Frozen shoulder may be defined as the abnormal pathological condition in where forms excessive scar tissue formation with muscle spasm or adhesion formation across the shoulder joints leading to an insidious painful condition, gradually progressive stiffness, limited range of motion, fibrous tissue formation, restriction of movement in the glenohumeral joint capsule, ligaments, tendons, and muscle. The shoulder joint is a ball and socket joint and the complex structure of the upper limb, surrounded by a strong fibrous membrane called the joint capsule, tendons, cartilage, ligament, nerve, synovial fluid, with a group of muscles patchy, fibrinous synovitis, capsular contraction and fibrinous adhesions, fibrotic with inflammatory contracture of the rotator muscle and pain is usually constant, worse at night, and with cold weather.
Types of Frozen Shoulder
Frozen shoulder can be either
- Primary (idiopathic) – It is a kind of frozen shoulder that are caused are unknown, and it basically occurs in a late stage of life and diabetics works as primary frozen shoulder.
- Secondary frozen shoulder – It is defined as that associated with blunt trauma, accident, rotator cuff disease, and shoulder impingement; cardiovascular disease; osteoarthritis, osteoporosis, hemiparesis, etc.
Three phases of clinical presentation
- Painful freezing phase – The duration 10-36 weeks. Pain and stiffness around the shoulder joints are the first symptoms with no history of injury. Acute pain or nagging constant pain is worse at night and morning stiffness with little response to non-steroidal anti-inflammatory drugs and oral steroids.
- Adhesive phase – The duration and occurs at 4-12 months. The pain gradually subsides but the stiffness remains and ongoing progress. Pain is the main symptom only at the extremes of movement. Gross reduction of glenohumeral movements, with near-total obliteration of external rotation, may feel pain.
- Resolution phase – The duration and takes 12-42 months. It is followed by the adhesive phase or recovery freezing phase with spontaneous improvement in the range of movement and pain-free condition. The mean duration from onset of frozen shoulder to the greatest resolution is over 30 months and more.
Causes of Frozen Shoulder
Frozen shoulder or adhesive capsulitis is included bony growths, wear and tear, and calcium deposits in the supraspinatus tendon that may cause frozen shoulder or adhesive capsulitis. Other causes include an inflamed fluid-filled sac or a hooked formation in the acromion process, in where the tip of the shoulder blade curves down more than usual to lead to frozen shoulder or adhesive capsulitis. Sometimes ligaments and tendons in the joint capsule become shorter due to weak muscles or putting abnormal strain on the muscle’s power.
All of these things can cause parts of the shoulder tendons (“rotator cuff tendons”) and the fluid-filled sac called the bursa to become pinched between the acromion and the head of the upper arm bone humerus when you lift your arm.
Subacromial pathology and rotator cuff tendinopathy
Post-stroke shoulder subluxation
Referred pain (cervical spine or malignancy, e.g., Pancoast tumor)
- Acromioclavicular and glenohumeral osteoarthritis
Rotator cuff impingement
Shoulder impingement syndrome
Residual shoulder pain or stiffness
Rupture of the biceps and subscapularis tendons
Complex regional pain syndrome
Symptoms of Frozen Shoulder
- The first symptom of frozen shoulder is pain and progressive stiffness, limited range of motion, fibrous tissue formation, restriction of movement in the glenohumeral joint capsule, ligaments, tendons, and muscle.
- The second symptom of a frozen shoulder is impossible to get dressed up and out, cooking, clean, reach a back pocket, or shift gears while driving a car, putting the arm up and back.
- A feeling of pain and tightness in the whole shoulder area.
- A feeling of tightness especially when you are throwing a ball overarm in cricket-playing, golf
- Decrease range of motion is lost in the following direction such as external rotation, abduction, internal rotation, forward flexion.
- Pain on the back and decrease the range of motion.
- Dull, aching pain with paresthesia, itching, numbness
- The referred pain and may felt in whole shoulder joints to the arms, forearms
- The sleep disturbance and the problem with deprivation
- Severe sharp pain and with rapid movement (eg. trying to catch mobile phone)
- The difficulty with activities of daily living such as dressing, driving, and personal care.
