The term “Frozen Shoulder” refers to a painful symptom of the shoulder that can severely limit its range of motion and so giving the impression that the shoulder is “frozen”. The condition affects women more than men, and occurs most frequently in women aged from 45-65. Health-care practitioners prefer to use the term “adhesive capsulitis” as while the term “frozen shoulder” is common, it isn’t entirely accurate.
There are several problems in the shoulder that may be painful and limit the range of motion in ways similar to adhesive capsulitis. An important method of distinguishing adhesive capsulitis from other shoulder problems is to evaluate the way in which motion is restricted at the shoulder joint.
In the glenohumeral joint, the capsular pattern for motion to be limited is first in external rotation, then in abduction and finally in medial rotation. Thus if a client has difficulty bringing the arm up in abduction but has no problems externally rotation the shoulder then it is unlikely that the client has adhesive capsulitis.
The glenohumeral joint has the greatest range of motion of any joint in the body. When the shoulder is in a neutral position (with the arm by the side), there is some slackening of the glenohumeral joint capsule on the underside which is necessary to allow full range of motion of the joint. When the arm/shoulder is moved to other positions, the underside of the capsule becomes taut.
Adhesive capsulitis develops when a portion of the joint capsule adheres to itself and prevents full movement of the joint. As the capsule is highly innervated, it is extremely painful when the adhesions pull on the tissues of the capsule.
Adhesive capsulitis is generally categorized into primary and secondary. In primary adhesive capsulitis there is no obvious cause for the condition – clearly frustrating for practitioners. There may be some correlation between a significant emotional trauma and the development of primary adhesive capsulitis.
Secondary adhesive capsulitis will often develop as the result of rotator-cuff tears, arthritis, shoulder trauma, surgery, bicipital tendinosis, etc. With these injuries, there appears to be a process of fibrosis that is initiated by these other conditions. As such, the individual is usually limiting motion in the shoulder at the same time the fibrosis is occurring and the fold on the underside of the joint capsule is never fully elongated. Thus begins a vicious cycle as the adhesion causes limitation to shoulder movement and pain, thus worsening the problem.
Subscapularis trigger points have also been suspected of causing secondary adhesive capsulitis. This may result from irritation of the attachment site of the subscapularis which is close to the capsule. Local inflammation at the attachment may then cause fibrous adhesion in the capsule.
Frozen shoulder is often divided into three stages:
Freezing. Onset is usually between 2 to 6 months and this period is characterized by a gradual decrease in range of motion and an increase in pain.
Frozen.This stage occurs for between 4 and 12 months after initial onset. Motion will remain extremely limited although there may be a gradual decrease in pain levels.
Thawing.In the thawing period, there is a gradual return of range of motion and decreased pain. This stage can vary from a few months to several years.
Treatment and Massage of Frozen Shoulder
Treatment should always be directed by a trained health-care practitioner who is suitably qualified to diagnose adhesive capsulitis. Most treatments begin with a relatively conservative approach aimed at increasing the range of motion of the glenohumeral joint. Simple movements such as letting the shoulder hang like a pendulum may encourage a gradual increase in range of motion. With adhesive capsulitis, if exercise is too vigorous then further damage and inflammation of the joint capsule may occur.
Massage techniques used to treat frozen shoulder should encourage relaxation of the muscles surrounding the shoulder. Simple effleurage and broad cross-fibre sweeping strokes are often used to assist in restoring proper movement to the joint. As discussed above myofascial trigger points in muscles such as subscapularis may also play a role in adhesive capsulitis. These may be treated with static compression or compression with active movement.
If conservative treatment is not successful, a more aggressive stance may be taken of forced manipulation of the shoulder joint whilst the shoulder is anesthetized. Whilst this can produce dramatic improvements in the range of motion, it is extremely painful.