Adhesive Capsulitis, also known as Frozen Shoulder, is a debilitating condition characterized by progressive shoulder stiffness, loss of motion, and severe pain, especially at night (7).

The condition is challenging to diagnose and treat, and its cause (etiology) remains a mystery. Researchers are yet to agree on a definitive cause for the condition. However, it is thought to result from an inflammatory process leading to scar tissue formation and contractures in the joint capsule (18).

Frozen Shoulder has a prevalence rate of 2-5% in the general population, and it is more common in women than in men (23). Individuals between 40 to 65 years old are more likely to develop the condition (7). Studies have also shown that Frozen Shoulder occurs more frequently in patients with diabetes mellitus, with an occurrence rate of 10-20% (18).

Frozen Shoulder is considered a self-limiting condition lasting up to several years (18). However, with the right treatment strategy, patients can experience relief within a shorter time frame. A systematic review and meta-analysis of randomized controlled trials showed that manual therapy and exercise effectively treat Frozen Shoulder (19).

CAUSES OF FROZEN SHOULDER

The causes of Frozen Shoulder remain a mystery, leaving patients frustrated and confused. Researchers have categorized Frozen Shoulder into primary and secondary types based on the condition's origin (7).

Primary & Secondary Frozen Shoulder:

• This type of Frozen Shoulder has an unknown cause and is often called idiopathic.

• Secondary Frozen Shoulder: This type of Frozen Shoulder results from a suspected cause or surgical incident.

Risk Factors

Several risk factors have been associated with Secondary Frozen Shoulder, including:

Smoking

• Extended periods of immobilization

• Trauma, injury, or previous surgery to the shoulder

• Diabetes, lung disease, heart disease, hyperthyroidism, and Parkinson's disease

It is important to note that smoking increases the risk of rotator cuff pathologies and shoulder dysfunctions in general (8).

SHOULDER JOINT ANATOMY

The shoulder joint (glenohumeral joint) is a complex structure consisting of a ball-and-socket joint, ligamentous capsule, and numerous supporting structures (3). The ball of the joint is formed by the end of the upper arm bone (humerus), while the socket (glenoid fossa) is located on the shoulder blade (scapula).

The glenohumeral joint is surrounded by a ligamentous capsule full of synovial fluid that lubricates the joint and allows for smooth movement (20). Synovial fluid is a viscous, lubricating fluid secreted by the membrane lining the joints and tendon sheaths. The articular capsule, with numerous folds, is designed to allow optimal movement.

Although the glenohumeral capsule alone is not very strong, it is surrounded by the rotator cuff muscles, which act as active ligaments and provides stability for the various structures of the shoulder (10). The fascia that runs through these muscles also plays a critical role in stabilizing the shoulder joint.

In summary, the shoulder joint is complex, consisting of numerous supporting structures, including the ligamentous capsule, synovial fluid, articular capsule, rotator cuff muscles, and fascia. These structures work together to provide stability and optimal shoulder joint movement.

During glenohumeral joint motion, the subscapularis muscle, one of the rotator cuff muscles, plays an important role in reducing friction on the humeral head to provide shoulder stability. To achieve this, the subscapularis muscle coils around the coracoid process of the shoulder blade (scapula). (27)

In addition to the subscapularis muscle, the subscapular fascia and subcoracoid bursae also reduce friction on the humeral head during shoulder movement. This helps to maintain shoulder stability and prevent injury. (27)

PHYSIOLOGICAL CHANGES WITH FROZEN SHOULDER

Physiological changes that occur during the development of a Frozen Shoulder have been well-documented in current literature (2). The following changes take place during this process:

• Inflammation and thickening of the capsule surrounding the shoulder joint

• Extreme rigidity of the capsule

• Decreased synovial fluid levels within the capsule

• Contraction of the joint capsule

The inflammation and contraction of the capsule lead to less space for the humerus (upper arm bone) to move around, resulting in pain, stiffness, and loss of motion in the shoulder (7).

Patients with Frozen Shoulder typically experience difficulty with two ranges of motion, primarily shoulder abduction and external rotation (7).

