WHAT IS A “FROZEN” SHOULDER
A “Stiff” shoulder can mean different things to different people. We explore the meaning of stiff shoulder as it refers to sub-optimal range of motion for performance that is physically and, at times, mentally debilitating. The lack of motion from a stiff shoulder can have significant impact on daily living, vocation, and recreation.
WHAT FACTORS ARE RESPONSIBLE FOR A “FROZEN” SHOULDER
There are 4 major reasons a stiff shoulder develops:
- Rotator Cuff tear – ( this is a dynamic muscular issue that is not related to our current topic but definitely limits overhead motion).
- Adhesive capsulitis (AKA “frozen shoulder”) – insidious onset with the adherence of the capsule causing contracture of the shoulder that results in significant range of motion loss in multiple planes. It has long term restrictions that can last up to 18 months. It normally has three phases of progression: freezing, frozen, and thawing.
- Post-operative – more specific stiffness than adhesive capsulitis. This can be a natural process of the surgery and other times it can be a complication. E.g. patient wearing a brace/sling for several days/weeks after
rotator cuff surgery.
- Post-injury – any injured tissue or inflammatory process that does not allow for full range of motion.
A stiff shoulder pathology can worsen if ignored in a minimal state of ROM loss. Continuing to use a shoulder with sub-optimal motion during activity can lead to further devastating results and injury. Cited in numerous case studies, treatment to the minimally “frozen” shoulder could have prevented long-head biceps and rotator cuff damage in the shoulder.
HOW TO GAIN FULL MOTION WITH A “STIFF” SHOULDER:
There are 5 key principles for treating the “frozen” shoulder. These apply to all shoulders which lack range of motion, regardless of the particular diagnosis.
# 1 – Understand the capsule
Understanding the anatomy/biomechanics of the shoulder and the capsular ligaments that give it passive stability is vital. These ligaments function as all other ligaments of the body, to give restraint and stability to specific motions that can cause damage or strain.
The key ligaments of the shoulder are: superior, middle, inferior glenohumeral ligaments (most common capsular loss of overhead motion), and coracohumeral ligament.
Knowing which ligament has adaptively shortened is crucial to treatment of the shoulder. Various degrees of shoulder motion limitation are evidence of which key ligament has adaptively shortened (tightened). For example, one can identify the inferiorglenohumeral ligament (IGHL) as the culprit through observing limited motion with external rotation at 90 degrees of abduction.
A thorough evaluation of which part of the capsule is restricted is the first step in knowing which specific area of the shoulder needs joint mobilization.
# 2 – Know when to push shoulder limits
A frequent question from students is, “how do I know how hard to push the shoulder?” Laying on a table and having your arm cranked to the end range of motion is not how a shoulder should be appropriately stretched. Too much force can lead to a “rebound” effect which worsens range of motion and can cause further damage. The key to optimal capsule load is to know and understand the “end feel” of the joint in order to prevent spasm and injury. There are several ways that a capsule of the shoulder will feel during stretching. The end feel that is necessary for best outcomes is “capsular”. A capsular end feel will indicate that the appropriate ligaments of the shoulder are on stretch and that a more aggressive approach can now be explored.
If there is a spasm end feel, the focus is on decreasing the pain and inflammation with light motion, soft tissue mobility, and appropriate modalities. Pushing through this spasm end feel will only make things worse and the patient will not be compliant to their treatment and home exercises. Once this spasm end feel is abolished, then there is a green light for more advanced manual therapy.
#3 – Frequent Motion
It is necessary to have a home exercise plan that is tailored to the capsular ligaments that are limiting functional motion. Guarding and over protecting motion at home will likely lead to further stiffness and dysfunction in the shoulder .
Motion is critical for the human brain’s neuroscience and how it perceives pain and functional limitation. Appropriate movement communicates to the brain that this is appropriate and necessary, which lessens the limitations and guarding. The goal is to slowly progress motion on every therapy session. This happens when the patient consistently performs frequent motion to end range at home. A speed up and speed down stretching approach, meaning the patient decides to take the weekend off on stretching and they return to baseline with motion, will also likely lead to further stiffness.
Take, for example, a patient that starts therapy with 90 degrees of flexion and gains 10+ degrees of shoulder motion in one session. The following visit, the patient returns with the same 90 degrees of motion. If that gained motion is not maintained, it indicates that the stretching activity at home was not done with enough frequency. Re-gaining full motion is a steady and gradual process that requires compliance to specific shoulder stretches with appropriate reps, sets, and hold times. It can be slow, but is much faster than the alternatives.
#4 – Sustained End Range (TERT)
In addition to frequency of motion, sustained end range motion is critical. Total End Range Time, referred to as TERT, neuromodulates the pain perceived by the brain and tells the brain that this motion of the shoulder is achievable and that there is no need to guard against motion. This fourth principle should be combined with frequency of motion as part of the home exercise plan throughout the day.
#5 – Low Load Long Duration (LLLD)
It is important to call out that LLLD does not mean an aggressive load on the shoulder. This fifth key does require more load than just the weight of the arm as seen in the TERT. LLLD stretching is opposite of what a typical short stretching session (e.g wall stretch) is at home or in the clinic. Short stretching has medium/high loads with quick/short duration holds of 1 minute or less. In contrast, LLLD optimal stretch hold time is up to 20 minutes, 4 times a day for a combined total of 60 minutes of stretching during the day.
Several studies that date back to the 1980’s show the strong efficacy of the LLLD type stretch. When this stretch is combined with heat, the gains are significantly higher due to improved extensibility of the collagen during the stretch.
A thorough, biomechanically sound evaluation with a physical therapist allows for early detection of a “stiff” shoulder with subtle loss of motion. This early detection will likely result in swifter recovery of motion and minimize debilitating effects. Gaining motion of the shoulder is not
easy and is a gradual process. Pushing of the capsule “more” doesn’t always translate to better results. Knowledge of end feel dictates how motion of the shoulder is progressed. Motion will continue to improve as the patient performs consistent end range stretches throughout the day that are combined with sustained loading with heat.