FROZEN SHOULDER

 Frozen shoulder,known as adhesive capsulitis, is a condition characterized by stiffness and pain in the shoulder joint. It typically develops gradually over time and can worsen over several months to years. The exact cause of frozen shoulder is not always clear, but it often occurs when the shoulder capsule thickens and tightens around the joint, restricting movements.

 Frozen shoulder typically progresses through three stages, each characterized by different symptoms and levels of severity:

1. Freezing Stage (Painful Stage): This initial stage involves increasing pain and progressive stiffness in the shoulder. It can last anywhere from 6 weeks to 9 months. The hallmark of this stage is pain, which may be especially intense at night and interfere with sleep. Shoulder movement becomes increasingly limited, particularly in external rotation and abduction (raising the arm away from the body). However, X-rays and MRI scans during this stage typically show no significant abnormalities apart from inflammation.
2. Frozen Stage (Stiffness Stage): In this stage, pain may begin to decrease, but stiffness and limited range of motion in the shoulder become more pronounced. Simple tasks like reaching overhead or behind the back become challenging. This stage can last anywhere from 4 to 12 months.
3. Thawing Stage (Recovery Stage): During this final stage, shoulder movement gradually improves, and range of motion begins to return. This stage can last anywhere from 5 months to several years. While movement may still be somewhat limited, most people experience a significant reduction in pain and a gradual improvement in shoulder function. However, it’s important to note that some individuals may not fully regain their pre-frozen shoulder range of movements

Causes

The exact causes of frozen shoulder are not always clear, but several factors can contribute to its development. These include:

1. Immobilization or Lack of Use: One of the most common triggers for frozen shoulder is immobility or lack of use of the shoulder joint. This can occur after surgery, injury, or prolonged periods of inactivity, such as during recovery from an illness.
2. Inflammation: Inflammation of the shoulder joint capsule, a connective tissue that surrounds the shoulder joint, can lead to the development of adhesive capsulitis. Inflammatory conditions such as arthritis or shoulder bursitis may contribute to this inflammation.
3. Scar Tissue Formation: Following injury or surgery to the shoulder, scar tissue can form in the shoulder joint capsule. This scar tissue can gradually tighten and restrict the movement of the shoulder joint, leading to frozen shoulder.
4. Systemic Diseases: Certain medical conditions, such as diabetes, thyroid disorders, and cardiovascular disease, have been associated with an increased risk of developing frozen shoulder. The exact mechanisms by which these conditions contribute to frozen shoulder are not fully understood but may involve changes in the connective tissues or impaired healing processes.
5. Age and Gender: Frozen shoulder tends to occur more frequently in individuals aged 40 to 60 years old, with women being more commonly affected than men. The reasons for this gender and age disparity are not entirely clear but may involve hormonal factors or differences in shoulder anatomy and function.
6. Genetic Predisposition: Some people may have a genetic predisposition to developing frozen shoulder, although the specific genes involved and their exact role in the condition are still being researches.
7. Diabetes:diabetic patients are more orone to having frozen shoulder

Pathology of frozen shoulder

Frozen shoulder, or adhesive capsulitis, is characterized by inflammation and thickening of the shoulder joint capsule. The pathology of frozen shoulder involves several key changes in the shoulder joint tissues:

• Capsular Inflammation and Fibrosis: The joint capsule, a structure of connective tissue that surrounds and encloses the shoulder joint, becomes inflamed. This inflammation leads to the production of scar-like tissue (fibrosis) within the capsule.
• Synovial Membrane Changes: The synovial membrane, which lines the inside of the joint capsule and produces synovial fluid that lubricates the joint, undergoes changes. It may become thickened and produce less fluid, contributing to joint stiffness.
• Contracture of Capsule: As fibrosis progresses, the capsule thickens and contracts. This results in a decrease in the volume of the joint space and restricts the movement of the humeral head (the ball part of the ball-and-socket shoulder joint).
• Adhesions: Adhesions can form within the joint capsule and between the capsule and surrounding structures, further limiting mobility.
• Vascular Changes: There may be changes in the blood vessels supplying the shoulder joint, contributing to the inflammatory process.Top of Form

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Clinical features

 The clinical features of frozen shoulder typically progress through distinct stages and include the following:

• Pain: Pain is often the earliest symptom of frozen shoulder and may be mild at first but gradually worsen over time. The pain is usually felt deep within the shoulder joint and may be aggravated by movement, particularly at certain angles or during specific activities.

• Stiffness: Stiffness in the shoulder joint is a hallmark feature of frozen shoulder. Initially, the stiffness may be mild and only present during certain movements or activities. However, as the condition progresses, the stiffness becomes more pronounced and may severely limit the range of motion in the shoulder joint.

• Decreased Range of Motion: As the stiffness worsens, individuals with frozen shoulder often experience a progressive decrease in the range of motion in the affected shoulder. This can make simple tasks such as reaching overhead, behind the back, or across the body challenging or impossible.

