Frozen Shoulder: Causes, Symptoms, Treatments - All About Physical Therapy

Frozen shoulder, otherwise known as adhesive capsulitis, is a condition in the shoulder characterized by stiffness, pain, and limitation of motion. It is typical in frozen shoulder to involve only one, although, few cases affect both shoulders. 

Causes:

Frozen shoulder usually happen after a recent injury or after a medical procedure or from, a medical condition such as stroke, diabetes, or mastectomy. The inability of moving the shoulder into its full range of motion because of pain results in stiffness of the tissues around the joint. Later on, shoulder movement becomes more difficult and painful.

Symptoms:

This shoulder condition usually develops gradually, becomes worse over time and then slowly resolve over the course of 1 year up to 3 years. Persistent pain and limitation of motion from joint stiffness are the most obvious symptoms seen in people with frozen shoulder. This condition develops in 3 stages and each stage can last up to several months.

Freezing Stage 

• The painful stage. More and more pain is experienced when you do any movement of the shoulder. Limitation of motion starts to become limited.

Frozen Stage

• Pain begins to diminish at this stage, but the stiffness still remain making shoulder movement difficult affecting daily activities.

Thawing Stage

• Shoulder movement slowly improves at this stage.

Risk Factors:

• Age. Common to people aged 40 to 70 years
• Gender.More often to women than in men
• After surgical procedure 
• Recent injury such as fracture
• Medical problems such as stroke, hyperthyroidism, hypothyroidism, diabetes, Parkinson's disease, or cardiac disease

Diagnosis and Test:

• Medical History to include a detailed description of the symptoms, present and past medical conditions, and medications and/or supplements taken.
• Physical Examination to include testing the range of motion of both shoulder joints. The affected shoulder will show limited motion, both active and passive.
• Imaging Test
• X-rays, which shows a clear image of the bone, help find other problems in the shoulder.
• Ultrasound and MRI give a better view of the soft tissues to rule out other problems.

Treatment

The aim of treatment for frozen shoulder is to ease pain and keep the mobility and flexibility of the shoulder. Here are some of the recommended treatment approaches of frozen shoulder.

• Medications. Over the counter pain-relieving and antiinflammatory drugs, such as aspirin and ibuprofen to cut pain and swelling.
• Heat application followed by gentle stretching to increase range of motion.
• Range of motion exercises, given by a physical therapist, to recover shoulder joint mobility.
• Ice and corticosteroid injection will help reduce pain and swelling.
• Transcutaneous Electrical Nerve Stimulation (TENS) give pain relief by blocking pain fiber that carries pain impulses.
• Joint Distention. A sterile water is injected into a joint to stretch the tissue so that movement is easier
• Shoulder Manipulation under anesthesia. You will receive general anesthesia and the doctor do manipulation to break adhesion.
• Shoulder Arthroscopy. This procedure is rarely done. The doctor uses a lighted, tubular instrument inserted into a small incision around the joint to remove scar tissue and adhesions.

Morton's Neuroma

Morton's neuroma, also known as Morton's metatarsalgia or interdigital neuroma, is a painful foot condition affecting the nerve passing under the ligament that connect the metatarsals. This foot condition often affects the third and fourth toes, may sometimes develop in the second and third toes. Also, it either affects one foot or both feet. A constant irritation or an excessive pressure on those areas of the foot or both feet develops a thickening of the tissues that surround the nerves leading to the toes. As a result, one may experience a sharp, burning pain at the ball of the foot. The sensation is feeling like as if you are walking on a pebble, a common description of this foot condition. Although it can occur at any age, the condition is more notable in runners and in middle-aged women who loves to wear high-heeled shoes. Besides, the incidence is higher in women than in men.

Causes

Although the exact cause remained unclear, many experts believed that Morton's neuroma is usually associated with irritation or pressure of the nerves between the toes. Aside from wearing high-heeled shoes and participating in high-impact sports like running, anyone with foot deformities such hammertoes and flat feet will also have this foot condition.