- Lack of movement in all directions of your hand
- Symptoms will worsen at night and morning stiffness may be felt.
- Muscle contraction of the coracohumeral ligament limits external rotation of the arm and forearms
- Muscle contracture and tendinopathy and capsulitis may be felt.
- Dull” or “deep-seated pain in the rotator cuff muscle and spread into the biceps muscles.
Diagnosis of Frozen Shoulder
To find out what’s causing the symptoms, the doctor will ask questions like
when the pain occurs and how it feels,
whether there was an injury or accident, and
whether it could have been caused by things like overhead work or certain types of sports.
The physical examination that follows includes several tests that involve lifting and lowering your arms sideways, and moving your elbows in various directions, inwards or outwards. The doctor will also feel your shoulder. This is usually enough to diagnose subacromial pain. During the physical examination, your doctor can also rule out other possible causes of the pain, such as radiating neck pain or frozen shoulder adhesive capsulitis, or others.
- Look – On inspection, the arm is held by the side in adduction and internal rotation. Mild disuse atrophy of the deltoid and supraspinatus may be present. It is done manually.
- Feel – On the palpation, there is diffuse tenderness that may be felt over the glenohumeral joint, and this may extend to the trapezius and interscapular area to attempted splinting of the painful shoulder and stiffness present or not
- Movement – In the case of a true frozen shoulder there is an almost complete loss of external rotation movement. This is the pathophysiology sign of a frozen shoulder.[rx,rx] It also confirming that external rotation is impossible in the frozen shoulder with active and passive movements is important. In a frozen shoulder, all other movements of the joint are reduced, and if movement occurs this usually comes from the thoracic and scapular joint.
- Neer test – The neer impingement test is a manual test designed to reproduce symptoms of rotator cuff impingement through flexing the shoulder and pressure application. The symptoms should be reproduced if there is a problem with the supraspinatus or biceps brachii muscle. This test is also associated with the Hawkins-Kennedy Test.
- Jobe’s Test – Jobe’s test is a physical exam test that is used to detect anterior shoulder instability. It is used to distinguish between anterior part instability and primary shoulder impingement. This test should be performed after the Apprehension test. This test was named for Christopher Jobe.
- Hawkins tests – This test is commonly used to identify possible subacromial impingement syndrome. The examiner or your doctor places the patient’s arm shoulder in 90 degrees of shoulder flexion position with the elbow flexed to 90 degrees position and then internally rotates the arm. The test is considered to be positive if the patient experiences pain with internal rotation.[rx]
- The injection test – can be performed if a clinician is uncertain of causes of shoulder pain based on history and exam. The subacromial space is injected with an anesthetic, typically 5 ml of 1% lidocaine. In patients with adhesive capsulitis or frozen shoulder, the ROM limitations and pain will persist after the injection. In patients with subacromial pathology, rotator cuff tendinopathy, or subacromial bursitis, tendinitis will show an improvement of pain and improved range of motion the test is positive.
- Palpation of sternoclavicular joint, clavicle, acromioclavicular joint, subacromial bursa, bicipital tendon.
- Evaluation of passive and active range of motion: Neck range of motion should be assessed that may reveal a neck source of shoulder pain. The Apley scratch test specifically tests a range of motion and in a normal exam, an individual should be able to reach C7 on external rotation, and T7 on internal rotation.
- Evaluation of distal pulses
- Strength testing: wrist extension tests the radial nerve, finger abduction tests the ulnar nerve, and thumb opposition tests the median nerve.
- Sensation testing
- Reflex testing: Triceps reflex tests C6-C8, biceps reflex tests C5 and C6, and brachioradialis reflex tests C5-C7.
