Classification of FSS (Frozen shoulder syndrome)
1. Primary (Idiopathic) Frozen Shoulder
2. Secondary Frozen Shoulder
1. Diabetes mellitus
1. Cardiopulomonary disease
2. Cervical Disc
4. humerus fractures
1. RTC Tendinitis
2. RTC Tears
3. Biceps tendinitis
4. Calcific tendinitis
5. AC arthritis
*from Coumo, F. Diagnosis, Classification, and Management of the Stiff Shoulder. In: Disorders of the Shoulder: Diagnosis and Management. Iannotti, JP and Williams GR (eds). 1999
Description of pain in primary FSS (Frozen shoulder syndrome):
The onset: After a period of pain, localized mostly in the shoulder and / or upper arm, begins the onset of severe limitation of movement of the glenohumeral joint in all directions.
Cause: Movement limitation is caused by the retraction of the glenohumeral joint capsule and adhesions of the subdeltoid bursa. Due to this condition of the glenohumeral joint the arm is not able to be elevated forward, actively or passively, more than 90 degrees. This movement is made possible by rotation of the scapula and forced posterior movement of the clavicle.
Cineradiography of the primary frozen shoulder reveals:
Cineradiography of the primary frozen shoulder reveals that not only is the movement pattern of scapula and clavicle changed, but also the relationship between the coracoid process and the clavicle. Further forward elevation of the arm is made impossible due to obstruction of the coracoid process by the clavicle. This obstruction results in the compression of the tissues lying between these bones causing pain. Postmortem examination confirms this theory.
Guided by these observations it is thus illustrated that patients with a frozen shoulder suffer pain, not only from the primarily affected tissues around the shoulder, but also from the compression of the tissues between the coracoid process and the clavicle during forward elevation of the arm. (Stenvers and Overbeek 1978).
Change in the thinking of the approach to FSS:
Many researchers and clinicians believe the effectiveness of existing physical therapy interventions can be improved by targeting the provision of specific interventions at patients who respond best to that treatment. The key messages are that subgroups should be identified (Hancock et al).
Frozen shoulder is a vast entity. This syndrome is classified in to primary & secondary. Depending on acuteness & time course of presentation FSS (Frozen shoulder syndrome) has 4 distinct stages.
1. Stage 1: "Pre-adhesive Stage"
2. Stage 2: "Freezing Stage"
3. Stage 3 "Frozen Stage"
4. Stage 4: Thawing Stage
The pain resistance sequence pattern is conspicuous in different stages. Many different articles claim, there are secondary myofascial shortening & stiffness of thoracic spine in addition to capsular tightness. Hence the treatment advocacy is varied yet not streamlined. Treatment involves:
1. Shoulder mobilization
2. Shoulder mobilization + or - capsular stretching
3. Shoulder mobilization + or - capsular stretching + or -myofascial stretching +or - *
4. Shoulder mobilization + or - capsular stretching + or - myofascial stretching + or -**
* AC ± SC± ST ± joint mobilization
** AC ± SC± ST joint mobilization ±thoracic mobilization
*** All mobilization procedures are appropriately supplemented with strengthening
Research report about effectiveness of joint mobilization in FSS:
Bulgen et al (1984) performing a RCT comparing passive mobilization techniques (3 times per week for 6 weeks, intensity unknown) with intra-articular steroid injections, ice therapy followed by PNF, or no therapy, reported following-term (6 months) advantages of any of the treatment regimens over no treatment.
Yang et al (2007) compared the use of 3 mobilization techniques----in the management of 28 subjects with frozen shoulder syndrome. ERM and MWM (Mobilization with movement) were more effective than MRM in increasing mobility and functional ability.
Research report about effectiveness of multidirectional stretching in FSS:
The vast majority of patients who have phase-II idiopathic adhesive capsulitis can be successfully treated with a specific 4-direction shoulder-stretching exercise program. Patients with more severe pain and functional limitations before treatment had relatively worse outcomes. More aggressive treatment such as manipulation or capsular release was rarely necessary, and the efficacy of early use of these treatments should be further studied.
Content of the Pre-introduction class to shoulder techniques