Frozen Shoulder

A not-fun thing. Esp the 2nd time.

Adhesive capsulitis of shoulder - Wikipedia

Adhesive capsulitis (also known as frozen shoulder) is a painful and disabling disorder of unclear cause in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain.

The normal course of a frozen shoulder has been described as having three stages:[3]

• Stage one: The "freezing" or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.[4]
• Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to nine months.
• Stage three: The "thawing" or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months.[5]

2004 study showed that "supervised neglect" has a higher rate of recovery versus physical therapy and passive stretching

"Supervised neglect" meant home exercises (pendulum exercises and active exercises within the painless range) and resumption of all activities that were tolerated. "Intense physical therapy" meant passive stretching and manual mobilization together with exercises beyond the pain threshold.

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How to Prevent Frozen Shoulder (Adhesive Capsulitis)

three major causes

Lack of Use of Your Shoulder Complex

For example, hunching over in front of the computer for several hours a day can create an alteration in the alignment of your shoulder blade and upper arm bone

Autoimmune Response

Emotional stress, a diet that includes plenty of highly processed foods, a weak digestive system, and a genetic predisposition for autoimmune activity can cause your body to eventually damage your own tissues

Stretch Your Shoulders

To stretch the entire shoulder region, take a towel in your right hand and hold it behind your head

Hold this stretch for about 30 seconds

Poor Biomechanics of the Shoulder Complex

Strengthen the Tendons Around Your Shoulders

Hanging on a bar for even 5-10 seconds a day can dramatically improve the strength of the tendons that surround your shoulders.

Stretch Your Spine

The best such stretch that I know of is to take a pillow and put it length-wise on the ground or on your bed, lie back on the pillow so that your bum hangs off the bottom of the pillow, your head hangs off the top and your arms are allowed to fall off the sides of the pillow to rest on the ground. If you don't feel that your mid and upper back are being stretched forward while you're in this position, add another pillow to increase the height of your arch. Rest in this position for as long as is comfortable, up to 15 minutes each evening.

Include Vitamin D and Friendly Bacteria in Your Diet

Eat Mainly Minimally Processed Foods and Adopt Healthy Eating Habits

In the event that you do have a genetic predisposition to developing autoimmune activity in your body

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Frozen Shoulder Guide (2018)

Frozen shoulder is a biological puzzle, and a common one. It’s hard to define precisely, diagnose accurately, or treat effectively

Sometimes shoulders just seize up, painfully and mysteriously

Nature of the beast: frozen shoulder is a biological failure, not a biomechanical one

fibrosis and/or contracture of the tendons and joint capsule surrounding the glenohumeral joint

Primary frozen shoulder is “out of the blue” frozen shoulder, occuring without any obvious connection to any other condition.

It is probably related to broader health problems. It mostly hits people over the age of forty, much more so if you have diabetes and/or cardiovascular disease.7 Those problems are commonly associated with obesity, and what they have in common is “metabolic syndrome” [NIH] — trouble with managing fats and sugars in the blood, and chronic low-grade inflammation everywhere.

Why such a dramatic point of failure? Why that tissue in particular? No one knows. But the relationship between frozen shoulder and metabolic syndrome is clear,

inflammatory over-reaction

How common is frozen shoulder?

probably 0.75% of the population

more than 12% of diabetics will get frozen shoulder, and about 30% of people with a frozen shoulder also have diabetes

Or it could be an infection

some cases of frozen shoulder.

Apparently sticking a probe into a shoulder, despite precautions, can sometimes result in an alien invastion of the joint. “P. acnes was the most prevalent organism

Shoulder neglect? An evolutionary perspective on frozen shoulder

An interesting theory is that frozen shoulder occurs because “the human shoulder evolved for high speed projectile throwing,”18 and it suffers from neglect in modern living.

Stiff but not frozen: the case for functional freezing

“Adhesive” capsulitis refers to a literal stuckness, and there’s no question that many or most frozen shoulders are literally stuck in a limited range. But could some frozen shoulders be less literally stuck?

What if, say, 60% of cases were 30% explained not by sticky joint capsule, but by an extreme reluctance to move (neurological inhibition)?

I’ve used a lot of questions to introduce this topic because — surprise surprise — no one actually knows for sure

Well that’s interesting: “stuck” shoulders not so stuck when unconscious

Five capsular release surgery patients were checked before and after being put under general anaesthesia

It’s really a shame it was such a small study.

All five of them had “significantly more passive shoulder abduction” when they were knocked out

How would functional freezing work?

three main ways that a functional limitation of shoulder ROM would probably work

The brain can “shut down” a joint with neurological inhibition. The brain might do that to the joint because it has become sensitized. The muscles may have gotten rotten with “knots” (trigger points)

Your brain is protecting you from yourself (or so it hopes).