Symptoms

A sharp, burning pain felt at the ball of the foot often worsen with activity and wearing tight shoes.
Unpleasant tingling sensation at the toe.
Pain increases over time.

Diagnosis

Examination may show a palpable mass at the toes, which is tender when pressed.
X-ray may help to rule out bone fracture.
A test on the range of motion to find any arthritic or an inflammatory condition of the joints.
Ultrasound and Magnetic Resonance Imaging are both good in visualizing the soft tissues, though quite expensive.

Treatment

The treatment is towards the symptoms. A conservative treatment is the first approach before going into an invasive intervention.

Wearing a orthotic device, those with foot deformities, will help relieve pressure on the toes.
Shoe change will help reduce pressure on the nerves, particularly the athletes.
Avoid high-heeled and tight shoes as well.
Foot massage provides pain relief.
Placing an ice pack at the sole provides pain relief.
Weight reduction  for obese persons to reduce strain on the feet.
Over the counter pain relievers and injections of steroids may help ease the pain and inflammation.
Surgical removal of the thickened tissues deemed necessary if all conservative treatments haven't worked. Although the surgery is successful in most cases, one may still experience the permanent sensation of numbness but not painful.

R.I.C.E Therapy

For the benefits of those who still have no idea on to how handle recent soft-tissue injuries, let me share with you the advantage of RICE therapy and how it promote faster recovery. Anyone, particularly the athletes and other physically active people, can have muscle strain, ligament sprain, bruise, and other soft-tissue injuries. RICE therapy is recommended on acute cases, usually the first 24 to 48 hours after injury. It doesn't mean RICE therapy is already enough, especially serious injuries. Better see your doctor for proper evaluation and management, like drug prescription and physical therapy. RICE, which stands for rest, ice, compression, and elevation, help reduce pain and swelling.

Rest

Right after the injury, take some time off from your activities. Stopping or limiting an activity promote faster soft-tissue healing. Remember, continued stress on the injured part will lead to further damage. If the injury is on the leg or ankle, crutches will help you move around without putting pressure on the injured part.

Ice

This treatment approach help control pain and inflammation. Icing works on reducing the size of the blood vessels, thereby decreasing the bleeding, the swelling, and easing pain. Never apply ice directly over the skin on the injured part, instead, wrap it around with a towel or any clothes. Commercially, there are cold packs available in medical shops. Apply icing for 15 to 20 minutes and repeat the procedure as long as you want. Icing works best during the first 24 to 48 hours after injury.

Compression

Compression,using a bandage, help reduce swelling as well as support to the injured part. Just remember not to wrap too tight to avoid cutting off blood supply to the injured area as well as more swelling below the affected area.

Elevation

While applying the ice, like sitting or lying, elevate the injured part above the heart level to help reduce swelling.

Charley Horse - Muscle Cramps

Charley Horse, otherwise known as muscle spasm or cramp, is a painful involuntary muscle contraction that doesn't relax for several seconds or more. In other words, the muscles become hard, stiff, and sore.I think almost everyone experiences muscle spasm, at any age, and occurring any time of the day. It can occur in any muscles, but they are most common in the calf and foot. Muscle spasm also occurs in the thigh, the hands, arms, abdomen, and on muscles in the rib cage area. Normally, spasm usually not prolonged or recurring, but if it continues to persist, better see your doctor to determine the cause and implement appropriate treatment.

