Frozen Shoulder

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Frozen shoulder is a condition that leads to pain and stiffness of the shoulder. It’s also known as adhesive capsulitis or shoulder contracture.
Frozen shoulder (sometimes called adhesive capsulitis of the shoulder) is a condition where a shoulder becomes painful and stiff. Shoulder movements become reduced or restricted, sometimes completely ‘frozen’.
It is thought to be due to scar-like tissue forming in the shoulder capsule. Without treatment, symptoms usually go but this may take up to 2-3 years. Various treatments may ease pain and improve the movement of your shoulder.
Frozen shoulder facts
• Frozen shoulder is the result of scarring, thickening, and shrinkage of the joint capsule.
• Any injury to the shoulder can lead to a frozen shoulder.
• A frozen shoulder is usually diagnosed during an examination.
• A frozen shoulder usually requires aggressive treatment.
Anatomy of shoulder joint
Shoulder joint is a ball-and-socket type of joint made up of three bones, your upper arm bone (humerus), your shoulder blade (scapula), and your collar-bone (clavicle).
The head of the upper arm ( humerus) bone fits into a shallow socket in your shoulder blade (scapula). Strong connective tissue, called the shoulder capsule, surrounds the joint.
To help the shoulder move more easily, synovial fluid (a type of lubricating material) lubricates the shoulder capsule and the joint.

Pain in Shoulder
Frozen shoulder affects about 3% of adults at some stage in their lives. It most commonly occurs in people aged between 40 and 65 years. It is more common in women. It is more common than average in people who have diabetes and in some other conditions, including overactive thyroid disease.
Either shoulder can be affected but most commonly it is the non-dominant shoulder – that is, the left shoulder in a right-handed person. In about 1 in 5 cases the condition also develops in the other shoulder at some stage.
Note: frozen shoulder is not a form of joint inflammation (arthritis) and other joints are not affected.
Frozen shoulder is the common name for adhesive capsulitis, which means that the strong connective tissues, which comprises shoulder capsule become inflamed or swelled due to any cause, resulting in the limitation of range of motion. When the tissues in shoulder joint become thicker and tighter, scar tissue develops over time. As a result, shoulder joint doesn’t have enough space to rotate properly.
Frozen shoulder is also called as cement capsulitis or shoulder contracture. In intense cases, it will be unable to move your shoulder whatsoever.
Frozen shoulder might be idiopathic yet is regularly connected with different infections and conditions.
The symptoms of frozen shoulder may vary according to the stages :
Freezing
• In the” freezing” stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months. Phase one – the ‘freezing’, painful phase. This typically lasts 2-9 months. The first symptom is usually pain. Stiffness and limitation in movement then also gradually build up. The pain is typically worse at night and when you lie on your affected side.

Frozen
• Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the “frozen” stage, daily activities may be very difficult. Phase two – the ‘frozen’, stiff (or adhesive) phase. This typically lasts 4-12 months. Pain gradually eases but stiffness and limitation in movement remain and can become worse. All movements of your shoulder are affected. However, the movement most severely affected is usually rotation of the arm outwards. The muscles around the shoulder may waste a bit as they are not used.

Thawing
• Shoulder motion slowly improves during the “thawing” stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years. Phase three – the ‘thawing’, recovery phase. This typically lasts between one and three years. The pain and stiffness gradually go and movement gradually returns to normal, or near normal.

The symptoms tend to gradually get worse over a number of months or years. You’ll typically experience shoulder pain for the first two to nine months, which can be severe, followed by increasing stiffness.
The stiffness may affect your ability to carry out everyday activities. In particularly severe cases, you may not be able to move your shoulder at all.
The condition may improve with time, but this can sometimes take several years.
The earlier frozen shoulder is diagnosed, the more likely it is that treatment can help prevent long-term pain and stiffness.

What causes a frozen shoulder?
Frozen shoulder is the result of inflammation, scarring, thickening, and shrinkage of the capsule that surrounds the normal shoulder joint. Any injury to the shoulder can lead to a frozen shoulder, including tendinitis, bursitis, and rotator cuff injury (rotator cuff syndrome). Frozen shoulders occur more frequently in patients with risk factors of diabetes, chronic inflammatory arthritis of the shoulder, or after chest or breast surgery. Long-term immobility of the shoulder joint can put people at risk to develop a frozen shoulder.

