Frozen Shoulder

Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.

What is Frozen Shoulder? (Adhesive Capsulitis)

Adhesive capsulitis (also known as Frozen shoulder) is a painful and disabling disorder of unclear cause in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain. Pain is usually constant, worse at night, and with cold weather. Certain movements or bumps can provoke episodes of tremendous pain and cramping. The condition is thought to be caused by injury or trauma to the area and may have an autoimmune component

One of the main problems is that frozen shoulder syndrome is often misdiagnosed, To keep things simple most experts define it as a "a stiff shoulder with less than 50% of normal range of active and passive motion in any direction". 

The important point here is that you can’t lift the shoulder and neither can anyone else lift it for you – it is completely stiff and locked. Other conditions can cause the shoulder to stiffen but typically, only in certain directions of movement

What does it feel like?

This depends on what phase you are in. The initial phase of Frozen Shoulder is characterized by an exquisite sharp catching spasm sometimes for no reason at all. Another characteristic of the early phase is night pain. The shoulder can ache and wake you up at night, disturbing your sleep (and your partners) and depleting your energy. You know you are in phase II when your night pain has gone away. Another key feature of all phases of a frozen shoulder is the loss of shoulder and arm movement. The stiffness can be very severe, especially when reaching behind your back or above your head. This can make the simplest of tasks, like brushing your hair, agonizingly difficult. Stiffness lasts through all three phases of frozen shoulder syndrome but starts to ease from phase II onwards.

What happens inside a frozen shoulder?

The shoulder ball and socket joint is surrounded by a fluid filled bag with 35-70ml of synovial fluid which helps to lubricate and nourish the joint; with Frozen Shoulder the capsule thickens and becomes tight and the fluid levels drop to an average of 5-10ml. Stiff bands of tissue (referred to as adhesions) may start to develop in and around the capsule. This is due to inflammation. The hallmark sign of a “frozen shoulder” is being unable to move your shoulder - either on your own or with the help of someone else.

Description

In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.

The hallmark sign of this condition is being unable to move your shoulder - either on your own or with the help of someone else. It develops in three stages:

Freezing

In the"freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

Thawing

Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

Cause

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder

Early symptoms of frozen shoulder

• A feeling of pain and tightness in the shoulder area.
• A feeling of tightness especially when putting the arm up and back, as you would do it you were throwing a ball overarm.
• Pain on the back of the wrist. (This specifically relates to frozen shoulder caused by subscapularis trigger points.)
• As time goes on, the symptoms will worsen although the pain may be reduced.

Frozen Shoulder and Diabetes

Frozen shoulder is much more common in diabetics; about 10-20% are affected (compared to 2-5% of the general population). It is not clear why this should be the case but experimental studies have shown that the soft tissues of the shoulder are stiffer than normal. All muscle fibres are ‘packed’ within other tissue called parenchyma. This packing substance is made of collagen. Collagen helps to make up the elastic component of the skin and muscles (as we get older our skin wrinkles as a result of decreased collagen production). US doctors NA Friedman and MM LaBan published a paper in 1989 in which they put forward two theories as to why frozen shoulder is more common in those suffering with diabetes.

Diabetes and Frozen Shoulder - Theory 1

Because Type I diabetics are unable to regulate their blood sugar levels naturally, there are many times during the day that the sugar levels may be high, which can lead to an accumulation of sugar-alcohol in the tissues. This sugar-alcohol is called sorbitol and it accumulates in the ‘ground substance’ of the connective tissues (collagen) where, because it has a higher osmotic pressure, it attracts water, making the tissues stiffer.

Diabetes and Frozen Shoulder - Theory 2

An alternative explanation has been put forward, whereby the properties of the collagen itself are attenuated. It has been suggested that the collagen becomes embedded with excess sugar called glycogen. This ‘glycosylation’ of collagen leads to more bonds and bridges being formed at a molecular level between collagen molecules, thus changing the internal structure of the collagen. This means that enzymes cannot efficiently replace normal collagen wear and tear, and the tissues get stiffer.

