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FROZEN SHOULDER
Definition
Frozen Shoulder is the common name given to a condition called Adhesive Capsulitis in which the shoulder becomes painful to move, and movement is often
completely restricted. As the condition progressively worsens over time, the shoulder"s ranges of motion become severely reduced.
In order to better understand this condition a basic knowledge of the anatomy of the shoulder joint can be helpful. The shoulder joint is comprised of the union of three bones, the upper arm (Humerus), the shoulder blade (Scapula), and the collar bone (Clavicle). At the location where these bones come together to form the joint,
they are held to each other tightly by several ligaments. The movements of the shoulder joint are accomplished by the actions of a group of muscles called the Rotator Cuff or the SITS muscles, namely Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis. The unique anatomy of the shoulder joint allows it to be the
most mobile joint in the human body. The shoulder is a "ball-and-socket" joint. The round end of the upper arm (Humerus) fits into a shallow groove at the end of the shoulder blade (Scapula), like a golf ball resting on a tee. This ball-and-socket joint is surrounded by a tough connective tissue called the shoulder capsule. The shoulder capsule acts as a sack that holds the synovial fluid needed for lubrication and smooth movement of the joint.
Now back to our definition of Frozen Shoulder or Adhesive Capsulitis. As the medical term suggests, this condition occurs when the shoulder capsule becomes inflamed (capsulitis) and this inflammation in turn causes bands of sticky connective tissue (adhesions) to develop between the joint"s surfaces. Moreover, the lubricating synovial fluid may decrease. The result of this sequence of events is development of pain and subsequent loss of movement in the joint. In some
cases, mobility may decrease to such extent that performing even simple everyday activities like combing hair, brushing teeth, or reaching for a wallet in the back pocket becomes difficult or even impossible.
Symptoms
Frozen Shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.
Stage I: Painful / Freezing
The first stage of Adhesive Capsulitis is the onset of the inflammatory process in the glenohumeral (upper arm & shoulder blade) joint capsule. Any type of inflammation involves an influx of several chemical mediators some of which irritate nerve endings in the involved tissue and cause pain. Thus, the first stage of Frozen Shoulder is marked by gradual onset of aching over the shoulder joint. This then progresses into a more widespread and more severe pain that becomes worst at night especially when lying on the effected side. This first stage can last anywhere from 2-8 months.
Stage II: Frozen / Stiffening
The second stage of Frozen Shoulder is marked by increasing stiffness and restricted movement of the shoulder. The long-term inflammatory process of stage I, especially if left untreated, leads to formation of scar tissue in the joint capsule. The outcome of the development of this scar tissue is a decrease in the synovial liquid of the joint, adhesion of sticking together of the joint surfaces, and eventually a significant decrease in the the range of movement of the joint. The level of pain experienced by the patient may decrease during this stage. However, as range of motion is drastically reduced, patient will have difficulty with everyday tasks such as dressing, brushing teeth or hair, carrying bags, or normal household choirs. This stage can last between 4-12 months, and muscle atrophy could be a problem if patient does not keep up with normal use of the shoulder.
Stage III: Thawing
The third stage of Adhesive Capsulitis is marked by spontaneous resolution of the condition. This means that for some unknown reason the adhesions and the scar tissue in the joint begin to "melt" away. The pain begins to subside markedly, and the range of motion starts to return. This stage can also last up to a year. Although the condition resolves on its own, in most cases full recovery of the range of movement may not be possible without proper treatment throughout all three stages.