- Provocative maneuvers
Tests for rotator cuff pathology
- Neer impingement sign – a positive test indicates shoulder impingement
- Hawkins-Kennedy test – a positive test indicates shoulder impingement
- An empty beer can test – a positive test indicates rotator cuff tear, specifically, supraspinatus muscle tear
- Drop arm test – a positive test indicates a supraspinatus tear
- External Rotation test – a positive test indicates an infraspinatus or teres minor tear
- Lift-off test – a positive test indicates subscapularis pathology
Tests for bicipital tenosynovitis and labral pathology
- Ferguson’s test
- Speed’s test
- Biceps load test
- O’Brien’s test: positive test indicates a SLAP (or superior labral tear from anterior to posterior) tear
Tests for shoulder instability
- Apprehension test or Jobe’s test: positive test indicates anterior glenohumeral instability
- Relocation test
- Cross-arm test: positive test indicates acromioclavicular joint degeneration/arthritis
- Adson’s sign tests for thoracic outlet syndrome
- Lhermitte’s sign may indicate cervical radiculopathy or spinal cord disease
- Spurling’s test tests for cervical spine disease[rx][rx]
A meta-analysis in 2008 concluded that the diagnostic accuracy of individual tests in the shoulder examination was limited, specifically that the Hawkins-Kennedy test and the Speed test have no discriminatory ability to diagnose specific shoulder pathology, and that results of studies evaluating other tests were too statistically heterogeneous to make meaningful conclusions about their diagnostic accuracy.[rx] Examination of the shoulder can be complex because the shoulder can present with more than one pathology at a time.[rx]
- Laboratory tests – Leukocytosis is one of the most important tests for frozen shoulder or adhesive capsulitis that supports the possibility of infection and bone-related disease. Blood cultures, urine examination, stool examination, or other possible primary symptoms of frozen shoulder or adhesive capsulitis, a bone infection that obligatory when a septic infectious frozen shoulder or adhesive capsulitis is being considered for examination. The and elevated inflammatory condition markers like ESR or CRP include suggesting an infectious or inflammatory disease condition of the tennis elbow or lateral epicondylitis and elbow upper side pain.
- A serum uric acid level – It is often considered by clinicians and doctors when got frozen shoulder or adhesive capsulitis, tendonitis is suspected, but it is not a reliable and dangerous condition as it may be spuriously elevated or high in acute inflammatory conditions or acutely during a or not.
- Random blood glucose – The reference values for a normal random glucose test in an average adult are 80–140mg/dl (4.4–7.8 mmol/l), between 140-200mg/dl (7.8–11.1 mmol/l) is considered pre-diabetes, and ≥ 200 mg/dl is considered diabetes according to ADA guidelines you should visit your doctor or a clinic for additional tests to over sure.
- Ultrasound – It is basically done to investigate the thickness of the fascia, ligament injury with a frozen shoulder or adhesive capsulitis are likely to have a thickened tendon with the associated fluid collection and that thickness values >4.0 mm that are the diagnostic of in frozen shoulder or adhesive capsulitis [rx]
- Musculoskeletal ultrasound – It can further visualize the tendon and bony attachment of the thigh sites, muscles, ligaments, and nerves. Ultrasound can also be used to identify the area and extent, nature of the injury frozen shoulder, or adhesive capsulitis and used to evaluate periodically during the recovery phase. The most common findings on ultrasound are focal, fluid, tenosynovitis changes in the common flexor tendon position, how much thickening of the tendon sheath, partial or full-thickness tears, and tear of the tendon.[rx][rx] Ultrasound did for dynamic imaging studies, which can provide the additional benefit in regards to evaluation for frozen shoulder or adhesive capsulitis
- Muscle Biopsy – Muscle biopsy is basically done to investigate abnormal congenital problems such as dutchmen muscular dystrophy, myasthenia graves, hemophilia, etc. A small part of the cell or tissue is collected from the thigh and send to investigate other abnormalities.
- X-Ray – Conventional x-ray and radiography is the most widely used imaging modality and allows for the detection of bone fractures, osteoporosis, and abnormal pathologies condition like fracture, osteoporosis, erosions, osteonecrosis, osteoarthritis, or a juxta-articular bone tumor, neoplasm, and frozen shoulder or adhesive capsulitis. Characteristic features of frozen shoulder or adhesive capsulitis include marginal osteophytes formation in shoulder joint space gradually narrowing, subchondral sclerosis formation in the frozen shoulder, or adhesive capsulitis
- CT Scan – High contrast CT scan is more effective to diagnostic procedures to investigate the frozen shoulder or adhesive capsulitis. Abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc.
