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Assess & Address

Frozen Shoulderby Whitney Lowe

The term "frozen shoulder" is commonly used to refer to a painful condition of the shoulder that severelylimits range of motion, making the joint appear to be frozen. While the title is common, it isnt technically accurate, andhealth!care practitioners tend not to use it. ather, "adhesive capsulitis"is the proper term for this condition. #n this articlewe use both, bearing in mind it is adhesion in the joint capsule that is the primary pathology.

$s the name suggests, the problem originates from adhesion in the glenohumeral joint capsule. #t is important to note thatnumerous problems in the shoulder may be painful and limit range of motion in ways similar to adhesive capsulitis. # haveseen demonstrations of massage techni%ues claiming to address frozen shoulder in which the client clearly did notpresent the characteristics of adhesive capsulitis. #nstead, the clients condition indicated another shoulder pathology,such as sub!acromial impingement. &roper and accurate assessment is critical for effective treatment.

PathologyThe greatest range of motion of any joint in the body occurs in the glenohumeral joint. While freedom of movement isnecessary in performing various actions of the shoulder, there is increased potential for soft!tissue injury. Withoutstabilization from the bony structures of the joint, much of the structural support must come from soft!tissue support. Thus,muscles, tendons, ligaments and the joint capsule make up the primary support for this joint.

The joint capsules fundamental role is in restricting e'cess motion. (owever, because there is such a great range ofmotion in the shoulder joint, the capsule must be able to allow a wide range of movement before it restricts that motion.The glenohumeral joint capsule is looser than many other joint capsules in the body in order to accommodate this greaterrange of motion.

The above image shows the glenohumeral joint capsule with the shoulder in a neutral position. )otice that when theshoulder is in this position, there is a slackening of the joint capsule on the underside. The underside of the capsule ismade up of capsular tissue as well as the inferior glenohumeral ligament. #n order to allow the full range of glenohumeralmotion, the capsule must be slack on the underside. $s other shoulder motions are performed, this portion of the capsulewill become taut while others slacken.

The pathology in adhesive capsulitis develops when a portion of the capsule *usually the underside+ adheres to itself andprevents full movement. The joint capsule is richly innervated, so when the adhesions pull on the capsular tissues, it isvery painful.

There are two categories of adhesive capsulitis primary and secondary. #n primary capsulitis, there is no easily apparentcause for the condition. #t is frustrating for many health!care providers because they arent able to identify what createdthe problem and help the patient-client better understand why it happened. #t is difficult to avoid the aggravating factors ofthe condition without understanding what triggered the problem.

What can make primary capsulitis more challenging is that, in some cases, there seems to be a correlation betweensignificant emotional trauma and the development of adhesive capsulitis. While there is not a clear cause-effectrelationship, this correlation can lead some health!care practitioners to presume the condition is primarily psychological innature. (owever, the seriousness of the problem should not be minimized simply because a structural or mechanicalcause cannot be found.

#n this case, the capsular adhesion occurs as a result of some other pathology. or e'ample, in the glenohumeral joint,secondary capsulitis will often develop as a result of rotator!cuff tears, arthritis, bicipital tendinosis *an abnormal conditionof the tendon when no inflammatory cells are present+, shoulder trauma, surgery or other problems. There appears to be aprocess of fibrosis that is initiated by these other conditions. /onse%uently, the individual is usually limiting motion in theshoulder at the same time that fibrous proliferation is occurring. $s a result, the fold on the underside of the joint capsule

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never gets fully elongated, and the fibrous proliferation causes the two sides of the fold to adhere to each other. $ viciouscycle then follows. The adhesion causes pain and limitation to movement, thus worsening the problem.

$nother possible cause of secondary capsulitis is the presence of myofascial trigger points. There is an indication thattrigger!point activity in the subscapularis muscle can set off a cascade of adhesion in the capsule. This may result fromirritation of the attachment site of the subscapularis, which is very close to the joint capsule. Local inflammation at theattachment site will then cause fibrous adhesion in the capsule.

$dhesive capsulitis can be a stubborn condition and last for many months. #n fact, it is not unusual for the problem to last

01 months or more. The severity of the problem and its recuperation time depend upon how early in its development it canbe halted.

The problem is often divided into three different stages

2 Freezing: 3nset is usually between 04 and 56 weeks. This stage is characterized by a gradual decrease in range ofmotion and an increase of pain.

2 Frozen:This period occurs between four and 07 months after initial onset. 8otion is likely to remain limited though agradual decrease in pain may be occur.

2 Thawing:This period is characterized by a gradual return of range of motion and decreased pain. This stage may beas short as several months, but it is not uncommon for it to last for years.

