Physiotherapy & Sports Injury Clinic

Case Study on Frozen Shoulder

Introduction 

Adhesive Capsulitis or Frozen Shoulder, according to many authors is a clinical disorder rather than a diagnosis. It was first introduced by Codman  1934. It is considered to be the final stage of a number of disorders which affect the shoulder. Synonyms include periarthritis, scapulocostal syndrome and degenerative tendonitis of the rotator cuff.(Roth,2003)

The disorder is characterised by an insidious and progressive loss of active and passive mobility in the glenohumeral joint. Despite research in the last century the aetiology and pathology of adhesive capsulitis remains enigmatic.(Watson,2000)

Capsular adhesions of the axillary recess, the inferior pouch of the glenohumeral capsule may play an important role in adhesive capsulitis.(Vermeulen,2000)

It is suggested that theses adhesions hinder normal expansion during abduction, resulting in diminished active and passive mobility of the shoulder.

Frozen shoulder is a common cause of shoulder pain and disability in the general population. Although it is a self limiting ailment ,its rather long, restrictive and painful course forces the affected person to seek treatment

A brief review of literature has offered various classifications and theories as to the cause of frozen shoulder.

This case study will outline the assessment and treatment using the Cyriax approach of a shoulder dysfunction syndrome and discuss the results with regard the known pathology.

AETIOLOGY:
 

Most cases of frozen shoulder are idiopathic(Primary frozen shoulder), but some maybe associated with certain factors such as diabetes mellitus, spinal lesions, trauma or prolonged immobilisation of the shoulder for some other cause(Secondary frozen shoulder).

It is recognised that frozen shoulder follows a definite sequence that occurs in three main stages. These have been described by Cyriax as follows: 

In the case of secondary frozen shoulder, the initial minor trauma and pain maybe minor, settling quickly.

Stage 1: Pain develops in the shoulder area some time after a minor trauma. The pain is felt in the shoulder and may refer into the C5 dermatome during inflammation. Pain is the key feature of this stage, with very little limitation of movement.

Stage 2: Pain together with loss of movement are the key features during this stage. There is constant pain and difficulty sleeping at night. The shoulder joint displays a definite capsular pattern.

Stage 3: Pain begins to settle and range of motion begins to return

Different treatment approaches for each stage have been put forward by Cyriax. The entire process may take up to two years to resolve. 

History of Presenting Complaint:

As elsewhere accurate diagnosis depends on careful history, physical examination and appropriate investigations.

Prior to assessment, it is necessary to obtain a detailed history of the onset(Acute or traumatic versus slow and insidious) and duration of the current, and any previous symptoms. Relating the stage of the pathology then gives an insight to the total management which is required. Information about the patient occupation, leisure interests and hand dominance is also obtained to form an accurate prognosis of the effect of treatment on lifestyle.

The patient chosen for this study was a 52 year old lady with a history of left shoulder pain following a fall onto her left shoulder 1 month previously. The patient is a hair dresser by profession. Following the fall the patient was referred by her General Practitioner for radiological inverstigations. Nothing abnormal was seen on the radiograph. Non Steroidal medication was prescribed over a course of three weeks. Initially these reduced the pain. Approximatley 2 months later the patient reported increasing levels of pain and difficulty sleeping at night due to pain levels.

At this point the patient was referred by the general Practitioner to attend for physiotherapy.

Overall the patient was quite depressed about her shoulder pain, as it was interfering quite badly with her sleep. She works as a hairdresser and was fearful that she may be unable to continue working. Her hobbies included walking and golf.

Subjective Examination:

On attending the physiotherapy department a subjective examination was carried out to determine the site and nature of the symptoms, the level of pain experienced, the behaviour of pain over a 24 hour period and irritability of the condition. Information was obtained and recorded on the appropriate assessment form with the inclusion of the body chart,(Fig 1).

The patient complained of pain:

1. Difficult to pinpoint, and felt deep in the shoulder and over the deltoid area.(P1)

2. Occasional pain along the posterior aspect of the arm to the elbow.

P1 was described as an intermittent nagging pain and was made worse by shoulder flexion and abduction and relieved by rest. She reported experiencing increasing levels of pain while at work by day, which wakes her at night especially if she moves onto her left side. She complains that she can no longer tie her brassiere from behind, though she can perform most functional activities with her right dominant upper extremity.