In summary, the development of a Frozen Shoulder involves a combination of inflammation, thickening, and contraction of the capsule surrounding the shoulder joint. These changes result in decreased synovial fluid levels and less space for the humerus to move around, leading to pain, stiffness, and loss of motion in the shoulder.

The Three Phases of Frozen Shoulder

The development of Frozen Shoulder is typically divided into three phases that last several months, as supported by current literature (19). These phases include:

1. Painful or Freezing Phase (2-9 months): This phase is characterized by pain with any movement and a decrease in the patient's range of motion.

2. Adhesion Phase (4-12 months): During this phase, the level of pain decreases, but the shoulder's range of motion substantially decreases. This reduction is due to the thickening of the joint capsule with excessive collagen, making daily activities challenging to perform.

3. Thawing or Resolution Phase (5-26 months): During this phase, the patient's pain decreases, and their range of motion begins to increase.

It is worth noting that while these are the classical phases of Frozen Shoulder, with the right program of therapy, exercise, and possible medication/injections, the duration and intensity of these phases can be greatly reduced (7).

EXAMINATION OF FROZEN SHOULDER

Several factors should be considered to examine a patient presenting with Frozen Shoulder effectively. The following steps are typically taken to evaluate such patients:

1. Check active and passive ranges of motion in the shoulder, cervical spine, and thoracic region. This step helps identify any limitations in the patient's range of motion, a common symptom of a Frozen Shoulder.

2. Check rib mobility, especially the first rib. Limited rib mobility can cause shoulder and neck pain and may contribute to Frozen Shoulder symptoms.

3. Check External Rotation of the shoulder: Testing the external rotation bilaterally can reveal a positive test when the affected side has a 50% or greater loss of rotation compared to the good side or less than 30 degrees of external rotation. This finding is common in patients with Frozen Shoulder.

4. Verify if at least two other ROM planes are reduced by at least 25% compared to the other side. For example, testing the shoulder in abduction and flexion can help identify other planes of reduced range of motion.

5. Check for active muscle guarding using the Coracoid Pain Test. This test involves applying digital pressure on the area of the coracoid process to determine if there is localized pain, a common symptom of a Frozen Shoulder (12).

Orthopedic Testing Videos:

The following videos demonstrate the orthopedic, neurological, and vascular testing that should be performed during an examination of a Frozen Shoulder:

Frozen Shoulder Testing

This video demonstrates some of the typical orthopedic examination procedures used to evaluate a patient with Frozen Shoulder.

Shoulder Examination - Orthopaedic Testing

This video utilizes orthopedic examination procedures to diagnose common causes of shoulder pain, including Frozen Shoulder, and explains the evaluation process.

Upper Limb Neuro Exam

The upper limb neurological examination is a critical component of the overall neurological evaluation that assesses the motor and sensory neurons that supply the upper limbs. This examination is crucial in detecting any nervous system impairment.

Peripheral Vascular Examination - Key Points

Performing a peripheral vascular examination is crucial to rule out signs of vascular-related pathology. It can help to mitigate potential cardiovascular and cerebrovascular complications through early detection and treatment. This video highlights some commonly performed procedures in daily clinical practice for assessing peripheral vascular health.

Checking all the Shoulder Joints

In addition to standard orthopedic and neurological testing, evaluating the mobility of all four shoulder joints is important. The following are the recommended procedures for checking the mobility of each joint: (7)

1. Sternoclavicular (SC) Joint - Check for elevation of 45°, depression of 5°, protraction of 15°, retraction of 15°, and axial rotation. A fused SC joint limits all shoulder motions.

2. Scapulothoracic Joint (ST) - Check for motion between the scapulae and the rib cage. The scapulae should be able to elevate, depress, protract, and retract over the rib cage, and there must also be upward and downward rotation in the glenoid fossa.

3. Acromioclavicular (AC) Joint - The acromioclavicular joint allows for a degree of axial rotation and anteroposterior movement. There should be a total glide and rotation of 20-30° with accompanying shoulder joint motions.

4. Glenohumeral (GH) Joint - In cases of Frozen Shoulder, the Glenohumeral joint is typically most limited in the anterior and inferior capsular region. The Glenohumeral joint should not be limited in all three planes of motion.

