Frozen shoulder or adhesive capsulitis is a condition in which the connective tissue around the ball and socket joint of the shoulder gets swollen, restricting movement and causing pain. Since movement is restricted in all directions, it makes even simple tasks such as wearing a shirt or combing hair difficult.

As the joint becomes stiff, doing any overhead activity becomes impossible. Jerks and sudden shoulder movements can cause tremendous pain and cramping that can last for several minutes. This condition can also lead to back and neck pain and make you feel depressed. In cold weather, the pain usually persists throughout the day and worsens in the night.

What causes frozen shoulder?

The exact cause of frozen shoulder is not known. However, immobilsation of the joint for extended periods [such as after surgery], can cause frozen shoulder.

The condition can also be a result of autoimmune reaction, when the body attacks its own tissues leading to inflammation.

At times, it occurs spontaneously without any obvious preceding trigger factors. In such cases it is called ‘idiopathic frozen shoulder’.

Who does it affect?

Frozen shoulder usually affects those over 40 years of age; and women are at a greater risk than men. Those at risk of frozen shoulder include diabetics, those with thyroid problems, rheumatoid arthritis, lung disease and stroke.

Also, heart patients and those with shoulder injuries, or who have had breast, heart or lung surgery are also prone to developing frozen shoulder. When recovery from an injury or surgery requires your joint to be immobile for long, your risk of frozen shoulder increases.

What exactly happens with frozen shoulder?

The cover of the shoulder joint contracts and scar tissues [adhesions] are formed, stiffening the shoulder. Normally the condition progresses in three stages:

• Stage 1: The first stage is the ‘freezing stage, which is painful and which usually lasts six to nine months. The intensity of pain slowly increases and then movements start getting restricted, due to pain.
• Stage 2: The pain starts to ease but stiffness persists. This stage lasts 4 – 9 months.
• Stage 3: This is the ‘thawing’ or recovery stage: After 1 – 2 years, frozen shoulder starts to recover on its own. The shoulder movements slowly start returning to normal in about five/six months.

How is frozen shoulder diagnosed?

Usually, a physician can diagnose frozen shoulder by inspecting the range of movement of your shoulder. He may then suggest a shoulder X-ray to rule out shoulder injury or arthritic changes. An MRI may be done to rule out other shoulder conditions having similar symptoms such tendinitis, bursitis or rotator cuff injury.

How do I manage this condition?

Management involves restoring full range of motion and reducing pain. To begin with, non-steroidal anti inflammatory drugs [NSAIDs] and physiotherapy are prescribed.

Physiotherapy usually begins with application of deep heat [short wave diathermy], ultrasonic therapy and various types of electrotherapy to reduce pain and inflammation.

This is followed by mobilisation of the joint and extensive stretching exercises to increase range of motion and to minimise the loss of muscle on affected arm [muscle atrophy]. A shoulder CPM [continuous passive motion] machine helps increase the range with minimal pain.

As range of movement increases with physiotherapy, different exercises are prescribed to strengthen the shoulder and avoid recurrent stiffness.

These exercises and stretches are to be performed several times in a day. Apart from daily physiotherapy, applying moist heat for 10 minutes by using a hot soaked washcloth on the joint helps as well.

Intra-articular corticosteroid injections in the joint are also commonly used to decrease the inflammation in frozen shoulder. This helps to decrease the pain and in turn allows more stretching and physiotherapy. However, on their own steroid injections are ineffective; they work only in conjunction with physiotherapy.

Will I need surgery for frozen shoulder?

Surgery is recommended only if conservative treatment and physiotherapy fail. An orthopedic surgeon can perform manipulation under general anesthesia [MUGA] of shoulder joint.

In MUGA, the patient is sedated and the surgeon mobilises the arm in order to break shoulder adhesions. [No cuts or incisions are involved in the procedure]. Sometimes, an arthroscope is inserted into the joint to cut the adhesions. This is done with or without simultaneous manipulation of the joint. Another surgical option is surgical capsular release, which is effective in cases where other efforts fail. However, this procedure is rarely performed.

In all above procedures, immediate physiotherapy is important as there is a high chance of recurrence.

Will my shoulder motion return to normal?

Most patients who suffer from frozen shoulder will have little shoulder movement restriction, even years after the condition resolves. However, this limit in motion can be minimized or even nullified with therapy and stretching exercises.

Can frozen shoulder be prevented?

Yes, you can prevent frozen shoulder with regular shoulder exercises. Move each shoulder in all possible directions in complete range—front, back, sideways and rotations.

One must be attentive to any shoulder pain or even minor shoulder stiffness. And if such symptoms are noted, it must not be taken lightly and immediate medical advice should be sorted. This will bring faster correction of problem and less suffering.

