Did you know that between 2-5 per cent of the general population will experience a “Frozen Shoulder?”

Did you know it’s more common in people with diabetes and thyroid diseases?

Did you know that it’s more common in women between the ages of 40-60?

Did you know that over 80 per cent of clients with frozen shoulder (one study) respond to conservative treatment?

WHAT IS A FROZEN SHOULDER?

• Evidence that there’s an “elevation serum cytokine levels”
  • Which is an over production of the cells that help with tissue repair
  • This causes ongoing inflammation and fibrosis (scar tissue formation)
• Loss of normal collagen production – new collagen is too tight and restricts the movement of the shoulder joint.
• Contracture or tightening is typically found in the “rotator cuff interval” (RCI) at the front of the shoulder.

HOW CAN I TELL IF I HAVE ONE?

• Painful and/or stiff shoulder with all movement directions
• Typically starts without any significant incident
• Accompanied by progressive loss of motion (freezing) in all directions
• Significant night pain
• Loss of outward rotation of more than 50 per cent
• Weakness of the internal rotations

WHAT CAN I EXPECT?

• Initial first three 3 months
  • Pain is greater than stiffness
  • Pain limiting movement in all directions of motion
  • Muscle guarding on passive movements
  • Difficulty finding comfortable sleeping position
• Stage Two (3-9 months)
  • Pain with all movements
  • Stiffness may be starting to be more of a problem than pain in the later stages
• Stage Three-Frozen (9-15 months)
  • Less pain but more stiffness
  • Still limited motion
  • Improved tolerance for exercises and physiotherapy techniques
• Stage Four-Thawing (15- 24  months)
  • Minimal pain
  • Motion improving

GAME PLAN

• Research supports in the early stages (more pain from hyper inflammatory) the use of a cortisone injection (results of pain reduction are best when combined with a physiotherapy-guided exercise program)
• Ultrasound and other modalities might actually aggravate the pain in the early stages
• Do range of motion exercises that don’t increase the pain in the early stages
  • Aggressive stretching in the early phases can aggravate the condition
• Physiotherapy-guided home exercise program
• Physiotherapy joint mobilizations in the frozen or thawing stages

 OTHER CULPRITS

• Rotator cuff impingement
• Rotator cuff or labral tears
• Neck problems
• Severe osteoarthritis
• Acute tendon calcification
• Tendonitis or bursitis
• Humeral fracture (proximally)

IF YOU’RE MOTIVATED:

1. Martin J. Kelley, Phillip W. McClurr, Brian G. Leggin. Frozen shoulder: evidence and a proposed model guiding rehabilitation. February 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

  We’re online in every place imaginable! Surf our website www.startlinephysiotherapy.com, then be our friend by moseying on over to our Facebook site by hitting the link there. To book an appointment at Start Line, call the clinic at 250-746-7463.

My interest in the shoulder has stemmed from having separated my shoulder playing hockey back when I was a teenager. I did not have any treatment to it until I was in my late 20s. Having to treat my own shoulder has given me personal insight into the shoulder joint and recovery from injury. 

When it comes your shoulder, you don’t have to live with the pain.

THE SHOULDER JOINT

• ball and socket joint
• held in place by ligaments
• surrounded by a capsule

ROTATOR CUFF

• group of four smaller muscles that work together to keep the ball centered in the socket                                                                                                                        

ROTATOR CUFF TENDONITIS/TENDONOPATHY

A common problem with the rotator cuff is IMPINGEMENT

• supraspinatus and sometimes the biceps tendons get pinched as the arm is raised overhead
• may result in TENDONITIS (inflammation of the tendon) or TENDONOPATHY (thickening/changing of the tendon structure).                                                                                                                                                                                                                                                     

COMMON CAUSE OF IMPINGEMENT 

1)     Poor Posture: Rounding of the shoulders. Slouching leaves less room under the arch.

• Stiffness and tightness in the middle back area can be contributing factors.

2)     Muscle Imbalances: Tight or weak muscles alter the movement and timing of the joint.

• Can be caused by repetitive strain or trauma injuries.

3)     Overuse: Too much, too soon, too frequently — not enough rest time.

4)     Trauma: Falls, sports (throwing, weight-lifting improperly, swimming etc.).

• The jarring of the muscle can cause a reactive muscle shortening.

5)     Shape of the Arch: Some collar bones are hooked, leaving less space for the cuff.

 TEARS

Rotator cuff tendons don’t get good blood flow and will often thin (attenuation) with age.

• Are common in middle age.
• Repetitive minor traumas accumulate, leaving the tendons weaker and more susceptible to tearing with a relatively minor injury.
• Rotator cuff tears can also occur with falling on the shoulder, or with major trauma in the younger individual.

 FROZEN SHOULDER 

• The formation of adhesions (scar tissue) of the shoulder capsule usually secondary to inflammation.
• As the capsule tightens, there’s pain and loss of range in all directions. 
• There are three stages:
  • Freezing: loss of movement
  • Frozen: no loss but no gain
  • Thawing: gradual regain of movement
• The process can take 1-3 years.
• If you get it in one shoulder, you’re more susceptible of getting it in the other.
• Often termed “idiopathic” because we don’t really know what causes it.
• Higher incidence in people
  • over 40 years of age
  • with diabetes (10-20 per cent of individuals affected)
  • heart conditions
  • hypothyroidism
  • hyperthyroidism
  • Parkinson’s disease
  • post-surgery
• Physiotherapy modalities can make it worse rather than better

 TREATMENTS

 Exercises

• Proper exercise prescription requires a thorough assessment by a physiotherapist to determine the underlying nature of the problem and what stage of healing the tissue is at.
• Shown in research to improve pain scores in clients with frozen shoulders *(see references below).

 MANUAL THERAPY

Joint mobilizations have been shown to improve pain scores in those with frozen shoulders* (see references below).

MODALITIES

• Ultrasound and iontophoresis have been shown to increase pain in those with frozen shoulders* (see references below).
• I suspect the ultrasound, which increases blood flow to the area treated, causes increased pain because of an underlying hypervascularization (increased vascularization) in those with frozen shoulders.

 INTRAMUSCULAR STIMULATION (IMS)

Personally I have found IMS to be very effective in treatment for:

• • shoulder impingement
  • rotator cuff strains
  • muscle imbalances (tight ropy bands of muscles)
  • anterior glenohumeral syndromes (muscles at front or back of the shoulder are pulling and/or pushing the shoulder ball out of its central alignment (often misdiagnosed as a “frozen shoulder”)
• I have not had success with lasting improved range of motion in “true” adhesive capsulities.

 CORTICOSTERIOD INJECTIONS

While this is beyond the scope of physiotherapy, research has indicated good short-term relief of symptoms.

 IF YOU’RE MOTIVATED:

1. Information from Bahram Jam, APTEI newsletter: www.aptei.com

2. Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009 May;89(5):419-29. Epub 2009 Mar 6.

 3. Martin J. Kelley, Phillip W. McClurr, Brian G. Leggin. Frozen shoulder: evidence and a proposed model guiding rehabilitation. February 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

  We’re online in every place imaginable! Surf our website www.startlinephysiotherapy.com, then be our friend by moseying on over to our Facebook site by hitting the link there. To book an appointment at Start Line, call the clinic at 250-746-7463.