Frozen Shoulder: An online Text Course- Colibri
The shoulder joint complex is a biomechanical system that functions on a delicate balance between mobility and stability. Multiple activity of daily living, work tasks and recreational/ sports pursuits are dependent on mobility in multi-planar directions. From the earliest moments in life, the shoulder joint functions in elevation motions to position the hand in space. For this discussion, the term elevation, will include the cardinal planes of flexion and abduction and the essential intermediate functional plane, called the plane of the scapula (POS). The malady labeled frozen shoulder (FS) was defined by Codman in 1934, as an indistinct condition with a longstanding dysfunction of up to two years, which posed a challenging treatment demand. The American Shoulder and Elbow Surgeons current consensus definition is:
“Condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder.”
Despite amazing advances in medical technology and research design, aspects of Codman’s assertions still apply to today’s management of FS. The classical studies by early practioniers of orthopedic medicine such as Cyriax, Simmonds and Travell, emphasized manual techniques as primary treatment methods for the resolution of FS, particularly the idiopathic type. Since the early scientific studies, a staggering level of additional research has investigated shoulder stiffness, to the extent that Zreik (2016) reviewed 5,411 studies in their meta-analysis of targeted interventions! In this course, we will define the terminology of FS and related motion loss problems of the shoulder, list the variable etiologies and concomitant dysfunctions, review the scope of the problems and then identify the time- phased spectrum of shoulder stiffness. We will also analyze the multiple treatment options that encompass the application of manual treatment principles and techniques, in order to present a practical sequence of guidelines to restore functional levels in affected patients.
Scope of FS and Terminology Issues
FS is a condition of insidious and at times spontaneous onset of anterior shoulder pain, that gradually worsens to cause loss of active and passive mobility and progressive limitation of many common daily functions. Frequently the patient tends to protect the shoulder from elevation motions and consequently, self-immobilizes toward a sling position. Part of the conflicting nature of shoulder stiffness as described in scientific literature results from the use of several interchangeable terms; specifically, FS, idiopathic shoulder stiffness, adhesive capsulitis and arthro-fibrosis of the capsular-ligament-complex (CLC). Bunker (2009) has subsequently re-defined this group of dysfunctions with the term, contracted capsule, which accurately encompasses much of the long-term treatment challenges. In addition, decisions on the type and timing of treatment modalities vary widely between conservative, medical and invasive options and blending of available interventions. “… there is no consensus as to the most efficacious treatment of this condition”. (Cho,2019, D’Orsi, Kelley,2012, Page,2017, Georgianous,2017) Furthermore, there is dissent regarding the most reliable diagnostic tools. (Zappia,2016) These equivocal statements underscore the need to analyze our programs, explore available evidence and the critical need of conducting future and ongoing research initiatives. Descriptive of maturing professions, Jette has applied the analogy of “expanding the shoreline” of our confirmed knowledge and defining what aspects of therapy interventions work; when and in what circumstances, and importantly, at what costs. (Jette,2012,2016) Thus, we will compare literature perspectives on the efficacy of the above treatment options, emphasizing the conservative, non-medical approaches routinely applied in physical and occupational therapy and sports medicine programs. Multiple FS and AC studies show the societal prevalence between 2%-5%. (Pandey,2022, Kelley, 2009). Today, the frequency is projected on an upward trend. Beyond the dysfunction and suffering with individual daily activities, the loss of work productivity is estimated to approach twelve billion dollars in costs in 2000! (Johnson,2005) Women are more prone to shoulder stiffness problems, particularly idiopathic FS, from uncertain causation. One study determined that AC was more common in younger men than in other age or gender groups. (Lundberg,1969) FS and additional shoulder stiffness problems manifest between ages forty to sixty and treatments for these problems are more resistant in people over sixty years old. The occurrence of FS increases the likelihood of the problem in the contralateral shoulder by 5-34%. As we consider a forthcoming classification scheme for FS or other painful stiff problems, there is a high predisposing factor from two health issues: diabetes and thyroid diseases. The incidence of FS or adhesive capsulitis (AC) rises to from 10% – 38% with diabetes and thyroid problems. (Pandey,2022, Milgrom,2008, Kelley,2009, Shah,2015, Zreik,2016, Ryan,2016) Notably, Shah (2015) determined that external rotation (ER) losses average 22 degrees for diabetic shoulder limitations; contrasted to common level of ER deficits in primary FS. The diabetic patients also demonstrated diminished scapular compensation problems, both factors favoring a more rapid recover. Therefore, it is vital that the clinician address this aspect in the history and review of systems with the assessment session. The recognized higher incidence of thyroid disease in women (8-9x than that of men) may also explain the higher incidence of FS. (Chiavato,2019). An additional theorem based on my personal clinical experience implicates the greater degree of capsular hyper-mobility and lower protective upper quarter strength (adjusted for weight) that many females carry across decades (Sheridan,2006); which results in eventual inflammation changes and capsular micro-traumas in later adult ages toward sixty years.