Clinical Tip: No muscles attach directly to the SC joint. The SC joint motion somewhat mimics the reciprocal motions of the Scapulae. The muscles that attach to the clavicle that may affect clavicular motion are the SCM, deltoid, pectoralis major (clavicular head), subclavius, and trapezius.

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DIAGNOSTIC IMAGING FOR FROZEN SHOULDER

Your healthcare provider may order X-rays to rule out any associated or pathological conditions. In cases of Frozen Shoulder, it is recommended that patients undergo plain radiography imaging. This imaging can help rule out infections, metastatic processes, large areas of calcification, avascular necrosis of the humeral head, or charcot joints.

It is also important to note that patients who smoke or have a smoking history should undergo a chest X-ray with apical views to rule out a Pancoast Tumor. This type of tumor can irritate the brachial plexus, potentially causing Frozen Shoulder-like symptoms.

In summary, X-ray imaging can be an essential tool for identifying underlying conditions related to Frozen Shoulder, particularly in patients with a smoking history or other risk factors.

DIFFERENTIAL DIAGNOSIS FOR FROZEN SHOULDER

When diagnosing a Frozen Shoulder, practitioners must consider several other conditions that can present with similar symptoms. These other conditions should be considered in the differential diagnosis (15), and may include:

1. Bursitis: Patients with bursitis will exhibit an increased passive range of motion (PROM) compared to Frozen Shoulder. Both syndromes will be very painful during the initial stages.

2. Osteoarthritis: As with Frozen Shoulder, abduction and external rotation will be limited in active range of motion (AROM). However, PROM will not be limited to cases of osteoarthritis.

3. Rotator Cuff Syndrome: Symptoms of Rotator Cuff Syndrome can be very similar to Frozen Shoulder. In some cases, MRI or ultrasound may be necessary to differentiate between the two syndromes.

It is important for healthcare providers to differentiate between these conditions to ensure proper treatment is provided. While the symptoms may appear similar, proper diagnosis can lead to more effective management of the patient's condition.

FROZEN SHOULDER TREATMENT

Manual therapy and exercise should be considered the first line of treatment for all stages of Frozen Shoulder, as considerable research supports their effectiveness (19). Manual therapy aims to reduce pain, increase mobility, and provide functional improvements in activities of daily living (ADL). The specific combination of treatment and exercise recommendations may vary depending on the current phase of the Frozen Shoulder.

Several manual therapy approaches can be used depending on each patient's specific needs. However, it is important to note that qualified practitioners should only perform these procedures. Here are some examples of manual therapy approaches:

Joint mobilization: Joint mobilization involves the passive movement of the affected joint within its anatomical range of motion. It can help to reduce pain and increase joint mobility in patients with Frozen Shoulder. (25)

• Shoulder Joint mobilization: Shoulder joint mobilization is a manual therapy technique commonly used to treat frozen shoulder. This technique involves the mobilization of the shoulder joint to improve joint motion and stretch contracted peri-articular structures such as muscles, ligaments, and tendons. Studies have shown that joint mobilization can be an effective treatment approach for frozen shoulder, helping to improve the range of motion and decrease pain. In a randomized controlled trial, patients who received joint mobilization in addition to exercises showed significant improvements in shoulder pain and function compared to those who received exercises alone. (30)

• Soft tissue mobilization: Soft tissue mobilization involves the application of manual pressure to the soft tissues surrounding the affected joint. It can help to reduce pain and improve mobility by releasing adhesions and trigger points (5).

• Trigger point release: Trigger point release involves the application of manual pressure to localized areas of muscle spasm or tension. It can help to reduce pain and increase joint mobility in patients with Frozen Shoulder (4).

• Myofascial release: Myofascial release is a technique that involves the application of sustained pressure to the myofascial tissues. It can help to reduce pain, improve joint mobility, and increase flexibility (24).