NAT Network Survey - Winter/Spring 2014

During the period March - July 2014, Niel Asher Healthcare interviewed 109 therapists who regularly use NAT as part of their treatment protocols and who have treated one or more diabetic frozen shoulder patient within the previous 12 months. As part of this study, the therapists (including osteopaths, physiotherapists, chiropractors, massage therapists, sports massage therapists) were questioned regarding the effectiveness of NAT when treating diabetics. 88% (or 96) interviewees agreed with the statement that "Diabetic Patients treated with NAT responded with significant reduction in pain and increased 

Frozen Shoulder and Menopause

It’s a fact that more women are afflicted with frozen shoulder than men - and the majority of these women will contract frozen shoulder when they are undergoing menopause.

Here are some useful tips to help avoid “menopausal shoulder”:

We know it’s a cliche - but regular exercise could help you avoid a frozen shoulder. Find an exercise regime that works for you and which includes exercises specifically related to your shoulders. Long term lack of mobility is one of the major suspected causes of frozen shoulder syndrome. Please visit our shoulder exercise section for more information.

Always remember to stretch before exercise. You need to be sure that your body is warmed-up so that your shoulders can move more freely and easily. Visit our shoulder exercise page for more information.

Where possible, avoid strenuous activity of the shoulders during the time of the month. This is the time when your hormones are acting to loosen ligaments and thus make you more prone to injury.

It’s another cliche - but you’d be well advised to watch what you eat, especially as your diet relates directly to bone density and general health. Be sure to include plenty of fresh fruit and vegetables. Stick to low-fat milk and dairy products made with low fat milk; and try to limit the amount of red meat that you eat to a healthy minimum.

If you are currently suffering from a “menopausal” frozen shoulder, you should follow the general advice within this website. In particular, we recommend that you read the information regarding common treatments.

Prevention

To prevent the problem, a common recommendation is to keep the shoulder joint fully moving to prevent a frozen shoulder. Often a shoulder will hurt when it begins to freeze. Because pain discourages movement, further development of adhesions that restrict movement will occur unless the joint continues to move full range in all directions (adduction, abduction, flexion, rotation, and extension). Physical therapy and occupational therapy can help with continued movement.

How Can a Physical Therapist Help?

Your physical therapist's overall goal is to restore your movement so that you can perform your activities and life roles. Once the evaluation process has identified the stage of your condition, your therapist will create an exercise program tailored to your needs. Exercise has been found to be most effective for those who are in stage 2 or higher.

Stages 1 and 2

Your physical therapist will help you maintain as much range of motion as possible and will help reduce the pain. Your therapist may use a combination of stretching and manual therapy techniques to increase your range of motion. The therapist also may decide to use treatments such as heat and ice to help relax the muscles prior to other forms of treatment. The therapist will give you a home exercise program designed to help reduce the loss of motion.

Stage 3

The focus of treatment will be on the return of motion, with your therapist using more aggressive stretching and manual therapy techniques. You may begin some strengthening exercises as well, and your home exercise program will change to include these exercises.

Stage 4

In the final stage, your therapist will focus on the return of "normal" shoulder body mechanics and your return to normal, everyday, pain-free activities. The therapist will continue to use stretching, strength training, and a variety of manual therapy techniques.

Sometimes, conservative care cannot reduce the pain. If this happens to you, your physical therapist may refer you for an injection of anti-inflammatory and pain-relieving medication into the joint space. Research has shown that although these injections don’t provide longer-term benefit for range of motion and don’t shorten the duration of the condition, they do offer short-term benefit in reducing pain.

Exercises-

Hints & Tips for Living with Your Frozen Shoulder

What you do with your shoulder on a daily basis is important both for managing pain and increasing the rate of recovery. There are simple things you can think about as you go about your daily life to make the ordeal of your frozen shoulder more bearable.

Walking

Walking through a busy supermarket or going on the Tube at rush hour may not sound much to most people, but for somebody with a frozen shoulder it can be a very stressful experience. The fear of a fellow shopper or passenger accidentally bumping into the shoulder is constantly present. In that type of scenario it may be difficult not to remain tense and protective towards the shoulder.

However, whenever possible it is important to allow the shoulder to relax and straighten the arm when walking. The tension caused by fear of pain will only compound the problems.

This is what to do when walking:

• Relax the shoulder down


• “Let it swing”, swinging the arm along the side of your body like you would under “normal” circumstances. It may feel odd initially but if you persevere, you will soon get used to it.


• Breathe and relax

Swinging the arm during a very acute phase may be painful, so achieving the first two points is enough.

