FROZEN SHOULDER

This ill understood condition9 of frozen shoulder, is characterized by pain and stiffness on all movements, increasing over a period of months, .

The pathology is adhesive capsulitis¹ - inflammation of the envelope which contains the gristle covered bone ends.

It involves the shoulder joint proper. This is different to tendinitis in the rotator cuff or the long head of biceps.

All shoulder movements are restricted, and painful when pushed to their limit.
One cannot raise one's arm fully above one's head², nor reach up behind one's back. Reaching behind the neck and over the other shoulder, are restricted.



A medical check including blood tests for inflammation, is important. This is to rule out such conditions as polymyalgia rheumatica and inflammatory arthritis, which need very different treatment.

Plain X-ray of the shoulder to rule out long standing osteoarthritis, is in order. This is uncommon at the gleno-humeral joint, presumably as it is not weight bearing.

I have yet to break anyone's arm doing the stretches described, but it could be prudent to check for osteoporosis as well.

Blood tests of thyroid5 and autoimmunity6 are worth considering.


If frozen shoulder is suspected, it is really urgent to start stretching⁴ exercises. One can definitely stop the process this way, and avoid the prolonged disability usually experienced.



Lay flat on your back with your arms close by your sides. Lift your affected arm as far as you can. If you can lift it past vertical, relax it and just let the weight of the arm do the stretching.

You are aiming to get it right back, in line with your body (fully elevated.)


Usually you will need help with the stretching, however.

This particular stretch is painful and a fair amount of force is needed, compared to other stretches.

It needs to be done every 2 to 3 days, ideally as soon as any reaction to the last stretch wears off.

In addition to visits to your therapist, stretches at home are needed.

strech for frozen shoulder

Your assistant should place the heel of one hand against the outer edge of the shoulder blade and the other just below your elbow.

Steady, moderate force is applied to push your arm up, while preventing your shoulder blade from moving. If the person can tolerate the pain, I continue this for several minutes and hope to see a few degrees of extra elevation.

The gains may be small and the stretching needs to be done frequently.

It does work, however. In my experience, frozen shoulder definitely does not need to progress if it is treated early.

A lot of times it resolves within 2 or 3 treatments and one is left not knowing whether it would have progressed to frozen shoulder.


A cortisone injection into the joint can be useful in the early stages. It may give partial relief of pain, and allow stretching to be done.

Hydrodilatation treatment can be given by a radiologist, where the joint is stretched up by injecting saline solution.

Surgery combined with cortisone injection, may be useful7.

Radiofrequency ablation of the nerve to the shoulder joint8, can be useful too.

POLYMYALGIA RHEUMATICA

This condition is worth picking up because it responds very well to conventional medical treatment.

People with pmr may complain of aches, but on questioning the other striking feature is marked stiffness in the mornings. (It is an inflammatory condition.)

The aches are usually around the shoulders and arms, but can be around hips and thighs.

Your doctor will also be feeling around your temples, looking for thickened and tender temporal arteries. Temporal arteritis is a giant cell arteritis, 10-30% of which can look similar to polymyalgia rheumatica.

It is vitally important to pick this up as it can lead to blindness, unless it is quickly treated with large doses of cortisone.

There is a specific test for this condition. A length of the thickened artery is removed surgically, and the microscopic anatomy (histopathology) examined by a pathologist.


There is no specific test for PMR³, but inflammatory markers in the blood are likely to be increased and blood tests for rheumatoid factor and anti–citrullinated protein antibody negative.

Probably the best test for it is to administer a small dose of cortisone and watch for a dramatic overnight improvement.

The treatment is long term cortisone, but fortunately usually in small doses.

Intravenous vitamin C can give temporary relief.



SHOULDER INFLAMMATION

Inflammatory arthritis may be exudative as opposed to the adhesive capsulitis of frozen shoulder. Here the joint space is distended with inflammatory fluid.

It is quite difficult to see swelling when your shoulder joint is inflamed, because of the large deltoid muscle covering it.

You are probably the best judge, as you know what it normally looks like.

If your shoulder is painful and stiff, you will obviously be seeing your health professional anyway.

Be sure to tell them if you've had any other joints painful lately,or any skin rash, as this may be part of a general arthritic condition, such as that of psoriasis.


FRACTURED NECK OF HUMERUS

A swollen painful shoulder after a minor fall in an elderly person, may be a fracture of the upper end of their arm bone.

This is a common result of osteoporosis.

The bones may have been jammed together as they broke, so that it may look as though it is arthritis of the shoulder joint rather than a fracture.

A plain X-ray is going to sort this out.

More on treatment of rotator cuff problems - your rhomboids

Return from frozen shoulder page to shoulder anatomy page.




Notes and references for frozen shoulder page.

1. J. S. Neviaser Adhesive capsulitis of shoulder; study of pathological findings in periarthitis of shoulder. J. Bone Jt. Surg (1945) 27 p. 211

From Cyriax..

"He (Neviaser) dissected post mortem, or inspected at operation, sixty-three shoulders with limited movement on clinical examination. He found that the capsule of the joint, instead of showing the normal laxity, was tight, closely applied to the head of the humerus and under such tension that it gaped widely when incised anteriorly...microscopy showed (it) to be the site of reparative inflammatory change. He suggested 'adhesive capsulitis' as a suitable term."

"Active fibroblastic proliferation" described more recently, amounts to the same thing. It is not acute inflammation as in gout, but what happens when the body is over that stage and is walling off some irritative focus.

2. The joint capsule is normally particularly loose at the bottom, to allow us to raise our arm right up above our head.

An arthrogram (X-ray with joint full of radio-opaque dye) now shows markedly less space in the joint (even 5 ml instead of 30ml) and loss of the loose recess at the bottom.

3. From the 2012 Provisional Classification Criteria for Polymyalgia Rheumatica by the European League Against Rheumatism and the American College of Rheumatology.

"over 70% of respondents agreed on the importance of 7 core criteria (all achieving 100% support in round 2). These were aged 50 years or older,symptom duration 2 weeks or longer, bilateral shoulder and/or pelvic girdle aching, duration of morning stiffness more than 45 minutes, elevated erythrocyte sedimentation rate (ESR), elevated C-reactive protein (CRP), and rapid corticosteroid response. More than 70% agreed on assessing pain and limitation of shoulder (84%) and/or hip (76%) motion."

http://www.rheumatology.org/practice/clinical/classification/jra/FINAL_PMR_Class_Criteria_paper.pdf


4. This applies to many conditions where one's ability to actively raise the arm fully is impaired. It may be quite difficult, as when spasm of muscles follows a stroke, or in an acute injury when the acromio-clavicular joint has been sprained.

The ac joint will be protected if one does the stretch laying on one's back, even if the scapula is not held back. One's weight resting on the scapula will keep it still enough to avoid hurting the ac joint now (compared to standing and trying to raise one's arm.)

5. Prevalence of hypothyroidism in patients with frozen shoulder.

6. I've been unable to find anything about this but the female preponderance and association with hypothyroidism give the idea some credence. .Cyrex have tests for joint autoimmunity.

7. Arthroscopic capsular release for idiopathic frozen shoulder with intra-articular injection and a controlled manipulation

8. Treating frozen shoulder with ultrasound-guided pulsed mode radiofrequency lesioning of the suprascapular nerve: two cases.

9 The frozen shoulder: diagnosis and treatment. Prospective study of 50 cases of adhesive capsulitis
These people diagnosed three clinical groups, virtually all with radioisotope bone scans positive at shoulder, some at wrist as well.
The neurological group are also called complex regional pain syndrome.


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