What causes frozen shoulder?
Frozen shoulder occurs when the flexible tissue that surrounds the shoulder joint, known as the capsule, becomes inflamed and thickened. The causes of frozen shoulder are not fully known. It’s not fully understood why this happens. A few factors may put you more at risk for developing frozen shoulder.
The following can increase your risk of developing a frozen shoulder:
Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.
Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.
• Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson’s disease, and cardiac disease, Cervical spondylosis like conditions, Hypertension
• Most often in people 40 to 70 years old, probably due to wear and tear of the joint
• More often in women (especially in postmenopausal women) than in men, probably due to low level of calcium in the body resulting in osteoporotic or osteopenic conditions.
• Most often in people with chronic diseases, probably due to low immunity.
• Dupuytren’s contracture– a condition where small lumps of thickened tissue form in the hands and fingers
It’s estimated that up to 1 in 20 people in the whole world may be affected by frozen shoulder at some point in their life. Most people who get frozen shoulder are between the ages of 40 and 60. The condition is more common in women than men.

Symptoms
Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.
Signs and Symptoms of Shoulder Pain
Any injury or disease to the shoulder joint can cause shoulder pain. The injury can occur ligaments, bursa, tendons surrounding the shoulder joint, ligaments, cartilage, menisci, and bones of the joint. This is an extremely mobile joint and is always at risk for increased injury.
Common Symptoms Are:
• Joint pain.
• Tenderness around the joint.
• Stiffness.
• Achene’s upon movement of the joint.
• Swelling over the joint.
Serious Symptoms Accompanying Shoulder Pain Are:
• Difficulty in carrying objects.
• Difficulty in using the arm.
• Trauma causing deformity of the joint.
• Shoulder pain at rest or at night when sleeping.
• Persistent shoulder pain.
• Inability to raise the arm.
• Swelling in or around the shoulder joint or arm.
• Bruising around the shoulder joint or arm.
• Signs of infection such as fever, redness etc.
• Weakness in the shoulder and arm.
• Other unusual symptoms.
Shoulder pain symptoms and signs
Shoulder pain can be a result of injury or disease of the shoulder joint. Injury can affect any of the component comprising the shoulder joint like ligaments, bursae, or tendons surrounding the shoulder joint. Injury can also affect the ligaments, cartilage, menisci (plural for meniscus), and bones of the joint.
What are symptoms and signs of a frozen shoulder?
Symptoms and signs of a frozen shoulder include:
pain
stiffness
and loss of range of motion of the shoulder.
The shoulder range of motion is limited when either the patient or an examiner attempts to move the joint. The shoulder can develop increased pain with use. These symptoms can make sleep very uncomfortable. Continue Reading

Common injuries of the shoulder can lead to inflammation of the bursae (bursitis) or tendons (tendonitis) and result in rotator cuff dysfunction as well as instability and frozen shoulder.
How is frozen shoulder diagnosed?
A frozen shoulder is suggested during examination when the shoulder range of motion is significantly limited, with either the patient or the examiner attempting the movement.
Underlying diseases involving the shoulder can be diagnosed with the history, examination, blood testing, and X-ray examination of the shoulder.
If necessary, the diagnosis can be confirmed when an X-ray contrast dye is injected into the shoulder joint to demonstrate the characteristic shrunken shoulder capsule of a frozen shoulder. This X-ray test is called arthrography.

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining damaged by frozen shoulder.

.The tissues of the shoulder can also be evaluated with an MRI scan.
How frozen shoulder is treated
Most people with frozen shoulder eventually get better, even without treatment. However, appropriate treatment can help reduce pain and improve the movement in your shoulder until it heals.
The type of treatment you receive will depend on how severe your frozen shoulder is and how far it’s progressed. Possible treatment options include:
• painkillers or analgesics ( NSAIDS)
• corticosteroid injections
• shoulder exercises
• physiotherapy
Depending upon the condition or basic cause, if the symptoms haven’t improved after six months, sometime surgery may be recommended.
Frozen shoulder generally gets better over time, although it may take up to 3 years.
The focus of treatment is to control pain and restore motion and strength through physical therapy.
Nonsurgical Treatment
More than 90% of patients improve with relatively simple treatments to control pain and restore motion.
Physical therapy. Specific exercises will help restore motion. These may be under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before the stretching exercises.. Below are examples of some of the exercises that might be recommended.
• External rotation — passive stretch. Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body. Hold for 30 seconds. Relax and repeat.

  • Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.

Forward Flexion – Supine Position
• Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

Ayurvedic Treatment for Frozen Shoulder
In Ayurveda, the condition of frozen shoulder is correlated to Apabahuka.

