Frozen Shoulder: By: Denise Dela Cruz

FROZEN SHOULDER
By: Denise Dela Cruz

What is Frozen Shoulder?
 It is a disorder 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.
The Glenohumeral joint
 It is a ball and socket joint with

3 degrees of freedom and has
little bony stability.
 The hemispheric-shaped head of
humerus rests on the small,
shallow, inclined plane of the
glenoid cavity.
 Surrounding the rim of the
glenoid is a cartilaginous
labrum, or lip.
 The loose thin joint capsule covers the joint from
the neck of the glenoid to the anatomic neck of
humerus.
FROZEN SHOULDER
 A common chronic affectation

characterized by pain and
limitation of shoulder motion
that slowly becomes worse over
a period of 3-12 mos. And then,
for reasons that are not
clear,follows a course of gradual
improvement to a normal or
near –normal state.
 It is seen most frequently in
patients over the age of 40
years and is more common in
women than men.
 The disorder has also been
called: periarthritis, obliteraive
bursitis, and diffuse rotator cuff
tendinitis.
Pathology
 Edema, fibrosis, and round cell

infiltration in the joint capsule—
indicates a low-grade
inflammatory process.
 The synovial recesses may
become adherent; such
adhesions obliterate parts of the
joint cavity and sharply limit
joint motion.
 The periarticular tissues lose
elasticity and become shortened
and fibrotic, thereby firmly
fixing the humeral head in the
glenoid cavity.
 Muscle atrophy becomes
pronounced.
Clinical Picture
 May have insidious onset, may

follow direct or indirect trauma,
or may be a sequel to injuries of
the distal part of the limb.
 May also follow CVA or come
about as the result of referred
shoulder pain from cardiac or
cervical nerve root affectations.
 It frequently follows
supraspinatus tendinitis,
subacromial bursitis and other
shoulder pathology.
 The pain is accentuated by attempts
at scapulohumeral joint motion,
particularly abduction, ER, and
extension.
 The shoulder pain is usually diffuse
but may radiate to the anterolateral
aspect of the shoulder region, biceps
muscle belly, flexor surface of the
forearm and inferior angle of the
scapula.
 Tenderness may be elicited over the
intertubercular sulcus and the tendon of
the biceps muscle and diffusely about the
joint capsule.
 The main physical finding in frozen
shoulder is decreased active and passive
mobility in the scapulohumeral joint.
 Restriction involves ER and abduction;
stiffness may progress to almost complete
loss of scapulohumeral motion.
Stages of Frozen Shoulder
 “Freezing”- characterized by intense pain even at
rest and LOM by 2-3 weeks after onset. These
symptoms may last 10-36 weeks.
 “Frozen”-characterized by pain only with
movement, significant adhesions, and limited GH
motions, with substitute motions in the scapula.
Atrophy of deltoid,rotator cuff,biceps and triceps
brachii ocuurs. This stage lasts 4-12 months.
 “Thawing”- characterized by no pain and synovitis
but significant capsular restrictions from adhesions.
This stage lasts 2 to 24 mos. Or longer. Some
patients never regain normal ROM.
Common Impairments
 Night pain and disturbed sleep during
acute flares.
 Pain on motion and often at rest during
acute flares.
 Mobility: dec. jt. Play and ROM, usually ER
and abduction with some limitations on IR
and elevation in flexion.
 Posture: possible faulty postural
compensations with protracted and
anteriorly tipped scapula, rounded
shoulders and elevated protected shoulder.
 Decreased arm swing during gait.
 MS. Performance: general ms weakness
and poor endurance in the glenohumeral
muscles with overuse of the scapular
muscles leading to pain in the trapz and
posterior cervical muscles.
 Guarded shoulder motions with scapular
motions.
Common Fuxnal
Limitations/Disabilities
 Inability to reach overhead, out to the side,
and behind the back; thus, having difficulty
in dressing (such as putting on a jacket or
coat or women fastening undergarments
behind their back), reaching hand into back
pocket of pants (to retrieve wallet),
reaching out a car window (to use an ATM
machine), self-grooming (combing of
hair,brushing teeth, washing face) and
bringing utensils to the mouth
 Difficulty in lifting weighted
objects, such as dishes into
cupboard
 Limited ability to sustain
repetitive activities.
Diagnosis
 An Arthrogram or an MRI scan

