Frozen shoulder, medically known as adhesive capsulitis, causes disturbances to activities of daily living. A number of people take over-the-counter drugs to alleviate the condition. But research shows a more promising path of treatment towards improved joint motion.
What is frozen shoulder?
Maria never knew what to do.
She has been experiencing pain in her left shoulder for a time now. This prevents her from doing overhead activities – a disruption to her normal duties as a librarian. Though it was most painful during the onset, the limitation of motion in her left shoulder is still present.
Maria decided to see her GP. Testing included X-ray, which showed nothing of note. Her medical history didn’t reveal any clues that may trigger such a condition.
The verdict? FSS.
Maria’s case is the classic presentation of Frozen Shoulder Syndrome (FSS). An unidentifiable factor causes a global restriction of movements of the shoulder. Most of the times, it affects just one side but bilateral involvement has been reported.
Specifically, the case above is called Idiopathic or Primary FSS.
If a stiff shoulder is caused by events such as micro or macro trauma, post-injury, post-operative, and due to another known disease, it is aptly called Secondary FSS.
Stages of FSS
Both primary and secondary FSS has a natural presentation consisting of three stages over a period of about 2 years:
|1. Freezing (Painful Stage)||A slow onset of pain is felt. As it worsens over a period of 6 weeks to 3 months, the affected shoulder loses global motions.|
|2. Frozen (Adhesive Stage)||Lasting for approximately 3 to 9 months, pain intensity subsides. But is present at the extremes of motion range. The stiffness; however, remains.|
|3. Thawing (Recovery Stage)||The previously restricted motions gradually return to near normal. This occurs after 5 to 26 months.|
Table 1. The Natural Presentation of FSS. Scientific studies hold a consensus that the condition’s course spans three stages.
Who it affects
Maria is among the many. The National Institutes of Health reports approximately 5% of the general population, in a way or another, have symptoms of FSS.
Women between the ages of 40-60 years old are more commonly affected. The presence of metabolic diseases, such as Diabetes Mellitus (DM), increase the risk further.
Basic Shoulder Anatomy
A pre-requisite to a thorough understanding about FSS is a grasp of relevant shoulder anatomy.
© https://kneeandshoulderclinic.com.au/wp-content/uploads/FrozenShoulder-pic2.png Image 1. Relevant anatomy of the shoulder shows that the smooth tissue of the capsule has thickened resulting to stiffness and concomitant pain.
The shoulder is a ball-and-socket type of joint consisting of three bones: the humerus (upper arm bone), the scapula (shoulder blade) and the clavicle (collarbone). The interconnections of these bones allow substantial degrees of freedom – enabling you to move your arm around in space.
Rather than its bones, the shoulder complex relies on its muscles and ligaments for support and stability.
Further, the humeral head fits into a socket found on your shoulder blade called the glenoid cavity. This is surrounded by strong connective tissue. And a synovial fluid lubricates the shoulder complex to enable smooth gliding movements.
Why FSS occurs
Ah, that is the difficult question! The exact mechanism leading to FSS remains enigmatic.
However, the current hypothesis states that an inflamed joint capsule triggers adhesions and fibrosis (thickening) of the synovial lining. Synovial fluid volume is then reduced.
Should someone also have Diabetes Mellitus (DM), this increases the chance of abnormal collagen repair. This can predispose to the secondary type of FSS.
These factors eventually lead to muscle contracture due to pain guarding and subsequent stiffness.
At this point you may ask, how does FSS differ from other conditions? You may have family members or friends who have experienced a similar set of signs and symptoms including (but not limited to):
- shoulder impingement
- shoulder muscle tendon inflammation (rotator cuff tendinitis)
- inflammation of a fluid-filled cavity ( shoulder bursitis)
- degenerative arthritis
FSS can be described through this hallmark: the inability to move the shoulder both actively and passively in the absence of any intrinsic (or internal) pathology. This simply means you are unable to move your shoulder on your own or even with assistance from others.
The other mentioned conditions contribute to limitation of motion actively, but the patient, in most cases, can achieve joint freedom through passive ROM; or with the help of others. This helps to rule conditions in and out as the correct diagnosis is vital to establishing a concrete, suitable and helpful treatment plan.
As with most conditions that bring pain and discomfort, a typical treatment path for frozen shoulder includes medications. Two mainstay drugs include NSAIDs and oral corticosteroids.
But what do evidenced-based practices say about these?