Apabahuka is a disease that usually affects the Amsa sandhi (shoulder joint). From ayurvedic point of view , the problem of Frozen shoulder is due to vitiated vata dosha. Due to the causative factors the vata dosha gets vitiated and get accumulated in the Amsha sandi ( shoulder joint) and causes dryness and then emaciation of the lubricating fluid present inside the joint capsule and other soft structures too. Which ultimately leads to pain,swelling, stiffness and restricted movement too. Some times kapha dosha also gets vitiated with the vata dosha as boths the doshas have few same vitiating causes. So, depending upon the vitiating dosha, the frozen shoulder can be divided into two conditions :-
1. Vata dominating condition, where the vata dosha only get vitiated, resulting mainly acute pain, tenderness etc.
2. Vata kapha dominating condition, where vata along with kapha dosha also gets vitiated, resulting mainly stiffness, heaviness, pain, restricted movement etc.
The stiffness to the joints is contributed by Kapha Dosha. Because of involvement of Kapha Dosha, in many patients, cold exposure and at night time, the stiffness worsens.
Frozen shoulder causes:
The bones, ligaments and tendons of shoulder joint are covered in a capsule of connective tissue. It can be imagined as ball (capsule), containing the shoulder joint within it. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.
Causes for frozen shoulder as per Ayurveda:
(i) External causes —
Injury to the vital parts of the body (marma) or the region surrounding shoulder joint
Excess exposure to wind, a.c, sleeping with wrong posture, trauma etc
(ii) Internal causes —
Vata and kapha too, aggravating diet and activities. Excess of pungent, bitter and astringent tasting foods, etc.

Ayurvedic Treatment for Frozen Shoulder
People affected with frozen shoulder generally try analgesics steroids, anti-inflammatory medications, etc which relieves the pain for some time but is not a definitive cure of pain as a result of which there is recurrence of pain on a frequent basis. Because of this, the affected individual resorts to using injections and tablets repetitively and hence instead of eliminating the main cause of the pain and relieving the symptoms, it actually increases them in severity.
The main aim of Ayurvedic treatment is to eliminate root cause of pain. Permanent relief from symptoms is the definitive cure for this disease.
Ayurvedic treatment for frozen shoulders should be aimed toward rectifying the vitiated dosha. Override of vata dosha has occurred because of the build-up of toxins within the joints. Ayurvedic treatments for frozen shoulders can then aim to by eliminating all the toxins, and treating stiffness and pain and ultimately preserving the joint structures naturally. Keeping this aim in mind all types of treatment should be done

Treatment with use of Ayurveda includes Panchakarma therapies like abhyanga, swedana, nasya, purgation(virechana) especially and the use of herbal medications like Kashayas, Aristas, use of oils both internally and externally in order to remove the offending toxin permanently from the body. In the Panchakama treatment, use of oil massage also called as Abhyanga, doing steam bath called Swedanam along with Nasyam and Navarakizhi, which is a unique Panchakarama treatment usually done. It is recommended to do at least 7-10 days of Panchakarma therapy at a minimum followed by a 7-day period of rest.

Line of treatment of Frozen shoulder

  1. Oleation (Snehana) – to the shoulder girdle from back of the neck to the tip of the corresponding arm is usually beneficial.
    2. Swedana (Sudation) – After the oilleation, mild sudation should be carried in the oleated area; this stimulates the nerve endings and improves blood circulation too. Thus the pain and stiffness are relieved.
    3. Nasya (oleagenous errhines) does have significant effect in this condition as it stimulates the nerve endings. Nasyam is a well-known Panchkarma therapy for Urdhvajatrugata Rogas means the diseases above the shoulder, that includes ENT problems, headache related problems, ophthalmic or eye related problems, nervous system related problems etc.
  2. Basti treatment (rectal enema with oils / herbal decoctions) might be required to bring about Vata Balance, quickly.
    External Ayurvedic procedures useful in Frozen shoulder:
    The below therapies help to relieve pain and stiffness of joints
    Rejuvenates the degenerated connective tissue.
    Abhyanga – oil massage. The medicated oils are listed below. Usually oils are slightly heated over a water bath, before massage. Usually steam therapy is given after massage, especially to relieve stiffness.

Pizhichil – streaming of hot oil, along with simulatenous massage. Pizhichil, a widely accepted ayurvedic therapy in which medicated oil is squeezed in the body using a cotton cloth. This is done along with massage.