may confirm the diagnosis,
though in practice this is rarely
required.
Special Tests
 Apley’s Scratch Test
– Procedure: The seated patient is asked to touch
the contralateral superior medial corner of the
scapula with the index finger.
 Crank Test
– Procedure: The examinerabducts the arm to 90°
and laterally rotates the patient's shoulder
slowly.
 Rockwood Test
– The examiner stands behind the seated
patient. With the arm at the patient's
side, the examiner laterally rotates the
shoulder. The arm is abducted to 45°,
and passive lateral rotation is repeated.
The same procedure is repeated at 90°
and 120°
Treatment
 Pharmacotherapy
– Anti-Inflammatory
– Corticosteroids
– Saline solution preceded by local
anesthetic and followed by
hydroscortisone
 Surgical
– Acromioplasty– partial resection of
acromion or resection of AC joint,
if involved.
Phyiscal Therapy
>>PROTECTION PHASE
 For control of pain, Edema and
Muscle guarding
– Immobilization
– Intermittent periods of passive and
assisted motions within pain free ROM
and gentle joint oscillation techniques
are initiated as soon as the px tolerates
the movement in order to minimize
adhesion formation.
 Maintain Soft Tissue and Joint
Integrity and Mobility
– PROM on all planes, if pain decreases
proceed to AROM with or without
assistance using activities such as rolling
a small ball or sliding a rag on a smooth
table top in flexion, abduction, and
circular motions. Teach the px to avoid
faulty posture such as scapular
elevation or a slumped posture.
– Passive joint distraction and glides,
grade I and II with the jt. Placed in
a pain free position.
– Pendulum (codman’s) exercises-
are techniques that use the effect
of gravity to distract the humerus
from the glenoid fossa. No weight
is used during this phase of tx.
– Gentle muscle setting to all muscle
groups of the shoulder. The
emphasis is on rhythmic
contracting and relaxing of the
muscles to help stimulate blood
flow and prevent circulatory stasis.
 Maintain Integrity and Function
of Associated Areas
– Hand exercises using squeeze ball to
prevent RSD.
– ROM of elbow, forearm, wrist and
fingers several times while the shoulder
is immobilized. If tolerated, active or
gentle resistive ROM is preferred to
PROM for a greater effect on circulation
and muscle integrity.
– If edema is noted in the hand,
instruct the patient to elevate the
hand, whenever possible, above
the level of the heart.
>> CONTROLLED MOTION PHASE
 Control pain, Edema, and Joint
Effusion.
– Fuxnal activities
– ROM is progressed up to the point of
pain, including all shoulder and scapular
motions. The px is instructed in the use
of self-assistive ROM techniques such as
wand exercises or hand slides.
 Progressively increase Joint and
Soft tissue Mobility
– PJM stretch grades III and IV
oscilation, using techniques that
focus on the restricting capsular
tissue at the end of available ROM
to increase joint capsule mobility.
– Pendulum exercises with weights
on the hand to cause a grade III
distraction force.
– Self mobilization techniques:
caudal, anterior and posterior
glide.
– Manual stretching to increase
mobility in shortened muscles and
connective tissue
– Self-stretching, if px tolerates
stretching.
 Inhibit Muscle spasm and
correct faulty mechanics
– PJM grades I or II to help decrease
ms spasm.
– Sustained caudal glide jt.
Techniques to reposition the
humeral head in the glenoid fossa.
– Protected weight bearing, such as
leaning hands against the wall, to
stimulate co-contraction of rotator
cuff and scapular stabilizing ms.
(wt. bearing causes jt.
compression, the benefits of jt.
Intermittent jt. Compression
stimulates synovial fluid motion).
– External rotation exercises to help
depress the humeral head.
 Improve Joint tracking
– Shoulder MWM for painful
restriction of shoulder ER.
– MWM to improve IR
 Progressively increase flexibility
and stretch
– Stretching and strengthening exercises
(active). Emphasis is on correct
mechanics, safe progressions, and
exercise strategy to return to function.
– If capsular tissue is still restricting ROM,
vigorous manual stretching ang jt. Mob
techniques are applied.
References
 Handbook of Orthopaedic
Surgery (Brashear)
 Therapeutic Exercise (Kisner)
 Clinical Kinesiology
(Brunnstrom)
THANK YOU!!


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FROZEN SHOULDER

By: Denise Dela Cruz

 It is a disorder in which the

 It is a ball and socket joint with

 A common chronic affectation

 Edema, fibrosis, and round cell

 May have insidious onset, may

 An Arthrogram or an MRI scan

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