- MRI – It is called magnetic radical imaging is also helpful to find the bone conditions, abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, frozen shoulder, or adhesive capsulitis. It is the final stage test to confirm that all frozen shoulder or adhesive capsulitis or any other abnormality suspected others condition forearms pain, such as shoulder pigmentation, soft tissue injury and bone tumors, osteonecrosis, osteomyelitis, arthritis, and stress fracture.[rx,rx]
- Bone scintigraphy – It is the most important test to diagnose bone cancer, neoplasm, fractures, necrosis of bone, and joints. It also helps to identify the tendon, sprained ligament, cartilage, muscle spasm, sprain, and strain with a frozen shoulder or adhesive capsulitis
- Nerve Conduction velocity test – It a special test for leg pain or thigh pain. It is the procedure where test the sensation of the peripheral nerve stimuli to send the central nervous system means brain. It helps to identify the sensory and motor nervous system problem from the central to the peripheral cell.
Treatment of Frozen Shoulder
- Physiotherapy – It is one of the most common and effective non-pharmacological treatments in the world. It has a variety of treatment modules to erase acute and chronic pain. It is especially helpful in muscle spasticity, spasms related to tennis elbow or lateral epicondylitis, and elbows upper side pain front side and backside pain. Inflammatory and noninflammatory pain is treated by ultrasound therapy, MRI, Shortwave, microwave, wax therapy, IRR, laser therapy, interferential current therapy, iontophoresis, short-wave diathermy (SWD), and pulsed short-wave diathermy (PSWD). Some studies have reported good outcomes with physiotherapy regimes of stretching and strengthening, with more favorable results than rest and reduced activity at short-term follow-up.[rx]
- Deep transverse friction massage – AIt is a special type of massage technique called transverse friction massage is often used in the frozen shoulder or adhesive capsulitis patients. It is applied to the tendons and the muscles, using the tips of one or two fingers to heal frozen shoulder or adhesive capsulitis.
- Transcutaneous electrical nerve stimulation (TENS) – It is called TENS devices that help to transfer electrical impulses that are helpful for the treatment of frozen shoulder or adhesive capsulitis. These are supposed to keep the pain signals from reaching the brain by blocking pain message signals and increase the secretion of endorphins that are the body’s natural pain killer.
- Extracorporeal shockwave therapy (ESWT) – Is a physiotherapy device that generates shock or pressure waves that are transferred to the tissue through the skin for healing frozen shoulder or adhesive capsulitis. This is case assumed that to improve the circulation of blood in the tissue and speed up the healing process of frozen shoulder or adhesive capsulitis.
- Eccentric exercises – It is partial help to healing tendons that are the mainstays of physiotherapy regimes. A stable shoulder and scapula function and strength are necessary for correct shoulder functioning; strengthening exercises of the scapular stabilizers that are including the lower trapezius, serratus anterior, and rotator cuff muscles.
- Percutaneous radiofrequency thermal treatment – A radiofrequency electrode pad is attached percutaneously under an ultrasound guideline which produces a thermal effect in the injured frozen shoulder or adhesive capsulitis when activated, inducing visual microanatomy and removing all pathological injured tissue. Good outcomes have been reported, and no reduction in tendon size has been observed in this case.[rx]
- Acupuncture – It is the China-oriented acute and chronic treatment system where are needle is used to stimulate the pain receptor to reduce pain. It is also helpful in some spasticity formation pain, stroke, hemiplegia, and chronic rheumatoid arthritis pain in the hand, and tennis elbow or lateral epicondylitis, and frozen shoulder or adhesive capsulitis.
- Extracorporeal shock-wave therapy (ECSW) – It has been proposed as an alternative to non-operative management for frozen shoulder or adhesive capsulitis. It worked by the generator of specific frequency sound waves that are applied directly onto the overlying skin of the frozen shoulder or adhesive capsulitis tendon.