It was established that there were no other relevant symptoms to be considered. 

Finally it was established that there were no other relevant current or past medical history that may affect treatment choice. The patient’s drug history consisted of distalgesic for pain relief.

Objective Examination:

The objective examination began with the patient standing undressed to the waist in a cubicle with a good light. The method for diagnosis of shoulder lesions as described by Cyriax was used during assessment.

On examination of posture it was noted that the patient had a slightly forward head posture. Slight wasting of the bellies of the musculocutaneous cuff musculature was observed.

Prior to examining the shoulder joint the Cervical Spine was assessed, as pathology of the cervical spine can have a major influence on shoulder pain. Assessment was carried out using six active movements as recommended by Cyriax. During these movements full range of motion in all directions at the cervical spine, without pain was noted. There was no provocation of the left shoulder pain during any of the cervical spine tests.

The affected limb was then taken through a group of ten active, passive and resisted movements to determine which structure was at fault. During the active elevation tests pain, range and willingness to move were being observed.

Active elevation was to 90 degrees and caused P1 at the end of range.

Passive elevation was limited to 90 degrees with P1 and had a hard end feel.

Active elevation through abduction was 80 degrees and caused P1 with a compensatory shoulder girdle elevation.

Passive tests were then applied to the joint during which pain, range and end feel was observed.

Passive lateral rotation was 45 degrees and caused P1 with a hard end feel.

Passive abduction was limited to 80 degrees and caused P1

Passive medial rotation was 70 degrees and did not cause pain.

Resisted tests were applied to examine the response in terms of pain and power to:the rotator cuff muscles, the adductors, and the biceps and triceps.

The patient exhibited left shoulder weakness, with strength grades of 4/5 for the motions of abduction, external and internal rotation.

A negative scarf test cleared involvement of the acromioclavicular joint and the lower fibres of subscapularis.

Palpation revealed no focal point of tenderness.

Clinical Diagnosis:

From the assessment it was evident there was a capsular involvement (most limitation of lateral rotation, followed by abduction, followed by medial rotation).The presentation correlated with the clinical signs and symptoms of adhesive capsulitis as reported by Cyriax:

 TREATMENT PLAN:

 The aims of treatment are taken from the examination and ideally should be agreed with the patient.

The aims were:

    1.Reduce Pain P1 and P2

    2.To restore range of motion at the glenohumeral joint

    3.To improve general strength of the shoulder joint musculature

    4.To enable the patient to continue working.

 Treatment consisted of Grade A mobilisation using the caudal and lateral distraction techniques. A grade A mobilisation is “a gentle movement of the affected part within the pain free range”.(Cyriax,)These techniques are advocated by Cyriax for the treatment of the irritable joint. Treatment was received twice weekly for 6 weeks. Additionally heat was applied to the shoulder joint for analgesic and extensibility effect. A home exercise was also formulated for the patient to encourage Range of motion.

REASSESSMENT:

Cyriax 1998 emphasises the importance of reassessment and this was carried out at the start of each treatment session. The following were selected as the parameters of reassessment:

Subjective:                                Sleeping at night

                                                Ability to lie on the left shoulder

                                                Pain levels

Objective                                 ROM at the glenohumeral joint

The treatment was administered twice weekly for six weeks.

Progress was slow. Range of motion improved slightly over the six weeks. Active abduction increased by 10 degrees with no improvement in lateral rotation.

Day time pain was only slightly diminished, and she still experienced a lot of pain while at work and following home exercises. Night pain was still present, although more manageable as a result of advice on arm placement on pillows.

At this point it was agreed that the patient would be referred to an Orthopaedic Consultant for injection with corticisteroid. The patient was advised about the importance of relative rest for approximately 14 days post injection.

When reassessed one week later the patient reported the following:

Objectively ROM remained limited albeit not to the same degree.

It is planned to continue physiotherapy treatment following the corticosteroid injection. With the aim of increasing range of motion.