5 Point Shoulder Joint Mobilization - Part 1: The Motion Specific Release "5 Point Shoulder Joint Mobilization" protocol is demonstrated in this video. The shoulder is often considered a single joint; however, in reality, it comprises five different joints. Understanding the interrelationships between the structures within these joints is crucial to address shoulder injuries successfully. The protocol aims to mobilize each of the five joints, reduce pain, and improve shoulder mobility. It is important to note that a qualified practitioner should only perform this procedure. (31)

5 Point Shoulder Joint Mobilization - Part 2:

Dr. Abelson demonstrates effective Motion Specific Release (MSR) procedures for shoulder joint mobilization in this video. These techniques aim to increase mobility and reduce pain in the shoulder joint by mobilizing specific structures within the joint. It is important to note that a qualified practitioner should only perform these procedures. (31)

6 ‐ Point MSR Rotator Cuff Protocol: In this video, Dr. Abelson demonstrates the 6 ‐ Point MSR Rotator Cuff Protocol: The rotator cuff comprises four major muscles and their associated tendons: supraspinatus, infraspinatus, teres minor, and the subscapularis. This group of muscles is also called the SITS muscles (the first letter of their names). The SITS muscles are involved in almost every type of shoulder movement. It is extremely important to have strong, flexible, and balanced SITS muscles to maintain optimal shoulder function. (31)

CONCURRENT TREATMENT

Frozen Shoulder is a condition that is often treated concurrently with medical practitioners. The use of manual therapy and exercise, in combination with anti-inflammatory medications and glenohumeral joint injections, can help break the pain cycle more rapidly. While some may wonder why they can't simply receive injections without therapy or exercise, research has shown that combining injections with manual therapy and exercise is more effective in improving function and achieving increased ranges of motion (13,22).

It is worth noting that anti-inflammatory medications are most helpful to patients during Phase 1 of Frozen Shoulder. These medications allow patients to tolerate therapy and exercise better. However, in cases with prolonged symptoms, anti-inflammatory medications have NOT been shown to decrease pain or improve function (6). Therefore, a comprehensive approach that includes manual therapy, exercise, and medication/injections (when appropriate) is recommended for optimal outcomes in treating Frozen Shoulder.

TREATMENT DURING PAINFUL OR FREEZING PHASE

During the Painful or Freezing Phase of a Frozen Shoulder, treatment strategies should focus on reducing pain and inflammation, improving blood circulation, and gradually increasing the range of motion. Some of the recommended treatment strategies, based on current literature, include: (9,17,28,31)

• Avoiding all painful activities.

• Applying heat therapy to the affected shoulder increases blood circulation and reduces muscle viscosity. This can be done using a heating pad or a warm towel.

• Performing exercises within a pain-free Active Range of Motion (AROM).

• Doing stretching exercises for a short duration (2 to 5 seconds), 4 to 6 times daily.

• Doing pulley or pole exercises, depending on the patient's tolerance.

• Performing pendulum exercises several times per day.

• Applying gentle manual therapy procedures, such as osseous and soft tissue techniques, increases the range of motion, reduces muscle viscosity, increases blood flow, displaces waste products, and speeds up healing.

Mobilizing/manipulating restrictions in the thoracic and cervical region if indicated.

It is essential to avoid forcing an increase in the range of motion during this phase.

TREATMENT DURING THE ADHESION PHASE

During the Adhesion Phase of a Frozen Shoulder, the following treatment strategies are recommended:

• Heat therapy: Use heat to increase blood flow, improve range of motion, and reduce muscle stiffness. (1)

• Stretching exercises: Perform stretching exercises within patient tolerance to increase active range of motion. The stretching exercises should become more aggressive and prolonged to increase plastic elongation. (17,26)

• Joint mobilization: Mobilize the shoulder joint to end-range to improve joint motion and stretch contracted peri-articular structures such as muscles, ligaments, and tendons. Shoulder joint distraction procedures can also be used for this purpose. (29)

• Manual therapy: Continue to perform Phase 1 manual therapy procedures within patient tolerance. Consider a larger kinetic chain and slightly increase the intensity. (9,11)

TREATMENT DURING THE THAWING OR RESOLUTION PHASE

Recommended treatment during this phase includes the following:

• Use of heat to increase range of motion and reduce muscle viscosity

• Increasing the frequency and duration of stretching routine to patient tolerance

• Application of pulley or pole exercises to patient tolerance several times per day

