The name itself is anything but welcoming. It is often dreaded by health care professionals, feared by patients, and in some cases too quickly diagnosed by doctors.
No matter how you view it, frozen shoulder is no small thing to manage and recover from.
Part of the difficulty in treating and diagnosing frozen shoulder (or, in more specific terms, adhesive capsulitis) is the lack of agreement by PTs, chiropractors and LMTs alike on how exactly to treat it, how to assess for it, or even what to fully expect when educating the patient on their prognosis. Timelines for recovery can range from six to 24 months for complete resolution of symptoms and full return to prior level of function. Oftentimes, despite how much work put into treating it, some suggest that recovery is spontaneous and the most we can do is help with quality of life and symptom management for patients struggling from this dysfunction.
Etiologies of the syndrome
There have been correlations—although no specific causations—linking the female sex, smokers, and even those with diabetes as having a potentially higher risk of developing frozen shoulder. However, when you consider that females constitute 50 percent of the population, the number of people who smoke and use tobacco-based products, and the increasing rate of diabetes in the young, it’s fair to ask whether these are reliable markers on which to base assumptions.
While assessing frozen shoulder, it is typical to see a gradual worsening of range of motion (usually in a capsular pattern and often without a specific mechanism of injury), increasing difficulty of glenohumeral and scapulothoracic dissociation, tenderness to palpation and tissue irritability with repeated movements. These worsening deficits significantly impact patients’ lives, often leading to drug-seeking behavior, cortisone injections, and potentially more invasive procedures such as surgery for capsular release.
While cortisone injections at the proper phase of the rehab process may be beneficial for reducing pain and increasing tolerance to therapeutic activities, more invasive techniques such as capsular releases tend not to result in significant improvement in range of motion or function. But why?
A new view
When initially considering adhesive capsulitis, it is natural to think it is the capsular tissue that needs the most intervention to aid in recovery. But that’s rushing to judgment. Thanks to the work of fascial anatomists, we now have a different view when it comes to looking at connective tissue.
The new realization is that muscles, tendons, capsules, etc., essentially run in series rather than running parallel to one another. In other words, the rotator cuff is the capsule is the tendon. Furthermore, as you become more educated in the structure of fascia, you see that fascia can contract (and stay contracted) independently of muscle activation.
Fascial contractility is a chemically mediated response that often shortens the myofibrillar network in connective tissue. This is likely due to the TGF Beta 1 enzyme initiating a cascade of fascial tonicity, which often accompanies decreased range of motion and pain. Moreover, the release of this enzyme is linked to the autonomic nervous system response in the body—the fight-or-flight programming.
When the brain and central nervous system perceive a threat to the body, the immediate reaction is a torrent of events aimed at survival and protection, and these are governed by the sympathetic portion of the system. Research correlates that slow, deep stimulus (such as massage that stimulates ruffini nerve endings) and reframing the environment can have an opposite effect on the body, thereby stimulating the parasympathetic nervous system, lowering TGF Beta 1 in the body, and promoting a more relaxed state.
This has implications for both practitioner and patient alike. Patients should be educated as to what pain is, and how and when to acknowledge the pain as “signal” or push through it as “noise.” Rehab may not be comfortable, but it doesn’t have to be further debilitating.
Patients need not be seen multiple times per week, particularly if using insurance, as there is no evidence that increased rehab visits result in faster outcomes. And for those who do respond to quicker treatments and interventions, think about questioning the initial diagnosis.
When dealing with the frozen shoulder patient, your long-term plan should include:
- Education on prognosis, pain science and creating a supportive environment including work and lifestyle modifications while dealing with the recovery process and finding ways patients can stay active.
- Focus. You cannot gain all range of motion back in one visit. So stay committed to increasing one range at a time. The shoulder is a ball-and-socket joint; therefore improving functional internal and external rotation should be the emphasis of treatments and home exercise programs. Oftentimes addressing rotational deficiencies will improve linear function of tissues.
- Set goals and hold patients accountable. Take measurements at every visit. Inform patients when they do well and let them know when they need to work harder or become more consistent with what you are asking.
- Keep strengthening. Even if it is with isometrics, maintaining strength is vitally important and will aid in the long-term recovery process when range of motion gradually returns.
A team approach to treating frozen shoulder, as with all other diagnoses, is vital. Depending on the age of the client, additional life stressors, and the goals of rehab, having a sports therapist, massage therapist, chiropractor or PT, and a strength coach can further assist in the recovery process.
Joe Lavaca, PT, DPT, OCS, is an experienced outpatient orthopedic clinician. He has obtained certification in movement screens for the FMS and SFMA, functional strength coaching, as well as fascial movement taping and performance movement techniques through RockTape. He stays current in the most up-to-date evidence-based research, which allows him to give individualized care to each of his patients. He can be contacted through rocktape.com.