The prescription of non-steroidal anti-inflammatory drugs (NSAIDs) is based on the pathophysiological tenet that FSS presents with inflammation at its onset. This type of drug may be best for early intervention – notably during the freezing stage.
You must remember, however, that FSS spans three stages. And as pain and inflammation diminish, NSAIDs may not bring the long-term results you seeking. A study by Van Der Windt et al states that NSAIDs present superior yet short-term efficacy.
There is no categorical evidence in favour of a specific NSAID with respect to efficacy in treating FSS. Further, prolonged use of NSAIDs may bring harmful effects such as a gastrointestinal ulcer.
For more severe cases, oral corticosteroids can be prescribed by your physician.
This drug may bring significant improvement but research shows a plateau of efficacy beyond six weeks. It must be noted that corticosteroids can result in hyperglycemic outcomes. Constant monitoring of a patient’s blood glucose is required.
Sans the pills – the active way
Several studies support favourable effects of passive motion and basic exercises in treating FSS. Patients report decreased pain index scores at rest, at movement and at night. Improved range of shoulder range of motion was also noted.
What follow are the cornerstone home-based exercises for frozen shoulder that can be performed when convenient and able:
- Pendulum (Codman’s) Exercise
- This exercise is a flexible one as it helps with preserving muscle contractility and range of motion. Added use of small weight causes light stretching of the shoulder structures. Further, gravity and added external weight bring light distraction that promotes synovial fluid flow.
Image 2. Pendulum exercise. 10 times per direction x 3 sets (for initial frequency, increase as tolerated). ©http://www.cascademassagetherapy.com/images/0204pic2.jpg
- Relax your shoulders.
- Lean forwards on a supporting structure, with the trunk bent at the hips at about 90 degrees.
- The pendulum or swinging arm motion is attained by moving the trunk back and forth. Remember, do not swing your arms. Let your trunk movement bring the arms into motion (front, back, sideways and circular direction).
- For low-grade stretch and distraction, the patient can hold a weight.
Watch this video here for how to correctly perform this exercise.
- Cross Body Reach
This is a basic yet helpful. However, you must devote at least 30 seconds for the stretch to be effective. The cross body stretch addresses the most restricted motion in shoulder pathologies; external rotation (rotating the arm away from body’s center).
- Use your good arm to support the affected arm, near the elbow.
- Bring the elbow across your body while exerting slight pressure.
- Hold for at least 30 seconds. Repeat five times.
Note: For beginners, hold duration can be reduced to 15 seconds. Repeat 10 times. Increase duration to 30 seconds once tolerated, and reduce repetitions (to five times).
- Hand Behind Back
– Orthopedic assessments point to internal rotation (the arm rotating inward toward the body) and abduction as the next restricted motions in cases of shoulder pathology, after external rotation. The compound stretch below addresses this pattern.
- Hold your problem arm’s wrist.
- Slowly stretch hand towards the opposing buttock. Hold for about 30 seconds. Repeat three times.
- Then slide your arm up along your back. Repeat five times.
- At the point where you need a challenge? Use a towel. Hold your arms in the same position, but with the affected side hand grasping the towel. With the good shoulder and arm, pull the towel upward, reproducing the former action.
See the video here for more stretches.
The shoulder relies on muscles for support and stability. Strengthening the musculature, specifically the shoulder rotators, can augment treatment after achieving increased range of motion.
4. External Rotation
- Choose a rubber exercise band by determining the resistance you can tolerate.
- Hold the band between your arms, with your elbows at your side at approximately a 90-degree angle.
- Bring the lower part of the affected arm outward (2-3 inches away).
- Hold for five seconds. Repeat 10-15 times.
5. Internal Rotation
- Go to a closed door in your house.
- Install one end of the exercise band at the doorknob.
- Hold the other end with your affected arm at a 90-degree angle.
- Pull the band toward your body, with a rotating motion. Hold for five seconds and repeat 10-15 times.
Note: Before you do this, make sure no-one will move the door!
Be patient and persist
The prerequisite to any successful treatment pathway, including frozen shoulder, is a comprehensive picture of a patient’s signs, symptoms, needs and current challenges. But with the complexity of the shoulder region, subjective information from the patient should be validated with reliable tests. This ensures that the plan will best suit the condition.
Maria, and others like her, do recover from FSS. After all, frozen shoulder is, thank goodness, self-limiting. Keep your eyes on treatment options, participate in your care, and here’s to a pain free, fully functional shoulder in your near future.
Dr. Rebecca Harwin
Chiropractor & Multi-book Author