Causes & Risk Factors
The precise cause of Frozen Shoulder is unknown. It can occur after a single traumatic injury to the shoulder, especially in the area of the joint capsule; overuse
injuries or repetitive stress such as in competitive sports; prolonged immobilization of the shoulder as in the case of a fracture. Women and people over 40 are more
likely to develop this condition. Moreover, certain statistical relationships have been observed that raise interesting questions. People with diabetes have a higher
risk of developing this problem than the general population. The same is true for people with chronic fatigue syndrome, people with history of heart disease or strokes,
and people with hypo- or hyperthyroidism. In view of these statistical relationships, adhesive capsulitis has been considered by researchers to have an autoimmune
component, meaning that the body"s immune system may attack the healthy parts of the body, in this case the capsule and connective tissue of the shoulder. In the
end, the only consensus about what really causes Frozen Shoulder is that it is unknown.
Diagnosis
Generally, adhesive capsulitis is diagnosed based on patient history and a thorough physical examination. During the exam, the doctor will test the patient"s active
movements by asking the patient to move the arm in all possible directions. The doctor will also test the passive movements of the shoulder by manually moving the
arm and shoulder himself. The doctor will palpate and press on parts of the shoulder to see what might cause pain. Loss of both active and passive ranges of motion
and a pattern of generalized (diffuse) shoulder pain are strong indicators of Frozen Shoulder. The doctor will test the end-feel of the joint (the point where the joint can
not move any further in that specific direction) which will be firm, but not as hard as joints with a bony end-feel. Its pattern of progression is predictable enough that it
can be identified without a specific blood marker or diagnostic test. X-rays and MRIs may be conducted to rule out other possible scenarios (bone spurs, osteoarthritis,
tumors, tuberculosis, etc.), but they are not diagnostic for Frozen Shoulder. Arthrograms (tests in which a contrast medium is injected into the joint space), give useful
information; not only do they show where adhesions may have developed, they also reveal how much fluid the affected joint can accommodate.
Treatment
Since Frozen Shoulder is considered an idiopathic (of unknown cause or origin) condition, no single cure or precise treatment option is available. After a diagnosis
is made, the doctor should consider all possible treatment options and discuss those options earnestly with the patient. It is generally accepted among physicians
that most Frozen Shoulder treatments involve controlling shoulder pain and preserving as much range of motion in the shoulder as possible to permit the patient to
perform everyday tasks. It is also generally accepted that, even with the proper and timely treatment course, a full or near-full recovery of the shoulder"s movement
capabilities will depend greatly on the patient"s commitment to a steady and continuous routine of daily range of motion exercises. This exercise routine - prescribed
and demonstrated by a licensed physical therapist, chiropractor, or orthoped - will ensure maintaining as much mobility in the shoulder as possible without stressing
the shoulder to the point of causing a lot of pain.
Medical Treatments:
* Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):
These over-the-counter drugs (such as Aspirin and Tylenol) may help relieve pain and inflammation.
However, since a great number of people suffer upset stomach and digestive problems with NSAIDs, their effectiveness must be weighed against their
possible adverse side-effects.
* Corticosteroids:
These are steroid hormones with anti-inflammatory properties. They can be injected straight into the shoulder joint and may help decrease
pain and shorten the initial painful phase of the condition. The injections are done in a series of 2-3 with a time interval of 1-4 weeks in between; the interval
depends on the effectiveness of the drug on the patient, the doctor"s clinical experience, and manifestation (if any) of side effects. Repeated corticosteroid
injections are not recommended because they could have adverse side effects (e.g. pain, infection, loss of soft tissue, osteoporosis).
* Shoulder Manipulation Under Anesthesia:
This procedure, as the name clearly indicates, involves putting the patient under general anesthesia and then
manipulating the shoulder joint to break up the adhesions without having the patient suffer a great deal of pain. Although this procedure can improve
range of motion if successful, the possible complications are serious: rupture of the joint capsule; tear of the Rotator Cuff muscle(s); fracture of the Humerus;
injury to the surrounding nerves and vasculature; soft tissue injury (cartilage, ligaments, bursa); complications arising from the anesthesia itself.
* Surgery:
In a small number of cases where the symptoms do not improve despite all other measures, arthroscopic surgery may be considered an option to
remove scar tissue and adhesions from inside the shoulder joint. Again, a successful surgical intervention will improve range of motion in the shoulder,
but it carries with it the risks generally associated with surgery, and can lead to significant post-surgical pain.
