What is Frozen Shoulder & How Can Manual Therapy Help?

Frozen Shoulder (aka Adhesive Capsulitis) involves pain and stiffness in the shoulder joint. Signs and symptoms typically begin slowly and gradually get worse over time. It causes significant restriction of active and passive range of motion at the shoulder; most frequently one's abduction and external rotation, although internal rotation can also be affected. It is a peculiar condition whereby you don’t always know what caused it.

What is actually happening to the shoulder joint when the pain first hits?

The shoulder’s joint capsule ligament (and for some, the neighbouring ligaments) suddenly flare up and become inflamed. Once initial flare up and pain subsides, the ligament(s) shorten and over time, they can adhere. The pain is highest at night so one's sleep is affected and sleep positions are often limited to one side and/or half-seated positions (lots of props!).

How to treat, When to treat?

There are varied approaches, but seeking a doctor's diagnosis is always reassuring and can also be a good way to rule out any underlying causes that may have triggered the flare-up. Aside from taking anti-inflammatories and/or analgesics, this particular condition can take a few weeks to a few years to repair. The healing time depends on how acute it was, how one lives, how and when one applied treatment and care. Seeking manual treatment does often shorten recovery time and really can help in getting back some of that lost range. If you do choose manual therapy, there are different ways to go about it. Who to see, in what order, what works best, etc.... To that end, it is a bit of an experiment on the client side but rest assured all manual therapies can assist in one’s healing journey.

Based on my experience as an RMT that has treated many cases of Frozen Shoulder, all with positive outcomes, and also as someone that has experienced it myself. (Something that creates a deeper understanding and sensory connection, if you will.) Below I’m providing you with a little insight into how I treat Adhesive Capsulitis. In this scenario, I would look at treating the cause, the injury itself and any compensatory changes.

Acute Phase

Intake:

Once your range of motion, pain values and any other necessary condition is assessed, we will review your treatment for each appointment.

Treatment:

The focus of this treatment is often more about calming the nervous system, thus relaxing muscle. I do this by using heat and slow, rhythmical touch via varied techniques. I then treat any muscle adhesions, trigger points or facial restrictions, and enhance movement and circulation in many associated joints (vertebral column or rib cage, for example). Time is often spent on treating compensatory tissues, such as the opposite shoulder/arm, or your back, neck and sometimes jaw and cranial tissues. I will most likely ice and stabilize the affected shoulder. This helps to reduce the inflammation and pain.

Self Care:

I often encourage rest, ice and comfortable elevation of the affected limb as much as possible. At times, I’ll provide gentle pain-free shoulder joint movement exercises. I, also at times, encourage a client to also see an Osteopathic Manual Practitioner and/or Acupuncturist during acute phases.

Treatment Plan:

I often recommend weekly 30 min or 45 min treatments for approximately a month or so. The treatment plan is discussed with you after each treatment. This condition heals at various rates for different people, so treatment plans are constantly shifting based on how you feel (pain and range of motion values).

Sub-Acute & Chronic Phases

Intake:

We will continue to review, assess and reassess your treatment at each session.

Treatment:

As the inflammation and pain diminishes on the affected shoulder, much of the allotted treatment time shifts to treating the affected shoulder. The shoulder at this time tends to be frozen, with limited range (varies from client to client but often stops at 90 degrees abduction, with little to no external rotation, sometimes internal rotation is affected too). The pain is now only felt at end range, and is what stops one from being able to move their upper arm (humeral head/ball) fully in the shoulder socket.

***It’s best to try & receive much of your treatment in the acute or sub-acute phase, when the tissues are still in their changing form.

Our main aim now is to safely manipulate tissues and joints that are now adhered on the affected (“frozen”) shoulder. I use various techniques and verbal cues to do this and often heat can now be applied directly on the affected side. Again, depending on the cause and possible other conditions, treatments from client-to-client do vary.

Self Care:

Continued pain-free and active shoulder movement exercises are provided. As the pain reduces and range of motion increases, strengthening exercises may need to be incorporated. This is when I tend to recommend the client see a Physiotherapist.

Treatment Plan:

As the shoulder continues to heal and improve; the sessions needed become less over time. Below is more information about some of the causes and symptom stages, should you wish to read more about this condition.

Causes of Adhesive Capsulitis are:

- intrinsic musculoskeletal trauma or disorder such as impingement syndrome, sub acromial bursitis, rotator cuff tendinitis or tears, dislocations, osteoarthritis, gout and inflammatory synovitis

- extrinsic disorders such as myocardial infarction, hemiplegia, pulmonary disorders

- trigger points in subscapularis muscle or shoulder blade area

- postural dysfunctions such as hyperkyphosis, protracted scapulae, head-forward posture

- disuse following shoulder injury or immobilization

- idiopathic factors; none of the above, unknown cause, no diagnosis

3 stages of Adhesive Capsulitis and just some of the Symptoms:

Acute Stage aka freezing phase, first stage or painful phase

- gradual onset of pain, perhaps after a minor trauma (ie reaching into the back seat of a car), or post cast or immobilization of injured shoulder.

Occasionally there is a major trauma such as a fracture, surgery or myocardial infarction. However, many don’t remember any precipitating factors at all (idiopathic).

- pain is severe at night. People often can’t sleep on the same side or either side. So sleep is often affected.

- muscle spasms may be present in rotator cuff, which adds to the pain

- stiffness is progressive setting in at 2-3 weeks post initial pain

- acute & subacute stages blend into each other

Subacute Stage aka frozen phase, second stage, stiffening phase

- severe pain begins to diminish

- stiffness becomes primary complaint so ADL (Activities of Daily Living) are often restricted like brushing your hair. The primary restriction is in the capsular pattern of abduction, external & internal rotation movements. And pain still occurs but at the end range of these restricted movement's.

- this stage can last between 4 - 12 months and disuse atrophy of the deltoid & rotator cuff muscles often result.

Chronic Stage aka thawing phase, third stage or resolutions phase

- pain is often localized to the lateral, upper arm and does diminish over time.

- the person can sleep better and is not woken by pain

- motion and function begin to gradually return, however, full range of motion is not always regained.

- this stage can resolve between 2 years - 10 years

References:

Clinical Massage Therapy

Understanding, Assessing and Treating Over 70 Conditions By Fiona Rattray (RMT) &

Linda Ludwig (B. A., RMT)

First Published , March/2000

Printed in Canada