Trigger points are a tough topic, because no one really knows exactly what they are

Shrunk, not stuck: a 150-year history of misleading names

The term “frozen shoulder” was coined by a Boston surgeon, Ernest Amory Codman, in 1934

The term “adhesive capsulitis” arrived in 1945

“Adhesive” may be the wrong word: shrunk, not stuck

Contracture [Wikipedia] is the shortening or hardening of tissue. In more familiar words, they’re saying the joint has been “shrink wrapped” by a joint capsule that has tightened, rather than surrounded by loose layers of joint capsule that have gotten stuck together.

there’s not much information about this adhesion versus contracture business

Diagnosis

it can only be diagnosed by eliminating all other possibilities

there is often confusion with other conditions

The dead giveaway symptom: a specific painful spot, on the coracoid process

It occurs in more than 95% of cases, but only in 10-15% of other kinds of shoulder pain. It’s sensitivity on a specific spot on the front of the shoulder, on the tip of a bone called the coracoid process.39 This odd little bone points forward like a finger, just below the end of the collar bone. If you feel around in the tissue there, it’s hard to miss — and if it hurts quite a bit (more than 3 on a scale of 10, say), that’s the sign you’re looking for.

Other shoulder problems that could be confused with adhesive capsulitis

But the rotator cuff can hurt, and when it does, it mostly limit active movement, whereas frozen shoulders are frozen even when you are relaxed and someone else tries to moves your shoulder for you (passive movement).

Prognosis

it ain’t self-limiting

My (wife’s) frozen shoulder story... aftermath of a very serious car accident... But there’s a peculiar wrinkle in her story: she actually already had a full-blown case of frozen shoulder when the accident happened. It cleared up completely for several months during the initial stages of rehab. And then it returned! It’s like the accident hit the “pause” button. What can we make of this? It’s hard to interpret for sure, but I think one possibility is that it means that the first phase of her frozen shoulder was functional

Treatment

It can’t be “cured,” but it probably can be managed and minimized

A huge 2009 survey of almost 2,400 physical therapy patients found that no one got better, at least by one way of reckoning.43 In a 2004 test with 77 patients, “supervised neglect” actually worked (slightly) better than “intensive physical therapy”!

there really is no known effective treatment for frozen shoulder [NHS] — nothing that actually prevents the capsule from adhering, nothing that can free it up without doing more harm than good, nothing that clearly, reliably makes the ordeal shorter or easier for most patients

However, range of motion can probably be preserved to some degree by early use-it-or-lose-it interventions.

Out of 32 trials, not one “compared a combination of manual therapy and exercise versus placebo or no intervention

Use it or lose it: movement therapy to try to maintain function and slow down the capsule’s adhering/contracturing, or speed up recovery

If you believe you are in the early stages of frozen shoulder, immediately begin a campaign of mobilizations: gently, thoroughly use as much of your range of motion as you can without excessive discomfort.51 And if you are somewhere the middle of the condition? Same thing, but with the goal of trying to prevent further range loss or regain it quicker.

Here’s a nice collection of miscellaneous exercises for the shoulder, with good illustrations: “7 stretching & strengthening exercises for a frozen shoulder.” [Harvard Health]

safe baby steps into the outer limits of your comfortable range

What if you can’t move it? Then imagine moving it. Seriously! Literally just visualize movement

Strengthening for frozen shoulder

My recommendation: Avoid strength training during the painful freezing stage — the risk of making a bad situation worse is just too great

As long as you are cautiously wearing out your muscles a little bit, 2 or 3 times per week, you’re providing a stimulus that might be therapeutic.

*But here’s a more specific approach to consider anyway …

Strengthening with the Meakins method: eccentric loading + “let it go”*

use it specifically with eccentric contractions: that is, contracting muscles while they lengthen.

An eccentric or braking contraction is an interesting but routine type of muscular contraction

To the extent that the freezing is functional, then it does make a lot of sense to work with the shoulder muscles.

So what exactly do you do? You slowly lower a small weight into a manageable stretch into your most limited movements. You make it as easy as possible at first, and you up the ante every few days. You tolerate a little discomfort, but not too much

See his article for full details with pictures: Frozen shoulder? Let it go, Let it go …

Stretching for frozen shoulder

Stretching is generally over-rated as a therapeutic tool: it doesn’t do most of what people usually assume it does (e.g. “prevent injury”), and flexibility is less important than people think

But it does increase flexibility, for whatever that’s worth … and frozen shoulder is a condition of decreased flexibility. So it seems like it could be a natural fit for this condition.

However, it’s super unlikely that pulling on the adhered/contractured capsule is going to change it.

What if it’s stiff, not frozen? What if the problem is “more of a functional limitation than a physical one,” a possibility discussed extensively above? In that case, I think there’s quite a bit more hope that stretching could be useful.

it actually has been studied … but very little

My recommendation: As with strengthening, I recommending taking it so easy with stretch during the painful freezing stage that you might as well not bother, just don’t risk the aggravation, stick to doing exercises within your pain-free range of motion. But after that? I think it’s worth trying. Just find the end of your range of motion and push up against it. Push lightly and less frequently at first, and if it causes no trouble, start ratcheting up the frequency and intensity.