Elakizhi – herbal poultice, are prepared with Vata balancing herbs such as castor leaves, Nirgundi (Vitex negundo), Dashamoola, Devadaru etc, tied in a pack by cloth. This is dipped in hot medicated oil and this is applied over the shoulder joints. Elakizhi is a well known herbal massage with Pizhichil which strengthens the muscles and facilitates mobility in the shoulder.

Navarakizhi – Especially useful in degenrative conditions. First Abhyanga (oil massage) is done, and then Rice pack, dipped in certain kashayams), made with cloth, is applied over the affected area.
Podi Kizhi – Herbal powders taken in linen bags, dipped in oil and applied over shoulder joint
Pichu – Cloth / cotton swabs soaked in hot medicated oil applied to the affected joint. Gives long time exposure of oil to the joints.
The duration of the therapy depends on the severity of the symptoms and can extend from a week to three weeks along with oral medications for about one month to four months.
Either a single or a combination of above therapies is used in Ayurvedic treatment of frozen shoulder.
Herbal oils for for frozen shoulder:
Vishagarbha Taila – used in Ayurvedic treatment of paralysis, stiffness of hands and legs, neck stiffness etc.
Mahanarayana Taila – a very famous herbal oil used in Ayurvedic treatment of arthritis, paralysis, and eye diseases. This oil is used for external application, orally and for many Ayurvedic therapies.
Dhanwantara Taila – used in the treatment of Vata diseases such as Rheumatoid and osteo arthritis, spondylosis, headache and neuro-muscular conditions.
Kottamchukkadi Taila – Ayurvedic oil used in the treatment of Vata disorders causing neuro muscular pains, sciatica, spondylosis etc. This oil is formulated based on Kerala Ayurveda practice.
Bala Taila – Nourishing in nature. Useful to reverse degeneration.
Prasaranyadi Taila – Especially useful to relieve stiffness
Oral Ayurvedic medicines for frozen shoulder:
Yogaraja Gulgulu – Useful in bringing down pain and to improve joint flexibiltiy
Rasnerandadi Kashaya – Useful when there is joint pain with stiffness
Shilajatu Vati – Useful when there is tissue degeneration
Prasaranyadi Kashaya and Sahacharadi Kashaya – Useful especially when there is stiffness.
Maharasnadi Kashaya – Relieves pain and inflammation
Dashamoolarishta – to relieve inflammation quickly
Vatavidhwamsa Rasa – used in the treatment of neuritis, colic pain, etc
Mahavatavidhwamsa Rasa – used in the treatment of Vata disorders, abdominal pain etc.
Vishamushti Vati
How long treatments and medicines are required for complete cure?
External therapies might be required for 7 – 21 days.
Oral medicines might be required for 2 months with gradual decrease in dosage based on progress.
Recovery can be accelerated with physiotherapy and Yoga.
Wholesome diet and habits in frozen shoulder:
1. Warm and unctuous food
2. Proper and regular exercise
3. Warm water bath loosens the stiffness.
Include anti-inflammatory spices such as turmeric and black pepper in diet.
Unwholesome diets and habits in frozen shoulder:
1. Cold water bath
2. Excess use of A/C rooms
3. Excess of oily and fried food
4. Heavy exercise
5. Improper laying, sitting and sleeping position etc.
Frozen shoulder is not a life threatening illness. But the condition will be miserable as his routines are disturbed. Also it causes difficulty to do his professional works as in each work role of hand and shoulder is certainly needed. So immediate attention and regular medication and constant exercises play significant role in this disease.
Physiotherapy for frozen shoulder is very useful. There are certain exercises that the physiotherapist will make you to do. But there are a few which you can do at home to improve shoulder joint flexibility.
Always start with the easiest one and stop when mild pain starts to appear.
A few exercises: Arm rotation exercises – clockwise and anti clockwise – 3 – 10 rounds.
While sitting straight, extend your arms forward, straight. Hold them straight for 5 seconds and then relax.
While sitting straight, extend your arms laterally, straight. Hold them straight for 5 seconds and then relax.
Yoga for frozen shoulder
Surya Namaskara
Adhomukha Shwanasana
Gomukhasana
Pashasana
Trikonasana
Ushtrasana
Some Of The Common Treatments For Shoulder Pain Are
• Rest: Resting the shoulder joint helps in reducing the swelling and pain.
• Heat and ice can also be used to help reduce swelling and pain in a shoulder injury.
• Physical therapy helps in recovery from shoulder pain by increasing the strength, mobility, and help patients in returning to their previous activity level.
• Stretching muscles and tendons that surround the shoulder joint help with some causes of shoulder pain and in relieving the pain.
• Some exercises also strengthen the muscles around the joint and relieve pain.

