Frozen Shoulder

what is frozen shoulder?

Frozen shoulder is a pathology that is still not fully understood. It is an inflammatory condition that affects the capsular tissue of the shoulder, which causes significant neovascularisation, collagen proliferation, fibrosis, and eventual contracture of the capsular, reducing the volume of the shoulder joint significantly.

All frozen shoulders loose significant amounts of movement, this is usually in many directions, and can be in differing amounts, but the fibrosis and contractures classically affect the anterior superior capsule and rotator interval of the shoulder. This limits the big three of reaching over head, reaching out to the side, and reaching behind the back.

Diagnosis of a frozen shoulder, like most things, is usually done mainly with the subjective history. Patients age, medical history, onset, nature, ages and eases all give clues of a frozen shoulder. Clinical examination to confirm a frozen shoulder is relativity simple, it involves looking for 3-4 movements that have EQUAL loss of both active and passive range of movement with significant pain at end of range, as well as doing resisted shoulder tests that usually produce no significant pain or weakness. This exam usually confirms a frozen shoulder. However many clinicians will also ask for an x-ray to check it is normal before they fully confirm a diagnosis of a frozen shoulder.

The x-ray is first used to help exclude shoulder joint arthritis, however a frozen shoulder and an arthritic shoulder usually have a completely different onset and history. The x-ray has also been suggested to check for sinister pathology that can masquerade as a frozen shoulder .

However this practice has been questioned recently due to the very low incidence of sinister pathology presenting as shoulder pain.

Treatment:

Treatment of a frozen shoulder is extremely varied from clinic to clinic, and from practioners to another. There are many options and interventions available with little consensus or evidence on what is best. The options for frozen shoulders range from leave it alone to spontaneously resolve.

Other more invasive treatments for frozen shoulder include intra-articular corticosteroid injections, or the increasingly popular, although highly dubious, high volume hydro-dilatation injections. Then of course there are surgical options such as manipulation under anaesthetic, which unfortunately are still being done despite the high risks of damage such as labral lesions, cuff tears, brachial plexus injury, and even fractures. The gold standard surgical procedure for frozen shoulders now is arthroscopic release of contractures.

Physiotherapy is of course also a common treatment for frozen shoulders. This can include massage, joint mobilisations, manipulations, passive stretching, acupuncture, electrotherapy, and exercise.

some of all these treatment options have more evidence of effectiveness than others.

A recent Cochrane review for frozen shoulder found that ALL manual therapy and exercise therapy was ineffective in the management of frozen shoulder.

Manual therapy and traditional physiotherapy methods for frozen shoulder do very, very little. Pulling and pressing patients with painful frozen shoulders, here, there, and everywhere, all with little effect, and all too no avail. these are generally a waste of time, energy, and resources, and more importantly they only tend to cause patients unnecessary pain and distress for very little benefit.

However, there is a ‘different’ method for treating frozen shoulders that have been using more and more over the years, which not only more effective, and far more tolerable for patients than ‘traditional’ physiotherapy, but more importantly it can be done independently, simply and easily by the patient with out a physio inflicting torture on them.

Method of treatment:

So what is this method of treating frozen shoulders? Well its using eccentric loading.

Eccentric exercise has been shown to have many benefits in the management of many musculoskeletal conditions, however they are not routinely used in the management of frozen shoulders.

One of the known benefits of eccentric exercise is improvements in joint flexibility via the processes of sarcomerogenesis. This is the physical addition of individual sarcomeres to musculotendinous junctions. This has been shown to produce a physical increase in the length of connective tissue, and so improves range of movement.

Sarcomerogenesis has been shown to occur in the lower limb very quickly, very simply, and very easily. In fact eccentric loading has been shown to produce significant improvements in range of movement in far less time, and with far less energy than traditional stretching, and of course you also get stronger.

patients find them not only more effective but simpler, easier and less painful to do than traditional stretching, and more importantly they seem to be more effective than ANY other kind of manual therapy.

There are a number of ways eccentric exercises can be done for frozen shoulders. one way to do them is to get the patient lying on their back. Then to hold a weight in their hand as they lower the weight slowly into external rotation towards a target that has been set just within their available tolerable range (a stack of books work well here).

They then return the arm to the start position, maybe using their other hand to assist on the concentric phase if needs be. They do a few reps and when the shoulder starts to feel ‘looser’ the target is adjusted and lowered by removing a few books to allow a little more movement to occur, a few more reps are completed, then the target re-adjusted again and so they continue as tolerated.

ask patients to do the reps slowly, the slower the better, and with a weight that is challenging to control down, but not too heavy as to feel ‘out of control’ or too painful. Don't give a fixed number of sets or reps, rather ask them to do as many as they can, and to try to do 3 sets in a row with a few minutes rest in between, but this is adjustable depending on the individuals pain and tolerance.

There is very little research on eccentric loading and sarcomerogenesis in the upper limb. One paper did show some changes in the myofibril length when eccentric training was compared against concentric, but it was a small study on healthy individuals and not that conclusive.

However, anecdotally when you use eccentric exercises like these on frozen shoulders you will see some really good results and marked improvements in range of movement and pain, very quickly, usually within one or two sets, some times even within a few repetitions.

what is happening is a couple of things.

First is the well known hypo-analgesic effect of exercise allowing the patient to become more tolerant to the exercise. also other psychological effects are at play when doing a resistance exercise with a painful body part. To begin with it can be a bit daunting and scary, but when done a few times and the patient realises and is reassured that they don’t cause more pain, and in fact they reduce it, this allows the protective, reflexive muscle guarding and increased tension of the shoulder muscles to… ‘let go’

Pain is a protective response. Pain causes muscles to guard. Frozen shoulders have a lot of pain. Frozen shoulders have a lot of muscles guarding. Eccentric exercises helps these guarding muscles to ‘let go’.

So The next time you have a patient with a frozen shoulder try using some eccentric loading exercises, and see for yourself how simple, easy and effective they can be. Of course you can supplement these with other modalities if you want.

Also try explaining to your patient’s with frozen shoulders to let it go