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Hydrotherapy exercise programmes consist of variety of water-based treatments and exercises that are designed for joint-pain relief, to condition and strengthen muscles. Hydrotherapy offers many of the same benefits associated with a land-based exercise programmes. However, it is especially helpful in cases where a land-based exercise programme is not possible due to pain, decreased bone density, disability or other factors. It also an effective approach for patients with rehabilitation needs or developmental disorders.

Hydrotherapy Exercise Techniques

Ai chi – Modelled after the principles of Thai Chi and yogic breathing techniques. The person stands in chest-deep water and performs a slow, rhythmic combination of therapeutic movements and deep breathing.

Aquatic PNF – Modelled after the principles and movement patterns of Proprioceptive Neuromuscular Facilitation [PNF]. The patient performs a series of functional, spiral and diagonal, mass-movement patterns while standing, sitting, kneeling or lying in water. The exercises may be performed actively, or with assistance or resistance provided by specialised equipments or a therapist.

Bad Ragaz Ring method – Based on the principles and movement patterns of Knupfer exercises and PNF. The person is made to do a series of exercise and relaxation patterns in horizontal position, supported by rings or floats in the water. The exercise is performed either passively or actively by the patient himself or with the help of therapist.

Fluid moves [aquatic feldenkrais] – Based on Feldenkrais Method. Exercises follow a sequence of movements based on the early developmental stages of the infant. The patient stands in chest-deep water, typically with his back to the pool and performs a slow, rhythmic combination of therapeutic movements and deep breathing.

Halliwick method – It is designed to teach balance and postural control. The patient is made to do series of activities which require more sophisticated rotational control in an attempt to teach him to control movement in unstable environment. The Halliwick Method combines the unique qualities of the water with rotational control patterns.

Swim stroke training and modification – It is a form of active hydrotherapy exercise, which makes use of swim-stroke patterns to rehabilitate.

Task-type training approach [TTTA] – It adopts ways to teach functional activities to stroke patients. The principles can be extended to include treatment of all patient disorders, particularly those involving neurological dysfunction. The TTTA is best described as a task-oriented approach because it emphasises on functional skills performed in functional positions.

Watsu – Based on the principles of Zen Shiatsu [massage]. The therapist stabilises or moves one segment of the body, resulting in a stretch of another segment due to the drag effect. The patient remains completely passive while the therapist combines the unique qualities of the water with rhythmic flow patterns.

Apart from various above techniques, simple exercises such as floating, general body movements, stretches, and walking in water is beneficial, as water’s natural buoyancy allows freedom of movement without jarring or straining the body. Its natural resistance encourages strengthening of the muscles, and its unique properties alleviate pain and facilitate ambulation skills.

Who benefits from hydrotherapy?

Hydrotherapy aids in pain reduction, muscle strength, joint flexibility, cardiovascular fitness and ambulation skills. Hence it is beneficial for those who have:

• Chronic pain
• Osteoarthritis and advanced osteoporosis [with susceptibility to and/or pain from fracture]
• Muscle strain or tears
• Low back pain
• Spinal cord injuries
• Post polio syndrome
• Shoulder, neck, back and pelvic injuries
• Cardiac conditions
• Obesity
• Bone, joint, or muscle disorders
• Neurological Impairments
• Cerebral Palsy and Stroke
• Post operative ankle, knee, hip and spine surgeries

Hydrotherapy is also helpful to treat diabetics and high blood pressure patients. Both conditions can improve and become more manageable with water-based exercise. All of these conditions can make it uncomfortable or painful, for patients, to exercise on a hard/padded surface or while standing. Water provides a much gentler, welcoming environment. Moreover, the perception of pain may be diminished as a result of many factors including the relaxing sounds as well as the warmth of the water during water therapy exercise, making it a different and often very pleasurable experience.

The buoyancy of water permits a greater range of positions/motions due to the virtual elimination of gravitational forces.

Benefits of hydrotherapy exercises

The physical properties of water make it a highly desirable medium for exercising:

• Water buoyancy eliminates the gravitational stress on the joints. This helps to improve balance and strength. Buoyancy is helps those who suffer from arthritis, injuries or obesity, who can get a cardiovascular workout without the risk of jarring/straining of joints or risk of falling.
• Water viscosity provides resistance to movements by means of gentle friction, allowing easy regulation of movements, while reducing the risk of further injury due to loss of balance and over exercising.
• The hydrostatic pressure of water enhances return of lymphatic fluid and venous blood, stimulating circulation and reducing swelling and inflammation in joints, making workouts easier and less painful. It also improves heart and lung functions and muscle blood flow.
• Immersion in water reduces pain signal feedback.
• The high specific heat of water carries heat to the tissues, further reducing inflammation and stimulating circulation, as well as increasing joint mobility and flexibility.
• Water induces relaxations and provides a feeling of psychological well being.

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