This will help to separate the shoulder joint allowing fluid back into the shoulder capsule. Also gently moving the arm will improve blood flow into the shoulder area and thereby ultimately improve healing and reduce pain.

Sleeping

Night pain and sleeplessness are some of the worst aspects of the frozen shoulder, especially in the early days. At first, you will probably not be able to tolerate pressure on your affected side. As your symptoms ease, however, you will find you can gradually ease into some type of position. The degree of night pain is directly proportionate to the amount of inflammation within the joint.

Some comfort and relief may be obtained by:

• Lying on your back, with a pillow lengthways under the affected arm(s) and shoulders, supporting them


• Try to avoid sleeping with the arm above your head. This inhibits shoulder tissue repair, which manly occurs manly at night


• Lying on your back with a good neck pillow

Posture

The benefits of maintaining a good posture are something that we Osteopaths often try to emphasize to our patients. During the frozen shoulder the posture you adopt is of great importance as it affects the speed of your healing and repair.

The shoulder girdle operates best when the shoulders are held back in their correct alignment. Round shoulders and long term poor posture causes the shoulder muscles and joints to work inefficiently and can lead to a “pinching” of the tissues; causing further damage. Also remember your neck posture; the neck muscles often become rigid in a frozen shoulder where they are ‘heaving’ around the stiff shoulder.

Changing your diet may help relieve 
your shoulder pain ????

• Ms.Varsha Raju Msc(Nutri), Dietician & Fitness Consultant

Are there any foods that can help prevent the onset of frozen shoulder?

The answer is actually "yes and no" …. Which needs some explaining!
The first thing to point out is that there is a scarcity of published research – so we have to rely on anecdotal rather than clinical evidence.

Prostaglandins are hormone-like substances that affect the body in variety of ways, including an effect on regulating inflammation. An anti-flammatory diet should include less foods that create inflammation-causing prostaglandins (PGE2), and should include more foods that create anti-flammatory prostaglandins (PGE1 and PGE3).

If you are suffering from a frozen shoulder you should try to reduce your intake of simple carbohydrates and fats, such as saturated fats and trans fats. Where possible, try to increase your intake of anti-inflammatory foods such as fruits and vegetables, oily fish (which contain high levels of omega-3 fatty acids), nuts, seeds, and certain spices, such as ginger.

“Shoulder At Work”

Although the pain of a frozen shoulder can be constant, the demands of life do not necessarily let up. At work you may spend a long time in the same position or perform some repetitive tasks. Here are some tips on how to get through the day with the least amount of discomfort:

• Avoid carrying heavy bags or cases for long distances; this has been demonstrated to precipitate tears in the supraspinatus a vital shoulder muscle.


• When working in front of the computer screen, take regular breaks. Get up and walk away from your work station and the P.C. for a couple of minutes every half an hour. This is important for the same reasons as above.

Make sure your chair has good back support and preferably adjustable arm rests.
Adopt the ‘ideal’ work posture if you are sitting at a desk. See below:

Ice

Ice can be particularly beneficial in the acute freezing (I) and thawing phases (II) when the inflammation is most active. You may feel skeptical about this, but so many people have enthusiastically described the relief they felt from applying ice to their shoulders that it is worth trying.

• Wrap some crushed ice or frozen peas in a towel and place over the front of the shoulder joint. Leave it there for 5 to 10 minutes.


• Let the area rest without ice for 5 to 10 minutes and repeat.


• The cycle can be repeated 4 to 5 times and can be done several times during the day.

You can also apply the ice to the back of the shoulder joint, the top, the side or other areas where there is acute pain. It is a good idea to ice the front of the shoulder even if it is not painful.
When ice is not appropriate (at work etc) then cold sprays or gels may be useful.

NB: never apply ice directly to the skin as it burns and leaves brown marks.

Heat

In the early stages of a frozen shoulder applying direct heat is not a good idea, though a warm bath may be helpful.

Warm packs / hot water bottles that are not too hot can be applied in the second and third phases.

If you find that heat does give you temporary relief, then an alternating cycle of 5 minutes ice 5 minutes warmth ending with 5 minutes ice can be tried.

NB: It is very important to end the cycle with ice.

For Further Advice & Consultation :Contact

Dr.Vijay Bathina

Chief Physiotherapist

  SYNAPSE PHYSIO CARE

09848857464