Causes and Risk Factors:

Muscle injuries as a result of bruise or contusion
Muscle fatigue
Performing an exercise in excessive heat or cold
A strenuous exercise or overuse of a specific muscle during exercise particularly the calf muscles among athletes.
Stress plays a part and is most often in the neck muscles.
Not having or insufficient stretching prior to actual exercise or activities.
Inadequate blood flow to the leg muscles
Pinched nerve from compression injury of the spine
Side effects to an individual on diuretics may lead to low potassium levels
Deficiency with potassium, calcium, and sodium in blood
Deficiency with calcium to a pregnant woman, a common complaint.
Obesity
Smokers
Older adults and infants

Remedies and Prevention:

Keep yourself hydrated throughout the day.Water alone is not sufficient. Sports drink will help replenish lost minerals.
Heating pads will promote muscle relaxation
Ice pack to follow later on to manage pain
Nonsteroidal Anti-iflammatory Drugs (NSAIDS), like ibuprofen, given if the pain continues to persist
Antispasmodic drugs may be given in severe cases
Nerve irritation may require surgery and physical therapy
Massaging or stretching the foot, ankle or knee in the opposite direction of the spasm may relieve pain.
Eat a well-balanced diet, rich in potassium and calcium
Stretching before and after exercise
Stretching before bedtime will also help
Do not overdo an exercise to the point of fatigue

Lateral Epicondylitis (Tennis Elbow)

English: Lifting backpack (Photo credit: Wikipedia)

I. Overview

The most common overuse syndrome characterized by inflammation or degeneration at the common extensor tendon that joins the forearm muscles to the lateral epicondyle of the elbow. The forearm muscles and tendons become damaged from overuse leading to pain and tenderness on the outside of the elbow. It is a strain injury from playing tennis or other racquet sports. However, you can still get tennis elbow even if you are not a tennis player and is actually more common in non-tennis players. Any repetitive gripping activities or several other sports can also put you at risk. The structures primarily involved are the wrist extensors, particularly the extensor carpi radialis brevis. It also affect the extensor digitorum, extensor carpi radialis longus, and extensor carpi ulnaris.

II. Functional Anatomy

A synovial hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm. The elbow joint complex made up of four articulation,  the humeroulnar, humeroradial, superior radioulnar, and inferior radioulnar joints. Muscles, ligaments, and tendons hold the elbow joint together to provide functional movements and dynamic stabilization to perform skilled and precise motions. The coordination of multiple muscles allows two degrees of freedom of movements,  the combinations of flexion-extension and pronation-supination. The two epicondyles are actually the bony protuberance at the distal end of the humerus, the medial and lateral epicondyle. The forearm muscle tendons attach the muscle to bone. In lateral epicondylitis, the injury is on the tendon attachment on the lateral epicondyle of the humerus. The tendon usually involved is the Extensor Carpi Radialis Brevis (ECRB). Experiences pain and localized tenderness in the lateral side of the elbow.

Elbow - coude (Photo credit: Wikipedia)

III. Contributing factors

1. Overuse
Any repetitive wrist action against resistance during extension and supination may produce damage to the forearm muscle, particularly the extensor carpi radialis brevis muscle which stabilizes the wrist when the elbow is in extension. An example is ground stroke (backhand) in tennis.

2. Work and Activities 
There is a risk to any work or leisure activities that has no proper training, techniques, and equipment.

• Tennis/Racquetball/Squash - Check equipment for proper fit
• Fencing
• Weight Lifting
• Painters/Painting
• Carpenters/Bricklayers/Plumbers 
• Seamstresses/Tailors
• Cooks /Butchers
• Politicians (excessive handshaking)
• Musicians (pianists, drummers)
• Raking
• Knitting
• A lot of typing
• A lot of mouse work

3. Age
It is more common to individuals in their late 30's and 50's secondary to the normal loss of extensibility of connective tissue with age

4. Symptoms 
The symptoms of tennis elbow include pain and localized tenderness along the lateral aspect of the elbow especially over the lateral epicondyle that sometimes radiates into the dorsum of the hand although the damage is in the elbow. Pain usually increases with activity like picking up an object, holding a glass/cup, opening a door, or making shake hands. The elbow ROM is usually normal and involved only one side.