- The use of low-level laser therapy – It has been proposed due to the stimulating effect of laser on collagen or types 2 collagen production in tendons to increase the healing of frozen shoulder or adhesive capsulitis. Although laser was not initially viewed as particularly useful among frozen shoulder or adhesive capsulitis therapies, a recent study has to indicate some short-term benefits when using an adequate dose and wavelength.[rx]
Armpit stretch – It is done with the support of your healthy arm, lift the arm with the frozen shoulder upper direction, and rest arms on a surface at about chest level. In this position, gradually or slowly bend your knee joints so that your armpit opens up and you can feel it stretching. Then stand up straight again.
External rotation stretch – It is a manual test perform by standing in a doorframe with the affected arm placed out to the side of your body, and the elbow joints bent at a 90-degree angle so that your forearm places is parallel to the floor. Keep the upper arm at your side. Then place the palm of your hand on the doorframe to stop the arm from moving. Now turn your upper body away from the arm to stretch the shoulder. It can be done with the supervision of a physiotherapist
Internal rotation stretch – In this case, patients stand with your back to the doorframe. Place the back of your hand on the affected side against your bottom so that your arm is at a slight angle. Now lean the back of that elbow against the doorframe gently “trapping” your elbow to keep it in place and turn your upper body slightly inward towards the arm. If feels pain the
- Manipulation under anesthesia (MUA) – In this treatment in which the shoulder is freed by rotation while the patient is under short general or local anesthesia. This is usually a day procedure treatment system and generally lasts a maximum of 15 minutes including anesthetic time. There is an increased chance of the risk of homers fractures.
- Whole-body cryotherapy (WBC) – It involves the exposure of extreme cold to the unclothed body in a chamber that circulates very cold air that is maintained between –110 ℃ to –140 ℃ for 2 minutes to 3 minutes. WBC is assumed to provide anti-inflammatory and analgesic effects to the body.[rx]
- Diet – Diet may be normal or according to the doctor mentions food you can take for you, such as papaya, banana, potato, nut cereal, seasonal fruits, and drink of water. In your daily routine meal must have magnesium, calcium, iron, zinc, folate, vitamin B complex, Vitamin A, Vitamin C, etc.
- Non-steroidal anti-inflammatory drugs (NSAIDs) – It is considered to be the fast-acting nonsteroidal anti-inflammatory drugs (NSAIDs) as including acetylsalicylate, aspirin, naproxen, ibuprofen, indomethacin, and etodolac, ketorolac in pain is acute. NSAIDs drugs work by inhibiting cyclo-oxygenase enzyme to prevent the synthesis of prostaglandins, prostacyclin, and thromboxanes. It has also some side effects of aspirin at high doses when used are including tinnitus, hearing loss, and gastric intolerance.[rx]
- Nerve relaxant – It is basically used to reduce neuropathic pain, inflammation, nerve root entrapment, myalgia, neuralgia, and fibromyalgia, and frozen shoulder or adhesive capsulitis. Your doctor may prescribe gabapentin, pregabalin, vitamin B1, B6, B12, etc. Major side effects are abdominal pain, nausea- vomiting.
- Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, tennis elbow, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, frozen shoulder or adhesive capsulitis, etc. A side effect may be nausea- vomiting, abdominal pain, cramping [rx]
- Topical diclofenac, camphor, menthol, and nitroglycerin – or glyceryl trinitrate has shown short-term benefits in the frozen shoulder or adhesive capsulitis but overall results for treatment for tendinopathy or lateral epicondylitis and tennis elbow have been mixed depending on the site of application.[rx]
Oral corticosteroids – These provide short-term pain relief for improved range of motion and function. The benefits often do not last longer than a few weeks, and the result is excellent for the treatment of frozen shoulder or adhesive capsulitis. Oral medications such as non-steroidal anti-inflammatory drugs (NSAIDs) and oral steroids can be used at the same time. Although the use of oral steroids has some limitations and is described in the literature they are not a commonly used interventional treatment in the UK. Major side effects are increase metabolism, muscle cramp, abdominal pain, electrolyte imbalance, etc.[rx]