Alternative Treatments:
* Physiotherapy:
Use of electrical modalities has been shown to be effective and beneficial in treatment of Frozen Shoulder without the risks of adverse side
effects.
TENS:
Transcutaneous Electrical Nerve Stimulation is a treatment that can be used to control pain. In this procedure, a tiny electrical current
is delivered to key points on a nerve pathway. The current, delivered through electrodes taped to the skin, is not painful or harmful. It
is not known exactly how TENS works, but it is thought that it might stimulate the release of pain-inhibiting endorphins or block pain
fibers that carry pain impulses to the brain. In treating Frozen Shoulder, TENS can prove helpful by decreasing the patient"s pain
through all three stages of the condition and by allowing the patient to perform the required range of motion exercises with less
discomfort and apprehension.
EMS:
Electrical Muscle Stimulation like TENS uses a small electrical current delivered through electrodes to cause contraction of a single
muscle or a group of muscles. EMS has proven extremely beneficial in avoiding atrophy and in strengthening muscles that have
been unused due to a period of inactivity (paralysis, immobilization, casting). EMS is also very useful in relaxing hypertonic and
spastic (tight, tense) muscles; it also increases local blood circulation causing delivery of more oxygen and nutrients to the site and
flushing out of metabolic byproducts such as lactic acid.
Ultrasound:
Ultrasonic waves (sound waves of a high frequency) are produced by means of mechanical vibration of the metal treatment head of
the ultrasound machine. This treatment head is then moved over the surface of the skin in the region of the injury. As the ultrasound
waves pass from the treatment head into the skin they cause the vibration of the surrounding tissues, particularly those that contain
collagen. This increased vibration leads to the production of heat within the tissue. In most cases this cannot be felt by the patients
themselves. This increase in temperature may cause an increase in the extensibility of structures such as ligaments, tendons, scar
tissue, and fibrous joint capsules. In addition, heating may also help to reduce pain and muscle spasm and promote the healing
process. Ultrasound may also stimulate the production of more collagen- the main protein component in soft tissue such as tendons
and ligaments. Hence ultrasound may accelerate tissue healing after an injury.
Cold Laser:
Cold Laser or Low-level laser therapy is the application of red and near infrared light over injuries or wounds to improve soft tissue
healing and relieve both acute and chronic pain. The low level laser light waves penetrate deeply into the skin and stimulate the
immune responses of our blood. This has both anti-inflammatory and immunosuppressive effects (both beneficial in treating Frozen
Shoulder). It is a scientific fact that light transmitted to the blood in this way has positive effect throughout the whole body, supplying
vital oxygen and energy to every cell. The following is a list of cold laser therapy benefits: it relieves acute and chronic pain; increases
the speed, quality, and tensile strength of tissue repair; increases blood supply; stimulates the immune system; stimulates nerve
function; develops collagen and muscle tissue; helps generate new and healthy cells and tissue; promotes faster wound healing;
reduces inflammation. This therapy modality has been in use in Europe for decades, and only recently it has been
approved by the FDA for use in the United States.
* Chiropractic:
The benefits of chiropractic care in prevention and treatment of Frozen Shoulder are many-fold. First and foremost chiropractic is
concerned with the proper alignment of the vertebral or spinal column (the back bone). The spinal column (normally made up of
33 individual bones) houses the spinal cord, the pathway of communication between the brain (body"s control center) and the rest
of the body. Together the brain and the spinal cord control every function of every organ, tissue, and cell in the body. Therefore, it
is imperative that the pathway of communication be free from any interference; and this is the main goal of chiropractic. By ensuring
that the spinal column is in proper alignment through specific adjustments (or manipulations) to the individual bones, chiropractic
care strives to keep the pathway of communication free from interference. Thus, chiropractic spinal adjustments not only relieve
the pain associated with such interferences (e.g. neck pain, back pain, arm / leg pain or numbness, headaches), they can also lead
to proper and optimal functioning of the body as a whole.