DISCUSSION:

Initially this patient presented with

 After reassessment following injection the results of this case study were:

In the literature many theories have been put forward regarding the cause of adhesive capsulitis (see aetiology). It is generally considered to involve an underlying inflammatory process of the joint capsule, with subsequent thickening and contraction. It is recognised that it can occur from a minor trauma. The patient in this case had fallen 3 months previously to the onset of pain.

Many treatments are used to try to combat adhesive capsulitis, but unfortunately there is no general consensus relating to its treatment. Following six weeks of intensive physiotherapy employing Grade A mobilisations, home exercises and heat, very little improvement was observed in the patient.

According to Cyriax frozen shoulder develops slowly in three stages (See introduction), based on this model of development, the patient displayed signs and symptoms consistent with Stage 2 ,the most irritable stage of the condition. Treatment recommended by Cyriax for this stage of the condition are Grade A mobilisations as applied to the patient in question. A further intervention, namely Corticosteroid injection is also recommended for this particular stage. Due to the severity of pain, the option of Corticosteroid injection was discussed and agreed by the patient

The application of Grade A mobilisation-a gentle movement of the affected part within the pain free range, has been advocated by Cyriax. Although frequently used by physiotherapists, there appears to be a paucity of research to substantiate their effectiveness. This is not to say that these techniques are ineffective, merely that we lack proof in research. Following a literature review, it appears that more work has been done into the area of corticosteroid injection, exercise therapy and end of range mobilisations.

Van der Windt,1998 found that 77% of patients treated with corticosteroid injection achieved treatment success compared with 46% of patients treated with 12 sessions of physiotherapy who were considered successful. Physiotherapy consisted of passive joint mobilisations, heat and electrotherapy. However treatment success was defined as the patient’s perception of improvement and no objective measurements such as range of motion were used.

Winters et al,1997 also compared the outcomes of patients treated with physiotherapy, manipulation or corticosteroid injection. Following 5 weeks of  treatment the injection group had a 75% cure rat e. the manipulation group had a 40% cure rate and the physiotherapy group had  a 20% cure rate. Cure rate was poorly defined and is unclear whether it meant complete resolution of symptoms.

In the case of the patient in this case study, response to Grade A mobilisations was poor, and she reported no overall improvement in pain levels or ADL. Objectively, there was a slight improvement in active shoulder flexion and abduction. Considering her occupation and her level of pain, the route of corticosteroid injection was chosen. A reduction in pain levels during ADL and at night was reported by the patient one week later. Objectively only a small increase in range of motion was observed. Further physiotherapy intervention is now planned with the aim of increasing range of motion, using Grade A mobilisations and home exercises.

Conclusion:

Many treatments are utilised to combat adhesive capsulitis, but unfortunately there appears to a lack of evidence regarding their efficacy. Corticosteroids would appear to have a place in the initial inflammatory phases to help alleviate pain. To be effective however, such injections need to be given by an experienced practitioner, entering at the correct site and using the correct dose. Once the severe pain has settled, Cyriax mobilisations can be applied with the hope of further alleviating pain and increasing ROM.

Clinical experience shows that each individual is different. Some people have a frozen shoulder that is fully resolved in 12 months, whilst other present at two years with significant pain and loss of function in their shoulder. The problem is that it is impossible to predict how long any individual’s symptoms are likely to persist for.

REFERENCES

Cyriax, J. (1998) Orthopaedic Medicine A Practical Approach. Oxford: Butterworth Heinemann

Roth, G. (1999) Matrix Repatterning: Wellness Systems,Tottenham,ON,1999

Watson, E and Sumaband, D.(2001) Shoulder Problems-A Guide to Common disorders, modern Medicine of Ireland,31,2.

Van der Windt,D A W M,KOes,B W, Deville, W,Boeke,A J P,De Jong, BA and Bouter,LM(1998).Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: Randomised trial, British Medical Journal,317,1292-96.

Vermeulen,H M,Obermann,W M, Burger,B J, Kok, G J,Rosing, P M nad van den Ende,H M C (2002) End range mobilisation techniques in adhesive capsulitis of the shoulder joint: A multiple subject case report, Physical Therapy,80,1204-13

Winters,J C, Sobel,J S, Groenier, KH.Aredsen,H J and Meyboom-de Jong,B(1997).’Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: Randomised single blind study’, British Medical Journal,314,1320-24.