17 Feb Frozen Shoulder (Adhesive Capsulitis)
Frozen shoulder is not an injury, but a disease process that effects only the people that carry a specific gene.
It does, however, need some kind of injury, to the shoulder or chest or upper extremity, whereby afterwards the patient stops moving the arm overhead. This injury can be everything from a fall on the shoulder or pain from a gym exercise to a very common culprit, a breast lumpectomy surgery. After the injury or surgery the patient is ‘afraid’ or the shoulder is painful to move so the patient does not move it. In time the shoulder joint capsule literally tightens up as the collagen fibers become taut and inflamed, rendering the shoulder painful on movement, or sometimes even sitting still. The less often the patient moves, the quicker the disease progresses. Think of it as a kind of ‘use it or lose it’ mentality to the 100th degree.
The joint motion is characterized by what we call a ‘capsular pattern’, which is not a normal pattern for most injured shoulders. This is what tips us off to the presence of adhesive capsulitis and not just tendonitis. The pattern effects range of motion rotating (putting a shirt on over your head), lifting to the side, followed by rotating inward (think putting on a bra or reaching your wallet in your back pocket). In addition, the amount of guarding and thickening of especially the palpable anterior joint capsule is strikingly different than the aforementioned. It generally effects more women than men and more towards middle age.
Although it is a faulty gene to blame, it is treatable, however it is important to choose someone who fully understands how the disease progression works.
It is crucial that two things are understood. One, that the provider recognizes there is in fact adhesive capsulitis present. If the shoulder is treated for any other issue the treatment will be less effective. And two, that in the acute stage no painful movements be made, in therapy or at home.
Most therapists and doctors think the acute stage is the first few weeks or month. This is not so. The acute stage lasts as long as there is still guarding (the patient is anxious to move and muscle spasms are present) and poor motion and pain present. The guarding I find to be the easiest predictor of the acute stage.
Therefore, ALL movements and home stretches must be non painful. ‘No pain no gain’ is not the mentality here. It is the opposite. I instruct the patient in this phase to try to rid any painful movement, even putting shirts on overhead. Button down shirts are extremely helpful as well as bras that close in the front instead of the back. The goal here is to restore some movement by breaking the spasm cycle and picking motions that do not hurt… yet doing it them extremely often. The idea of ‘motion is lotion’ applies here. The more you move in non-painful ways, the more joint lubrication the shoulder gets and the more it can relax. No matter how small the motion, continuity is key. Anytime the joint sits idle it will tighten up. This is the reason why mornings are usually painful.
Massage and joint mobilizations in a rhythmical pattern as well as muscle relaxants are very helpful in breaking the guarding and pain cycle to get the shoulder moving. The key is often to trick the muscles into calming down. Anti-inflammatories may also be helpful as well as ice for the pain. Often times heat is also helpful, as is stretching in the shower, to give the capsule some flexibility.
As soon as the acute stage is over, the focus is on rapid range of motion gains. Many patients worry about strengthening and many doctors ask us to strengthen, but this is not a vital part of the recovery. Range of motion is the only key to recovery. Until there is significant motion gains and little pain, strength gains will get us nowhere. Soon, as the shoulder calms considerably, the ‘no pain no gain’ mentality can be utilized to push range of motion gains late on and recover full movement. By this point, the patient will only have pain during the stretches and with therapy but will have no residual pain after the movement is over and on resting. This is drastically different than the acute phase.
Often treatment can take 6-12 weeks, making it one of the slowest and most painful problems we treat.
For patients who do not improve, doctors may manually manipulate the joint under anesthesia to help force it to move. However, this practice often backfires as the patient may start the acute stage all over again from the trauma of surgery, and quite honestly a good therapist should be able to help you avoid it if you do your homework. I will tell you we have never had to send a patient out for a surgery. It should not be necessary if you treat it right. It does, however, require a good bit of homework, keeping the joint moving and stretching often at home. Consistency is key.
Adhesive capsulitis is fixable. As far as prevention, we can’t prevent having the gene, but we can make sure if any joint, including the shoulder, is not moving properly and pain free that we see a doctor or therapist to evaluate. Any joint that does not move fully will eventually be painful.