Many of my patients say there’s nothing more miserable than a frozen shoulder, a sentiment surprisingly shared by most of the physios as well…
With a plethora of techniques, patients and physios both work tirelessly on a shoulder that won’t seem to budge. Is it indeed a test of patience for all or is there one miraculous key to unlock them all??
Table of Contents
Introduction
Frozen shoulder is a disorder where you can be completely fine one day and land up with inexplicable shoulder pain the next. Most people try to ‘tough it out’ (maybe it’s just a sore arm) but a series of painful sleepless nights usually brings them to the clinic.
Typically seen in 3 stages, this disorder usually remits in 2-3 years for most people. However, the pain and stiffness in this period is usually excruciating (with some females ranking it worse than childbirth) and a lot of day-to-day activities are restricted. Most shoulders do not recover their full ranges without treatments.
- Stage 1- The painful stage
- Stage 2-The pain and stiffness stage
- Stage 3- The stiff shoulder
True frozen shoulders have stiffness with normal X-rays.This is often a spontaneous condition of ageing. Activities restricted usually involve reaching overhead shelves, combing your hair, reaching your back pockets and sleeping on that side or on your back. Most people begin compensating with the other hand for routine activities. Almost all patients report night pain and sleep disturbance as the worst symptom.
Frozen shoulder treatment options
Physiotherapists usually use a combination of following options-
- Manual therapy-Joint and soft tissue mobilizations
- Exercises to improve shoulder movement and flexibility
- Exercises to strengthen the shoulder
Early intervention can get you back on track faster so it is quite important to not ignore the pain and seek prompt medical attention. Contrary to what you may think, not moving a painful shoulder is more harmful, hence consulting a physiotherapist is a good first step.
In cases not responding to these interventions steroid injections to the shoulder and manipulation under general anaesthesia are considered.
Evidence on manual therapy
Manual therapy includes techniques done by physiotherapists to improve joint movements. Frozen shoulder, or as its clinical name ‘Adhesive Capsulitis’ suggests, is a disorder where tightening of the joint capsule impedes shoulder movement.
Manual therapy is thought to stretch out the capsule and allow for freer movements, but its results in frozen shoulder do not look as promising. Though it has good effects on short term pain relief, it seems insufficient to maintain shoulder movements in the long term. A frustrating situation for patients and physios alike
Mobilizations, like electrotherapy and hot packs, seem to be good clinical tools to get the pain down and get the patient ready for exercise; but pushing and pressing frozen shoulders into new ranges is futile.
Eccentric exercises-an Emerging solution
Eccentric exercises for frozen shoulder is a trend currently favoured by physiotherapists. Eccentric exercises load a muscle in its lengthened position (think straightening out the arm after a bicep curl).
You are asked to hold a weight in your hand and gradually lower your arm into the movement being targeted, for example external rotation. The shoulder feels ‘looser’ after a few repetitions of this and then a new range is targeted in the next set. The reps need to be as slow as possible with a weight that is tolerated well.
What these exercises do is reduce the reflexive guarding of the muscles around the painful shoulder. These muscles are tightened as a protective response to the excruciating pain and they simply need to ‘let go’. This reduction in guarding is what allows you to move into a new range!
Currently, this treatment has a lot of anecdotal evidence rather than evidence from actual trials. But most patients report a reduction in pain and increase in the range with this program. These exercises also seem to be better tolerated than forcibly pushing the shoulder- a win-win for both, the patient and the therapist!
Stretch and Strengthen
Active exercise is the best way to maintain your progress in shoulder ranges. Stretches added to any multimodal program for frozen shoulder have shown good improvements in movement.
Stretches for a frozen shoulder generally target four movements- reaching overhead, reaching to the side, reaching the back of your head and taking the hand behind the back. Improving these motions is the key to regaining ease in daily activities. Doing these stretches at home is a great way to carry forward the benefits of your physiotherapy sessions.
While focussing on getting the stiff shoulder to move, it is important to not forget the scapula (shoulder blade)! The shoulder is not an isolated joint, it is part of a four-joint complex; all of which need to move correctly for best results. Hence it is essential to strengthen the shoulder blade muscles as well.
While strengthening the scapular muscles is necessary, the timing is a crucial factor. If started too early, it can increase stiffness. Your physiotherapist is an expert in determining when exactly to add this ingredient to the mix!
Physical therapy pearls for the frozen shoulder
- Hot packs, joint mobilizations, soft tissue mobilizations and gentle massage are all great adjuncts to muscle-focussed active rehab. Opt for them to obtain pain relief which will help you participate better in exercises!
- Learn how to sleep with a frozen shoulder- night pains and sleep disturbance is a real issue and needs to be tackled. There are solutions and alternative positions that need to explored to find out what works for you. While sleeping on the back, place a small pillow under the shoulder. You can also consider sleeping on the opposite side with a pillow in the armpit of the painful shoulder.
- Be patient with your body and rehab. Frozen shoulder takes time to recover. Do not force your shoulder into painful activities sooner than it can handle.
- Be diligent with your home exercises and physio sessions. Regular targeted movement is the key for full recovery. Do not stop physiotherapy until optimal mobility and strength is reached. It is also crucial to modify home exercises as per your individual progress-do not miss out on sessions with your physios!
- Celebrate small wins! This keeps up the morale and boosts your performance for the next target range!
