Adhesive Capsulitis / Frozen Shoulder

Adhesive Capsulitis is an insidious condition, characterized by fibrosis of the shoulder capsule and a progressive loss of shoulder range of motion in all directions(8). Adhesive capsulitis or "frozen shoulder" affects approximately 2% of the population(2). Of those affected, 70% are women and 20-30% will go on to develop symptoms in the opposite shoulder(1). Adhesive capsulitis occurs more frequently in diabetics and in persons over 40 years of age(3). Other factors may include trauma(3), immobilization(4), thyroid disease(5), autoimmune disease(6), stroke or myocardial infarction(7). It is characterized by pain and a progressive loss of active and passive range of motion in the shoulder.
Four stages are described in the literature:
1.Stage One, between 0-3 months: There is pain with active and passive motion, and limited motion in all directions.
2. Stage Two between 2-9 months: Known as the "Freezing" stage, this time period is marked by chronic pain with active and passive motion. There is significant limitation of motion in all directions.
3. Stage Three between 4-12 months: The "Frozen" stage exhibits significant limitation of motion in all directions, but minimal pain, except at end range of motion
4. Stage Four between 15-26 months: This "Thawing" stage presents with the gradual improvement in motion and minimal pain.
The goal of treatment is to decrease pain and inflammatory response, increase motion, and reestablish normal mechanics of the shoulder(1). A number of studies have found that physical therapy can be effective in the treatment of adhesive capsulitis(8-10). Physical therapy treatment may include exercise for range of motion, shoulder blade stabilization and joint mobilization.

Dislocation of the Shoulder

This condition may occur traumatically or may be recurrent. Dislocating once may be a singular event in a life or may be the beginning of a chronic problem. Treating that first event optimally with a period of immobilization then rehab is typical, but controversial. Allowing the overly-stretched, or torn ligaments and capsule of the shoulder to heal or scar down in those first few weeks may help prevent recurrence. The statistics tend to show that recurrence is common, especially under 20-25 years of age, and that immobilization and rehab may not always be helpful(1). Consulting a physical therapist is most important in order to be taught selective strengthening and stretching exercises that may counter the effects of the stretched tissues. Should dislocations become frequent, it can damage the articulating surfaces of the shoulder joint. Consulting an orthopedic surgeon may become necessary to surgically stabilize the joint. This is followed by intensive rehab.

References: (1)Chalidis B et al: Has the management of shoulder dislocation changed over time?; Int Orthop. 2006 Aug 15

Rotator Cuff

One can strain ("Impingement"), partially or fully tear, or have a degenerative condition of the rotator cuff. The cuff comprises the conjoined tendons of four muscles that intrinsically stabilize the shoulder joint. Falling on an outstretched arm, overuse and the effects of aging are causative factors. Chronic imbalance amongst the muscles can produce pain over time. There is often difficulty raising the arm overhead. The diagnosis is usually clinical. It is a common condition after 40 years of age. If a specific tear is suspected by the surgeon, or pain persists despite diligent physical therapy, an MRI may be indicated. A rotator cuff strain is often point tender at the shoulder with possibly some referred pain into the upper arm. There is rarely numbness/tingling. A Physical Therapist can assess any influence on the pain pattern coming from the neck, which often refers pain to the arm. Pain with raising the arm especially overhead is classic. This condition can often lead to losing range of motion(ROM), which needs attention immediately. Treatment comprises the preservation of ROM, rebalancing of the four rotator cuff muscles(by selective stretches and strengthening exercises) and optionally, some modalities. Ideal posture is essential to rotator cuff health. Proper arm-shoulder blade mechanics during movement can be assessed by the therapist. Rehab is critical to avoiding recurrence or worsening of this commonly chronic problem.
Recalcitrant pathology should be assessed by a surgeon. The post-op rehab after a rotator cuff repair is lengthy and arduous. In most cases, the arm is kept in a sling for about 4-6 weeks, during which time only passive and limited movement is allowed. Only at about three months can strengthening exercises be started. The rehab should be closely monitored by the therapist.

AcromioClavicular (AC) Separation

AC separations result from a fall onto the point of the shoulder or from landing on an outstretched arm. The collarbone separates from the shoulder blade. The severity is generally graded as I, II or III. Grade I symptoms are mild. Grade III results in more pain, a very visible bump and a popping sensation. Overhead activities are the most problematic. The latter two may involve wearing a sling for a while. A physical therapist will outline the safe exercises to regain range of motion and gradually, strength. Surgery for Grade III is still controversial, and probably depends on whether function is being significantly restricted.