IV. Diagnosis

1. History Taking

• Information from patient
• Age of the patient (usual age group affected 30 to 50 years of age)
• How your current symptoms developed and medications
• Any occupational risk factors
• Recreational sports activities
• Family and Past medical history like an elbow injury before, history of rheumatoid arthritis or nerve disease

2. Physical Examination

• Inspections for swelling or ecchymosis.
• Palpation of the extremity for pain and tenderness at the lateral epicondyle
• The severity, the occurrence, and location of pain in relation to movement/activity
• Always examine ROM of the shoulder, elbow, and wrist on the affected side to evaluate for radiohumeral bursitis, osteochondritis of the capitellum, or PIN entrapment.

3. Tests

• Laboratory and imaging studies rarely needed
• X-ray or MRI (magnetic resonance imaging) to diagnose tennis elbow or rule out other problems like osteophytes, degenerative joint disease, or stress fracture
• Electromyography if there is radial nerve involvement
• Special orthopedic tests

Mills test

• The examiner palpates the patient’s lateral epicondyle with a thumb while passively pronating the forearm, flexing the wrist and extending the elbow.
• Positive test is reproduction of pain near the lateral epicondyle
• This test is also to use to indicate radial nerve involvement

Cozen’s test  

• Patient actively make a fist, pronate the forearm as well as radially deviate and extend the wrist against a counterforce that is being applied by the examiner.
• The positive test is the reproduction of pain near the lateral epicondyle.

Tennis elbow test

• The examiner resists the extension of the 3rd digit of the hand while stabilizing more proximal
• The positive test is the reproduction pain or discomfort in the region of the lateral epicondyle because it stress the extensor muscles and tendon

V. Differential Diagnoses

• Medial Epicondylitis
• Cervical Radiculopathy
• Plica Syndrome
• Elbow and Forearm Overuse Injuries
• Little League Elbow Syndrome
• Radial Nerve Entrapment 

Medical Intervention:
There are many treatment options for tennis elbow geared toward the goals of decreasing inflammation and analgesia. 

Nonsurgical Treatment
1. The patient is advice to avoid activities or work that aggravates the injury and treats pain and inflammation with protection, rest, ice, compression, and elevation.
2. Pharmacological intervention 

• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation such as ibuprofen, naproxen, or aspirin
• Monitor the effects on the gastrointestinal (GI) tract and renal function  with long-term use
• Topical NSAID such as diclofenac may offer some short-term relief.

3. Modalities

•  Ultrasound phonophoresis with hydrocortisone 
•  Electrical stimulation iontophoresis with NSAIDs and/or corticosteroid (dexamethasone) 

4. Counter-force bracing /Resting splints to relieve tension of the involved wrist extensor tendons
5. Physical therapy

•    Stretching to improve flexibility
•    Strengthening to increase functional activities
•    Progress from concentric to eccentric exercises and then resisted exercises as   tolerated
•   All exercise should be pain-free
•   Stretch and warm up before any sport or activity that will exercise your elbow or    arm.
•   Apply ice on your elbow after exercise

6. Steroid injections are very effective anti-inflammatory medicines to relieve symptoms.


Surgical Treatment
1. Recommended if the symptoms do not respond after 6 to 12 months of nonsurgical treatments
2. Surgical Option:
    a. Open surgery

• The most common approach to tennis elbow repair that involves making an incision over the elbow.

   b. Arthroscopic surgery

• This outpatient procedure involves using miniature instruments and small incisions. 

3. Rehabilitation

• Usually last 4 to 6 months postop
• Start the exercise with stretching and light, gradual strengthening exercise 2 months postop

4. Surgical risks

• Infection
• Nerve and blood vessel involvement
• Long-term rehabilitation process
• Loss of strength
• Loss of flexibility
• Possibility of another surgery

Home Care Program

• Give the same therapeutic program to the patient
• Patient education on modification of the activities that exacerbate the symptoms and use ice, elevation and rest as needed
• Advice patient about continued stretching and excercise to decrease the risk of recurrence
• Advice about the danger of rushing the recovery as it may worsen the damage

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