulder treatment has the main objectives of reducing pain and regaining lost mobility. Often the patient finds relief and perceives clear improvements after a few weeks, simply by following these tips.

• Stretching and mobilization exercises: to improve the range of movement of the shoulder and to minimize the loss of muscle tissue. These exercises must be performed several times a day (at least three), without straining the movements, initially under the supervision of a therapist, then even in complete autonomy
• Heat: can help to loosen the joint block due to increased local vasodilation. Particularly useful is the application of damp heat (mud, paraffin, baths or compresses) for ten minutes before starting the stretching exercises. If you have the possibility it would be very useful to carry out the active / passive mobilization exercises in a hot water tank (35-36 ° C), just to take full advantage of the beneficial effect of heat and movement
• Other physical therapies such as ultrasound, laser therapy and tens are sometimes used to accelerate recovery
• Local cortisone injections help reduce pain in early stages. In their place, at this stage or during the recurrence of painful symptoms, oral or topical anti-inflammatory drugs can be used.
• Currently in experimentation: methods that foresee the local injection of particular substances able to "unblock" adhesions in a short time
• Complementary and alternative medicine: osteopathic maneuvers and acupuncture, if performed by expert hands, can certainly bring considerable benefits while minimizing the risk of side effects

During the entire rehabilitation period, sudden and demanding movements such as lifting heavy loads with a sore arm should be avoided. Usually the freezing phase is the least sensitive to the treatments, therefore the persistence of pain and reduced mobility in this phase, must not demoralize the patient that indeed, must continue and persist with the therapies undertaken. In the second period, characterized by greater instability, physical therapy is fundamental (some authors advise against it during the cooling phase).

Exercises for frozen shoulder
	PENDULUM EXERCISE, Codman type: standing up, bend the trunk forward (45-90 °) leaning with the healthy limb on a support (eg a table); relax the muscles of the injured shoulder and swing the limb gently: forward / backward; internally / externally; with circular movements in a clockwise / anti-clockwise direction and gradually increasing the width of the circle. During the movements keep the muscles as relaxed as possible. Repeat each movement 10-15 times. This exercise can also be useful in the initial warm-up or cool-down phase to improve the functionality of the shoulder complex and prevent injuries.
	EXERCISE OF INTERNAL ROTATION behind the back: grasp with the hand of the healthy limb the upper extremity of the rod (or elastic) and with that of the limb to rehabilitate the lower part. Bring the rubber band behind your back as shown in the figure and slowly raise the stick and the other limb as high as possible with the hand of the healthy limb. Hold for five seconds, then slowly return to the starting position and repeat ten times.
	SHOULDER EXTENSION: hold the stick behind your head while keeping your elbows extended at your hips as shown in the figure. The palms of the hands must be facing backwards (prone hand). Slowly push the wand backwards so as to move it away from the body without flexing the trunk forward. Maintain the maximum extension position for 5 seconds, then slowly return to the starting position and repeat ten times. Starting from the same position, repeat the movement by extending only one limb at a time. As in the previous case, perform 10 repetitions on each side maintaining the maximum extension position for five seconds; then repeat for the opposite side. To conclude, slowly raise the stick upwards by grasping it with both hands (taken in pronation) until the mobility allows (bend the elbows but without involving the trapezius in the movement; the clavicles will therefore be kept downwards)
	STRETCHING MUSCLE OF THE SHOULDER: Standing, slowly, try to bring the inner part of the elbow of the painful limb to the shoulder of the contralateral arm, using the opposite hand as shown in the figure. Without straining the stretch too much, hold the position for twenty seconds and slowly return to the starting position. Repeat 5-6 times
WARNINGS: before performing these exercises to increase shoulder mobility and improve the elasticity of the muscles and tendons that make up the rotator cuff, ask your doctor for advice. In particular remember to always perform a general warm-up before starting the stretching movements; wear comfortable clothing that does not hinder movement; choose a relaxing environment and respect the correct breathing technique; avoid sudden movements and excessive stretching. If there is pain in the shoulder during the movements, stop the exercises immediately and consult a doctor if the pain is particularly intense or does not disappear after a few days of rest.

Thanks to these measures, most patients suffering from frozen shoulder recover the function of the joint more or less completely within a year. However, it may happen that these treatments are completely ineffective.

If this happens, the patient will need to consult a doctor to examine the possibility of surgery. In reality, the doctor may decide to perform an anesthetic manipulation to break the adhesions that caused the painful shoulder. However, this maneuver is potentially harmful as it can cause humeral fractures and tendon injuries that make up the rotator cuff.

The doctor may also decide to opt for the arteroscopy capsualre release procedure. In this case, after the operation, a passive micromobing program associated with physical therapy will immediately be started to prevent the immobilization from favoring the recurrence of the disease.