Chiropractic treatments can also be greatly effective in treatment and management of Frozen Shoulder directly once the condition
has been diagnosed in the patient. Gentle adjustment (manipulation) of scapula, humerus, acromioclavicular joint, sternoclavicular
joint, and cervical and thoracic spine can ensure proper alignment of these structures. Low force instrumental adjustments, in
particular (e.g. Activator), may present certain benefits in these cases that the more forceful manipulations and/or mobilizations
cannot. The proper alignment of the mentioned structures can in turn help to decrease the loss of
movement in the shoulder joint and to balance the work load of the muscles responsible for their movement. An informed and
competent chiropractor would also utilize all the adjunctive modalities listed above (TENS, EMS, US, Cold Laser) along with other
manual therapies such as passive range of motion exercises, friction massage, trigger point therapy, and stretching and strengthening
exercises in his treatment plan.
Chiropractic used in the treatment of frozen shoulder addresses the most practical issue of all: getting the body to move easier,
and the person back to an active lifestyle. Once the body is aligned and can move with fewer restrictions, the need for pain-relieving
and anti-inflammatory medications decreases. Chiropractic-related therapies will also influence diet, exercise, and the maintenance
of the body's alignment. Maintaining a sensible weight, a healthy immune system, and a focus on adequate exercise is essential
for good health, especially for maintaining good blood sugar levels in diabetic individuals.
* Nutritional Management:
As with any musculoskeletal disorder or condition, a proper diet, certainly including the required supplements at the correct
dosage, will ensure less severe symptomology, faster recovery, and proper healing of the involved tissues. Frozen Shoulder is
a great example of such a condition because it involves virtually every type of tissue in the musculoskeletal system: a joint
capsule, the synovial fluid, several joints and muscle groups, tendons, and ligaments. Again, with most musculoskeletal injuries
and disorders in general and certainly with Frozen Shoulder in particular, there is usually an acute (painful, inflammatory) stage
and a chronic (recovery, rehabilitative, coping) stage. The nutritional and supplemental recommendations for the acute stage
include proteolytic enzymes (trypsin, chymotrypsin, bromelin), bioflavonoids (quercetin, hesperidin, rutin), and herbals such as
boswellia, ginger, turmeric, and cayenne. Without going into detail as to the nature and function of each of these nutrients,
it suffices to say that the combined actions of these natural substances have antiinflammatory and analgesic effects. In the
chronic and tissue healing stage, it is imperative to supply the body with the natural nutrients and supplements it needs to
properly and efficiently repair and/or replace the damaged tissues. Amino acids such as L-proline, L-cystine, L-lysine, glycine,
and arginine, along with glucosamine sulfate, alpha-ketoglutaric acid, methy sulfonyl methane (MSM), vitamin C, and iron are
needed for production of quality collagen and healthy ground substance. Calcium and magnesium supplements are needed for
healthy bones and muscles. Antioxidants such as vitamin E, zinc, copper, and manganese are needed to remove free radicals,
cellular debris, and metabolic byproducts. It goes without saying that a proper diet enhanced with the appropriate supplements
will not only aid in greater relief from the symptoms of Frozen Shoulder, but it will also promote speedy recovery and correct
healing of the damaged tissues.
Doctor"s Note
It is my hope that this article has been informative for the average non-healthcare-professional reader. In it I have tried to cover every aspect of the condition known
as Frozen Shoulder in simple and concise manner. The information gathered and used for this article came from several sources that are all readily available on the
internet to the public. The contents of this article should not be used in any way for self-diagnosis or self-treatment. Frozen Shoulder or Adhesive Capsulitis is a
serious health condition that warrants immediate attention and management from a licensed physician.
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