Intra-articular steroid injections – In frozen shoulder or adhesive capsulitis treatment the intraarticular steroid such as methylprednisolone, and triamcinolone injections have been shown to improve function more quickly, decrease pain, and increase range of motion. Often patients who receiving injections early in the frozen shoulder or adhesive capsulitis course are more likely to obtain a benefit. Multiple injections can be given to provide symptomatic relief permanently.[rx] Major side effects are increase metabolism, muscle cramp, abdominal pain, electrolyte imbalance, etc.[rx]
Hydrosilation or Arthrographic distension – In this treatment modality, the joint is injected with saline and steroid to dilate the glenohumeral capsule, tendons, ligament, or in which increased and dilatated of the joint capsule with sterile saline or other solution such as local anesthetic or steroid are used at the same time in supervision or guided by radiological imaging such as arthrography. This has been shown to reduce pain and improve range of motion and function in the short term. [rx]
- Suprascapular nerve blocks – It is another treatment procedure that may be beneficial in terms of pain relief but not a movement or increase range of motion of shoulder joints, and repeated joint distension may improve movement.[rx][rx]
- Sodium hyaluronate injection – A small number of diverse studies have found that sodium hyaluronate injection in the frozen shoulder or adhesive capsulitis is very effective that helps to control pain and increase range of motion. It may have a high risk of bias, provide insufficient evidence to make conclusions about the effectiveness of sodium hyaluronate in the treatment of the frozen shoulder.[rx]–[rx]
- Calcitonin – It is a kind of polypeptide hormone secreted from parafollicular cells of the thyroid. It plays a significant role in managing rheumatoid arthritis, osteoarthritis, complex regional pain syndrome, fracture, frozen shoulder or adhesive capsulitis, and metastasis of the bone tumor.[rx,rx] And it is also thought to decrease the systemic inflammatory response and stimulate the release of endorphins that are the natural pain killer in the body.[rx]
- Extra-articular collagenase injection – It is pushed into the anterior shoulder capsule midway between the bicipital groove and coracoid at the maximal external rotation in the supervision of the endoscopy procedure. It shows excellent results in an improved functional score, shoulder motion, and pain compared to injection of placebo (0.9% saline/2 mM CaCl2). Patients also benefited from subsequent injections. Side effects include tenderness and ecchymosis at the injection sites, which resolved between 7 and 14 days.[rx] MRI obtained or done 3 months after collagenase injection pushing to be sure to the clinically significant injuries to the rotator cuff or surrounding structures of shoulder joints.[rx]
The surgical treatment is the final stage of treatment of frozen shoulder or adhesive capsulitis. The surgical treatment is done when the conservative and manual with medicinal treatment are failed. The surgical treatment is following
- Arthroscopic Capsular Release – It is done due to complications of MUA and advances in arthroscopic techniques with ACR has become the most frequently used surgical intervention that was previously shown to confirm and lasting long-term improvements in symptoms of frozen shoulder or adhesive capsulitis.[rx] ACR also allows for visual confirmation of the diagnosis of frozen shoulder or adhesive capsulitis as well as the ability to treat concomitant intra-articular and subacromial diseases condition that may be contributing to the primary cause of the problem for frozen shoulder or adhesive capsulitis.[rx]
- Arthroscopic capsulotomy – Arthroscopic capsular release is an effective and safe method for the treatment of adhesive shoulder capsulitis.[rx–rx] Arthroscopic capsulotomy has two key advantages for the patient’s frozen shoulder or adhesive capsulitis. First, diagnostic arthroscopy confirms the diagnosis and rules out other potential causes of a painful stiff shoulder joint. Second, compared to hydrogenation, it allows for direct visualization of the tightened tendons, ligament, cartilage, thickened rotator cuff muscle, and contracted capsule to ensure adequate release. The standard arthroscopic capsulotomy is anteroinferior capsular release is the most popular and reliable surgical procedure. On the other hand, the utility of posterior capsular release or extended capsular release remains controversial.[rx–rx].
- Open capsulotomy – An open capsulotomy is rarely performed for recalcitrant adhesive shoulder capsulitis abnormalities because arthroscopic capsular release results in smaller surgical wounds and shorter postoperative recovery and superior to patient satisfaction. The open procedure remains an option when an arthroscopic capsular release has failed in improving pain and range of motion for adhesive capsulitis. The release of the capsule and rotator cuff interval has been found to restore motion and improve pain management.[rx]