What you can do at home to prevent frozen shoulders?
Do regular rotatory arm exercises.
Avoid continuous computer work, move often.
Oil massage with steam or hot water bath at least once a week.
Regular exercises and active lifestyle.

Risk factors
1. 40-year-old and older, particularly women.
2. People with prolonged immobility or reduced mobility due to Rotator cuff injury, fractured arm, stroke, after a surgery etc.
3. People who have certain diseases appear more likely to develop frozen shoulder. Diseases that might increase risk include Diabetes, hyper active thyroid, underactive thyroid, heart disorders, TB etc.

Who Is at Risk for a Frozen Shoulder?
The condition is more likely to occur in middle age and is more common in women.
If you have diabetes, your risk for the condition is three times greater.
Others at risk include:
people who must wear a shoulder sling for a long period after an injury or surgery
people must remain still for long periods of time due to a recent stroke or surgery
people with thyroid disorders
Prognosis of a frozen shoulder-
The prognosis of a frozen shoulder depends on its response to panchakarma therapy, exercises, and ayurvedic treatments as described above. Again, it is essential to avoid re-injuring the shoulder tissues during the rehabilitation period. Without aggressive treatment, a frozen shoulder can be permanent.
Can frozen shoulder be prevented?
For the Prevention of a frozen shoulder, it is very much necessary to avoid injury or re-injury to the shoulder, and strictly eye should be kept on the causes so that they should be avoided.

Massage for Frozen Shoulder
Frozen shoulder is a condition where an individual will experience pain and stiffness in the shoulder and is not able to lift the arm over the head. Frozen shoulder causes stiffness and restricted range of movement in the shoulder. This condition is medically known as “adhesive capsulitis.” However, adhesive capsulitis is a specific condition where there is a slow onset of stiffness and pain in one shoulder due to inflammation and tightening of the joint capsule. Usually the terms frozen shoulder and adhesive capsulitis are used alternately.
Massage treatments done regularly can help in alleviating the shoulder pain and loosening or relaxing the stiff shoulder muscles. Other treatments done for frozen shoulder also include heat therapy, home exercises, physical therapy, nonsteroidal anti-inflammatory medications (NSAIDs) and steroid injections. Immediate treatment leads to faster recovery, however, it can take anywhere from 12 to 18 months to completely restore the shoulder range of motion. Usually conservative treatments are sufficient for relief from frozen shoulder, but in some cases surgery may be required in order release the contracted shoulder joint capsule.
Benefits of Massage for Frozen Shoulder
Massage therapy is very beneficial in treating frozen shoulder as it increases the blood circulation to the injured region and also reduces the formation of scar tissue. Regular massage should be done to reduce the muscle stiffness. The pain and stiffness usually gets relieved after several massage treatments.
Massage Techniques for Frozen Shoulder
There are various combinations of techniques done by a professional massage therapist, which provides relief from shoulder pain and helps in the “thawing” process or the recovery stage.
Deep Tissue Massage for Frozen Shoulder:
One of the common techniques used to treat frozen shoulder is deep-tissue massage. In this technique, the massage therapist applies constant pressure to the muscles in order to release the scar tissue or adhesions which may be causing the shoulder pain.
Shiatsu is a Japanese form of deep-tissue massage which involves deep pressure on certain regions of the body. These are called acupressure points and helps in controlling the energy flow (“Ki” in Japanese) across the body and thus results in decrease in pain. Deep-tissue massage techniques should not be done in case of acute shoulder pain, swelling or inflammation, as it may aggravate the condition.
Trigger Point Therapy for Frozen Shoulder
Trigger point therapy is another massage technique which benefits the frozen shoulder. In this technique, steady pressure is applied on certain targeted points within the muscles. This helps in relieving the muscle spasms.
Heat Therapy for Frozen Shoulder:
Heat therapy is also very helpful in treating the frozen shoulder. It can be applied before or after a massage. Heat therapy can be also done for trigger point massage for frozen shoulder. It helps in relaxing the muscles and decreasing pain. Mild heat can be applied for multiple times daily using pads which are heated an hour before application.
Life Style
Do meditation
Walk or jog in the nature
Do not exhaust yourself!
Do not exercise with full stomach!
Do not hurt yourself!