• Difficulty with Activities of Daily Living: The pain and stiffness associated with frozen shoulder can significantly impact a person’s ability to perform activities of daily living, such as dressing, bathing, and reaching for objects. This can lead to functional limitations and decreased quality of life.

• Sleep Disturbance: Many individuals with frozen shoulder experience difficulty sleeping, particularly when lying on the affected side. The pain and discomfort may disrupt sleep patterns and contribute to fatigue and daytime drowsiness

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• Progression through Stages: Frozen shoulder typically progresses through three stages: the freezing stage, the frozen stage, and the thawing stage. Each stage is characterized by specific symptoms and changes in the severity of pain and stiffness.

• Gradual Improvement: Although frozen shoulder can be a debilitating condition, it usually resolves gradually over time, with or without treatment. The thawing stage is marked by a gradual improvement in symptoms, including a reduction in pain and stiffness and an increase in the range of motion in the shoulder joint.

• Recurrent Symptoms: In some cases, symptoms of frozen shoulder may recur or persist even after initial treatment. Recurrent frozen shoulder may require additional interventions, such as physical therapy or corticosteroid injections, to manage symptoms and improve shoulder function.

Diagnosis

• Physical Examination: During the physical examination, your healthcare provider will assess your shoulder mobility, range of motion, and any areas of tenderness or pain. They may perform specific maneuvers to evaluate the degree of stiffness and the presence of any impingement or inflammation in the shoulder joint.

• Imaging Studies: While imaging studies are not always necessary to diagnose frozen shoulder, they may be used to rule out other potential causes of shoulder pain and stiffness or to evaluate the severity of the condition. X-rays may be taken to assess for signs of arthritis or other structural abnormalities in the shoulder joint. Magnetic resonance imaging (MRI) or ultrasound may be recommended to visualize soft tissues, such as the shoulder joint capsule and surrounding structures, and to identify any abnormalities, such as inflammation or thickening of the capsule.

• Diagnostic Criteria: There are specific criteria used to diagnose frozen shoulder, including the presence of shoulder pain and stiffness, limitations in shoulder range of motion, and the exclusion of other possible causes of shoulder pain, such as rotator cuff tears or shoulder arthritis.

• Clinical Assessment: Based on the medical history, physical examination findings, and any imaging studies, your healthcare provider will make a clinical assessment and determine whether you meet the criteria for a diagnosis of frozen shoulder. Other conditions that may mimic frozen shoulder, such as rotator cuff tears or shoulder impingement syndrome, may need to be ruled out to ensure an accurate diagnosis.

Physiotherapeutic management

Physiotherapy plays a crucial role in the management of frozen shoulder by helping to relieve pain, improve shoulder mobility, and restore function. Here are some common physiotherapy interventions used in the management of frozen shoulder:

1. Pain Management: Physiotherapists may use various techniques to help reduce pain associated with frozen shoulder, such as manual therapy, soft tissue mobilization, and modalities like heat or ice therapy. These techniques can help alleviate discomfort and improve tolerance to other therapeutic exercises.

• Stretching and Range of Motion Exercises: Gentle stretching exercises are often prescribed to help improve flexibility and increase the range of motion in the shoulder joint. These exercises aim to gradually stretch the tight tissues surrounding the shoulder joint and improve mobility. Range of motion exercises may include pendulum exercises, wand exercises, and passive stretching techniques.
• Joint Mobilization: Joint mobilization techniques involve gently moving the shoulder joint through its range of motion to help reduce stiffness and improve mobility. This may include manual techniques performed by the physiotherapist or self-mobilization exercises taught to the patient for home practice.

• Strengthening Exercises: Once pain and stiffness begin to improve, strengthening exercises are introduced to help restore muscle strength and function in the shoulder joint. These exercises target the muscles surrounding the shoulder, including the rotator cuff muscles, deltoids, and scapular stabilizers. Gradually increasing resistance and intensity as tolerated can help promote muscle endurance and functional strength

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• Functional Training: Functional training exercises focus on improving the ability to perform activities of daily living and functional tasks that may have been limited due to frozen shoulder. These exercises aim to simulate real-life movements and challenges to promote optimal shoulder function and independence.

• Posture Correction: Poor posture can contribute to shoulder pain and dysfunction. Physiotherapists may provide education and exercises to help improve posture and alignment, which can alleviate stress on the shoulder joint and improve overall shoulder mechanics.

• Patient Education: Education is a crucial component of physiotherapy management for frozen shoulder. Physiotherapists may provide guidance on self-management strategies, activity modification, and ergonomic principles to help prevent exacerbation of symptoms and promote long-term shoulder health.

• Home Exercise Program: A personalized home exercise program is typically prescribed to reinforce the benefits of physiotherapy sessions and promote ongoing progress. Consistent participation in home exercises is essential for maximizing outcomes and maintaining gains achieved during therapy session.