• Use of manual therapy procedures to patient tolerance, considering both local and global tensegrity

Importance of early intervention

Research supports using manual therapy to improve patient function during any stage of a Frozen Shoulder. However, the greatest improvements are seen when the treatment is administered early. Therefore, seeking treatment as soon as possible is important to achieve optimal results. (14)

FROZEN SHOULDER EXERCISES

Frozen Shoulder Routine - Motion Specific Release: To help our patients manage their Frozen Shoulder at home, we prescribe a specific exercise regimen. The program typically includes pendulum exercises, 5-part proprioceptive neuromuscular facilitation (PNF) exercises, and partner stretches. These exercises are designed to improve the range of motion, reduce muscle stiffness, and promote healing. Here is a sample of the exercises we recommend for patients to perform at home.

5 Daily Shoulder Mobilization Exercises: This video is particularly beneficial for individuals who frequently engage in prolonged sitting due to work or leisure activities. These targeted exercises offer significant advantages in improving posture and mobility. By incorporating these exercises into your daily routine, you can anticipate considerable enhancements in shoulder health and range of motion.

Strengthening Internal & External Shoulder Rotation: As your range of motion improves, it is recommended to incorporate rotator cuff strengthening exercises into your routine. However, before starting any strengthening exercises, it is crucial to warm up your shoulder and perform stretching exercises. Specifically, focusing on strengthening internal and external shoulder rotation exercises can benefit Frozen Shoulder patients.

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WHEN CONSERVATIVE CARE IS NOT ENOUGH

If conservative treatment for Frozen Shoulder is ineffective, surgery may be an option (2). A selective arthroscopic capsular release may sometimes be recommended (2). Another surgical option is an inferior capsulotomy, which has positive outcomes in certain cases (21).

However, surgical intervention is typically not recommended until conservative treatment has been implemented for at least six months without satisfactory results (Buchbinder, R., Green, S., Forbes). Before deciding, it is important to carefully discuss surgery's benefits and potential risks with your medical practitioner.

CONCLUSION

In conclusion, Frozen Shoulder is a debilitating condition that can greatly affect a patient's quality of life. Diagnosing and treating it early is essential to prevent prolonged recovery times. Conservative care should always be the first line of treatment, and manual therapy, exercise, and medication should be combined for optimal results. Patients with Frozen Shoulder should consult their medical practitioner to rule out other conditions with similar symptoms and to obtain a proper diagnosis.

Surgery is seldom needed, and most practitioners recommend conservative treatment for at least six months before considering surgical options. However, if conservative care is not enough, surgical options are available. Selective arthroscopic capsular release and inferior capsulotomy have been effective in certain cases. Surgery's benefits and possible complications should be carefully discussed with your medical practitioner. Overall, with proper diagnosis and treatment, most patients with Frozen Shoulder can recover their full range of motion and return to their daily activities.

DR. BRIAN ABELSON DC. - The Author

Dr. Abelson is committed to running an evidence-based practice (EBP) incorporating the most up-to-date research evidence. He combines his clinical expertise with each patient's specific values and needs to deliver effective, patient-centred personalized care.

As the Motion Specific Release (MSR) Treatment Systems developer, Dr. Abelson operates a clinical practice in Calgary, Alberta, under Kinetic Health. He has authored ten publications and continues offering online courses and his live programs to healthcare professionals seeking to expand their knowledge and skills in treating musculoskeletal conditions. By staying current with the latest research and offering innovative treatment options, Dr. Abelson is dedicated to helping his patients achieve optimal health and wellness.

Despite being in the field for over three decades, Dr. Abelson remains open to welcoming new patients at Kinetic Health, save for the periods he dedicates to teaching or enjoying travels with his cherished wife, Kamali. However, be forewarned, he will anticipate your commitment to carry out the prescribed exercises and punctuality for your appointments (smile). His dedication towards your health is absolute, particularly in ensuring that you can revel in life unimpeded. He genuinely delights in greeting both new faces and familiar ones at the clinic (403-241-3772).

Revolutionize Your Practice with Motion Specific Release (MSR)!

MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.

Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.

Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.

With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!

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