Over-the-counter pain killers for frozen shoulder

Many people can probably get some additional relief from short-term, cautious use of NSAIDs, the non-steroidal anti-inflammatory drugs,56 which are:

My advice is to strictly reserve these for occasional “emergency” use, for taking the edge off when it’s most desperately needed.

Corticosteroid injections for frozen shoulder

the benefits don’t last, and the freezing of the joint proceeds relentlessly.

Several weeks, maybe four months at the outside. A 2007 review concluded that “up to three injections were beneficial, with limited evidence that four to six injections were beneficial.”

main use of corticosteroid injections for frozen shoulder should probably be to facilitate ROM-maintaining exercise through pain relief

Treating frozen shoulder with … diet? Yeah, it’s a long shot, but it’s an interesting long shot

An anti-inflammatory diet — also known as a healthy diet, with a few specific features — could conceivably reduce the severity and duration of frozen shoulder

As explained above, frozen shoulder is strongly associated with metabolic syndrome, which in turn is strongly associated with poor fitness, obesity, aging, a typical modern junky diet, genetics (of course), and maybe chronic stress, anxiety, and fatigue as well.

There is no evidence at all — zip, zero, zilch — that eating this way will specifically help a condition like frozen shoulder.

Treating frozen shoulder with a ketogenic diet (a longshot that might be worthwhile

This is a completely experimental treatment. However, like a standard anti-inflammatory diet (AKA “healthy”), it has a non-crazy rationale, and it’s safe and inexpensive to dabble in.

I have a separate article devoted to this topic which suggests some other possible strategies for reducing systemic inflammation. To the extent that any of them work at all (quite unknown), they would likely support recovery from frozen shoulder, especially (or perhaps exclusively) in the first and most inflammatory phase

Massage therapy for frozen shoulders: symptom relief at least, possibly more

in 2009 Jewell et al found that use of massage in the context of physical therapy “reduced the likelihood of a favorable outcome”!

not remotely the same thing as a well controlled trial of the efficacy of professional therapeutic massage … which has literally never been done!

functionally than literally frozen, and this is more likely in chronic cases. If true, then massage may could theoretically treat the root of the problem. If it works, here’s how it might work …

Reducing neurological inhibition with massage

The massage treatment itself should be low key as well: this is all about convincing the nervous system that there’s no danger.

However, note that there are also other, less expensive ways to “reassure” nervous systems about shoulders.

Treating trigger points with massage

basically … just rub the sore spots.

Although massaging nearly any muscle tissue in the area may be useful, there is one that’s worth some special consideration: Perfect Spot No. 14, The Most Predictable Unsuspected Cause of Shoulder Pain.

Ultrasound for frozen shoulder

Scientists seem to have almost nothing good to say about ultrasound.

Super ultrasound: shockwaves

no particular reason to think it would work

Desensitization and disinhibition

As discussed above, a functional freezing of the shoulder may be driven by neurological sensitization and subsequent inhibition

building up confidence that you can, in fact, still use your shoulder.

The basic template for all rehab is to “calm shit down” and then “build shit up,”73 also known as avoidance and exposure therapy.

Forcing the issue manually: joint capsule release with manipulation

Please do not allow a health care professional to attempt to forcefully increase your range of motion!

Doing the same thing under anaesthesia, although hardly safe, is much more promising …

Forcing the issue with manipulation under anesthesia (MUA)

Unfortunately, this is only an option for desperate patients, because there are substantial risks to this procedure.

Does it work? If only we knew! This is a pseudo-surgery, and like many surgeries,76 it is understudied and based more on seeming to make sense than any hard evidence

Forcing the issue with MUA lite, the Oolo-Austin Trigenics® Procedure (OAT)

The conventional treatment most similar to OAT is manipulation under aneasthesia (MUA, discussed above), but OAT is done with local anaesthetic instead of anaesthesia, which has alleged advantages

the shoulder is “now frequently anesthetized” during OAT, “patients do still experience some pain briefly.” Apparently so, because OAT also may involve injection of corticosteroids to “prevent post-procedural inflammation,” and “risks such as fractures or dislocations could exist.”

No independent studies of OAT have been conducted to verify these claims.

Forcing the issue surgically with arthroscopic capsular release and inflation

Although we don’t have good data on whether manipulation or cutting actually work, we do know that each one is roughly as good as the other.82 All other things being equal, I’d prefer not to get wrenched around.

Joint capsule inflation: arthrographic distension, hydrodilatation injections

It has barely been tested

As with arthroscopic release, I’d certainly try this before manipulation under anaesthesia, for the safety. But I certainly wouldn’t bet on the outcome. Remember that there’s no way this treatment method can work (in principle) if the joint is actually contractured rather than adhered

Appendices

Case study: an interesting example of a subtle biological X-factor

Related Reading

Notes

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