Adhesive capsulitis (AC), often known as frozen shoulder, is marked by an initial period of discomfort followed by a progressive restriction of active and passive glenohumeral (GH) joint range of motion, with a spontaneous full or nearly full recovery over a variable length of time.

This inflammatory disorder results in fibrosis of the GH joint capsule and produces a considerable reduction in range of motion, usually in the external rotation.

Frozen Shoulder could be:

Primary - Onset is frequently idiopathic (occurs for no apparent reason).

Secondary - A consequence of a known cause, risk factor, or surgical event.

There are a number of risk factors that can lead to a subsequent frozen shoulder. For instance, after a stroke, surgery, or an injury. The motor control of the shoulder may change following an injury, limiting range of motion and eventually stiffening the joint as a result of changing movement patterns made to protect the injured components.

More cases of frozen shoulder occur;

Women are more likely than men to present with a frozen shoulder; over 70% of those who do so are women.

With a prevalence of about 2-5% in the general population, among people aged 35 to 65, Because it's so common at that age, it's known as the 50-year-old shoulder in China and Japan.

There are 20% more cases of diabetes among the diabetic population.

Those who have experienced frozen shoulder have a 5–34% probability of eventually developing it in the opposite shoulder. There are 14% of cases where there is simultaneous bilateral involvement, according to research.

Risk Factors & Red Flags

• Diabetes mellitus (with a prevalence of up to 20%)
• Stroke
• Thyroid disorder
• Shoulder injury (Direct impact, dislocation)
• Dupuytren disease
• Parkinson's
• Complex regional pain syndrome
• Avascular necrosis (rare, but can occur)
• Tuberculosis

Characteristics/Clinical Presentation

Patients who have frozen shoulder will frequently describe a sneaky onset with a progressive increase in pain and a gradual decrease in active and passive range of motion.

Loss of external rotation (ER) in a dependent position with the arm at the side is one of the main presenting symptoms. Patients usually struggle with dressing, doing overhead tasks, grooming, and especially attaching clothing behind the back.

Phases

Acute/freezing/painful phase:  Shoulder pain that begins gradually and worsens over time, lasting between two and nine months, and that is sharpest while the shoulder joint is in motion.

Adhesive/frozen/stiffening phase: Beginning to feel better, there is a steady reduction of GH mobility in the capsular pattern. Only severe movements make pain visible. This stage could start at 4 months and last till 12 months.

Resolution/thawing phase: Improvement in functional range of motion that occurs naturally and gradually over the course of 5 to 24 months. Despite this, some research imply that the condition is self-limiting and can endure for up to three years. Nevertheless, according to other research, up to 40% of patients may continue to experience symptoms that limit their mobility after three years. According to estimates, 15% of people may experience chronic pain and long-term disability. Effective treatments that reduce the length of time that symptoms and incapacity last will significantly lower morbidity.

SPECIAL TEST

Shoulder Shrug Sign: Inability to raise the arm to 90° abduction without lifting the entire scapula or shoulder girdle is referred to as the "shoulder shrug sign."  was formerly linked to rotator cuff disease, but was more frequently linked to glenohumeral arthritis, frozen shoulder, and severe cuff tear.

PHYSICAL THERAPY MANAGEMENT

Despite the fact that numerous therapies have been researched, the ideal course of action for frozen shoulder is still unknown. The key to rehabilitation for the majority of patients is to engage in a physical therapy program. Additionally, Tedla & Sangadala's meta-analysis from 2019 found that PNF is highly beneficial at lowering pain, improving ROM, enhancing function, and lowering impairment.

Techniques

Initial Phase: Painful, Freezing

During this stage, your frozen shoulder pain relief and ruling out any additional causes are the main concerns.   

During this painful inflammatory period, very careful shoulder mobilization, muscle releases, acupuncture, dry needling, and pain-relieving kinesiology taping can help. TENS machine use has been demonstrated to lessen pain and increase range of motion.

Hot packs and other modalities can be used both before and during treatment. By lowering muscle viscosity and promoting neuromuscular-mediated relaxation, moist heat applied after stretching can aid to enhance muscle extensibility and range of motion.  

Second Phase: Decreased Range of Movement

A quick return to function is achieved through the use of gentle and targeted shoulder joint mobilization and stretches, muscle release techniques, acupuncture, dry needling, and exercises to regain your range of motion and strength. It's important to take precaution when introducing any overly aggressive activities. Stretching exercises by themselves don't seem to be as beneficial as mobilization with movement (MWM) style techniques. MWMs are specific procedures carried out professional shoulder physiotherapists with the necessary training.

Third Phase: Resolution

Gives you work out progressions, such as strengthening exercises, to help you maintain and control your greater range of motion.

During the thawing phase, physical therapy is most beneficial. Progress was generally made by increasing stretch frequency and duration while keeping stretch intensity at the same level as the patient could tolerate. The number of sessions each day can be increased, and the stretch can be held for longer durations of time. As the patient's level of agitation decreases, more strenuous stretching and workouts utilizing a pulley or similar apparatus can be carried out to affect tissue remodeling.