Assessment and evaluation$dhesive capsulitis is commonly evaluated through client history and physical e'amination. The condition affects women

more often than men, and occurs more fre%uently in women age 9:!6:. $ detailed client history isimportant to establish any characteristic patterns that indicate either a primary or secondarycapsulitis. The most prominent symptoms are pain and loss of range of motion. ;ysfunctionalbiomechanics and motion compensations. This image shows a client attempting to abduct theshoulder, with its motion limited by the adhered capsule.

$n important approach to distinguishing adhesive capsulitis from similar shoulder problems is toevaluate the way in which motion is restricted at the shoulder joint. 8ost synovial joints of the bodyare enclosed in a joint capsule. When there is pathology, there is a characteristic pattern to the

range!of!motion limitation in that joint. The pattern of limitation is uni%ue to each joint. #n the glenohumeral joint, thecapsular pattern is for motion to be limited first in e'ternal rotation, then in abduction, and finally in medial rotation.

To understand how to apply the concept of the capsular pattern, let

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Traditional methods of treatment8ost treatment methods begin with a conservative approach aimed at increasing the range of motionin the glenohumeral joint. Therapeutic movements, such as /odmans pendulum e'ercises *seen tothe left+, are often used. #n this e'ercise, the patient-client will let the shoulder hang while slowlyswinging it like a pendulum. This action encourages a gradual increase in range of motion. /areshould be taken with rehabilitative e'ercise, as progress may be slow. #f the e'ercises are performedtoo vigorously further capsular tearing might occur, aggravating the problem.

@trength!training programs are also used with the idea of increasing stamina in the supporting muscles. #t is thought that

increased muscular endurance decreases the load on the capsule in certain shoulder movements. (owever, overlyaggressive strength training is likely to increase pain sensations and lead to further capsular restriction. #n addition tostrength training, anti!inflammatory medications may be used. These include oral medications as well as corticosteroidinjections in the shoulder, although the benefits of this approach are controversial. The injections have long!termdetrimental effects on the integrity of connective tissue. They have been proven to cause degeneration in connectivetissues if done too fre%uently. or conditions where it is even %uestionable that there is a true inflammatory problem, theyare often discouraged.

#f conservative treatment is not successful, a more aggressive approach is sometimes used. While the capsule may besurgically mobilized, a more common procedure is forced manipulation. The shoulder is anesthetized and the joint isforcibly moved through its range of motion, essentially tearing the capsular adhesion free. Though this procedure canproduce dramatic improvements in motion, it can be very painful when the anesthesia wears off. #f the patient does notcontinue ade%uate movement, even more capsular adhesion may occur as a result of the treatment.

Massage techniquesTechni%ues that encourage rela'ation of the muscles surrounding the shoulder girdle are a mainstay for massageapproaches. @imple techni%ues, such as effleurage and broad cross!fiber sweeping strokes, are useful. >ecause themuscles often become fibrous and shortened due to the limited range of motion in the shoulder, restoring their propermovement is an important aspect of addressing this problem.

When muscles are unable to move through their full range of motion, restoring proper movement canbe challenging. #n this case, active engagement techni%ues work well. The image to the left shows anactive engagement method for the pectoralis major, which often becomes restricted in adhesivecapsulitis. The client is instructed to hold an isometric contraction *horizontal adduction+ in thepectoralis major and then slowly let it go. $s the client releases the contraction, the practitionerperforms a longitudinal stripping techni%ue on the pectoralis major fibers.

8yofascial trigger points in muscles such as the subscapularis may also play arole in the perpetuation of capsular adhesion. These trigger points can betreated with static compression methods or compression with active movement*ight igure+. ;uring compression with active movement, the practitioner

maintains pressure on the trigger point while the client moves through as much of the range ofmotion as possible *internal and e'ternal shoulder rotation+.

$nother goal for the massage therapist is to encourage elongation of theadhered capsular tissues. This is accomplished with various stretching procedures. (owever, donot e'pect results to come %uickly. #n addition to ! or in conjunction with ! massage techni%ues,stretching methods should emphasize the motions of e'ternal rotation and abduction, and will getthe best results when performed slowly to stretch the adhered tissues. or e'ample, with a passive

stretch in lateral rotation, the client is taken just to the point where discomfort starts and then heldthere *see Left igure+. While in this position, the client is encouraged to breathe deeply and rela'the shoulder as much as possible. $fter holding the stretch for 74 seconds or more, the client is

slowly brought back to the neutral position. The procedure can be repeated several times.

Conclusion$dhesive capsulitis can be debilitating and cause long!term impairment. &roper treatment can mean the differencebetween a several!months!long disability or one of several years. Aven with therapeutic results, this condition may re%uirea long rehabilitation. $s a result, the client may get depressed about the lack of improvement in his-her condition. &ositivestatements regarding even small amounts of improvement will go a long way toward encouraging active participation inthe rehabilitation process. This is also where your knowledge of the condition will be highly valuable, as your clientsattempt to learn more about their own bodies and what they can do to return to optimum health.

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