Frozen shoulder is a clinical entity and commonly follows unresolved or intractable progressive rotator cuff lesions. It may also follow a history of dislocations, fractures and the arthritides, to mention a few related problems. It should be suspected clinically when painful glenohumeral limitation is followed by less pain in which the joint motion is decreased. In this clinical scenario, the reduced pain is due to less shoulder joint motion, which would otherwise evoke pain on motion and constitute the acute phase of this process.
The subacute phase presents with slight restriction of glenohumeral motion, but with pain on motion in excess of the pain which would be common to the relative clinical findings. In this phase, the fibroadhesions are progressing to form an osteofibrous case. With continued progression, the chronic phase results in an immobile shoulder with absence of pain, and a resultant scapulothoracic motion rather than a joint motion.
The pathophysiology of this process involves progressive venous stasis, congestion, and ischemic anoxia leading to an edematous, proteinaceous exudate and inevitable fibrosis. As this process develops, auscultation of the shoulder components with attempted motion by the patient evokes crepitations, which become more audible as this process progresses until motion is no longer possible. As shoulder motion approaches the point of absence, the crepitations become less audible due to the reduced motion.
In the early, acute inflammatory process, cryotherapy or contrast therapy are the modalities of choice, with use of a loose sling following treatment. The arm should not be kept tight against the chest wall, but should allow for some movement within the sling. This may encourage healing by areolar rather than collagen tissue.
In the subacute or chronic phase, the entire shoulder component may be wrapped in a silicone gel wrap which has been heated in a microwave oven to a point sufficient to deliver heat to the patient, but avoiding erythema ab igne. This modality will expend heat energy in such a manner as to avoid this problem if it is heated properly. This method will provide for reflex vasodilation. If crepitations were auscultated on examination, it is recommended that interferential current be applied and the electrodes should be positioned to provide for the perfusion of current in the scapulothoracic interspace. This author will be happy to answer inquiries as to this positioning process.
Lidocaine/cortisone phonophoresis may be used in treating this lesion, but will require much time and careful delivery to be effective. This application of shortwave diathermy using a triple-drum electrode may be effective in preparing the patient for any exercises prescribed in the rehabilitation process.
If the patient exhibits a "drop arm" finding, or the presence of any large concretions within the shoulder field radiographically, or a significant calcified lesion, they should be referred for surgical correction. The patient should be instructed in good postural habits and encouraged to avoid the "droopy shoulder" syndrome.
It is not common to achieve full recovery from this problem if it has progressed to the subacute or chronic phase. It is common to have residual pathology with some reduced motion of the joint in this lesion, and exacerbation is to be expected.
R. Vincent Davis, DC, PT, DNBPM
Independence, Missouri
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