Frozen Shoulder

[21st century Physio]

Hi All,

Im a University Student. Just have a few questions about effective treatment for adhesive capsulitis.

I'm basically just looking for some Physio's who have experience treating this condition to write what treatment techniques worked best for them. Most of the reading I have done suggests that a corticosteroid injection combined with vigorous shoulder joint mobilisation is most effective?

Also what exactly is hydrodilation and when would you advise this form of treatment to a patient with frozen shoulder?

Cheers,

Simon

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[Physiobase]

In hydrodilation, the glenohumeral capsule is filled with an infusion to "stretch" the capsule, in a hope of freeing the shoulder. Frozen shoulder is poorly disgnosed (over diagnosed) and is therefore poorly discussed. As is the cause!

Arthroscopic investigation shows a very red, angry and irritated synovium. Surgery and clean up is successful in returning movement soon rather than later. Other recommend doing nothing and it will self heal in 1-2 yrs, the later often being close to the truth.

I would look for a cause (perhaps a ruptured rotator cuff tendon or even a bankart lesion perhaps from sleeping on an unstable shoulder). Then address the issues and perhaps clean up the joint if you want a quick result.

Conservative management with connective tissue release, particularly to subscapularis, inhibition of upper traps with taping, rotator cuff balancing exercises etc all assist in the rehab - but if it isn't happening steadily I would look to arthroscopy from a good shoulder guy.

[21st century Physio]

Thanks PB

[arkesh_physio]

hi,
i believe maitlands mobs are quite effective in AC.
inf & PA glides are useful.
no time now,gt back later.
could u give details of the patient?

[sanagupta]

Hi!
want to ask if we use Mailtalnd's mobilisation..along with active and strengthening programme how long does it take frozen shoulder to resolve...what about the pain....
Regards
sana

[MrPhysio+]

As always, the diagnosis must be correct before attempting treatment. If the patient has had the problem upwards of 3 months, has lost shoulder internal rotation (hand behind back), has reduced flexion eg less than 90 degrees, and has night pain being unable to lay on the shoulder, glenohumeral hydrodilation is the gold standard procedure. Aggressive physiotherapy will worsen the problem. Asking a worker to wait 12 to 24 months for eventual rsolution of symptoms is cruel and uneconomic, and is likely to result in pain behaviours and very poor return to work / activity outcomes.
Radiologists seem to have taken over the procedure, using guided imaging for the capsule. The most effective method that I have encountered depends upon a Doctor with good surface anatomy skills to perform an in rooms procedure, about 20 minutes, unguided by imaging. (Based upon the original American Orthopaedic article). A local anaesthetic injection is used, then a mixture of saline, anaesthetic, and a small amount of cortisone (celestone), which is injected into the capsule via syringe. The Doctor can feel the capsular resistance, then giveway at points. The maximum volume is 40 millilitres. Repeat procedure is not performed, if necessary, for at least 8 weeks.
Post procedure, as soon as possible, the shoulder is taken through range of movement exercises, with the patient doing the same at home.

Normal cortisone injections into the shoulder should be avoided, as after the second injection it has been reported that tissue tendon rupture can increase to 50%.

Capsular dilatation does not work if there is a capsular tear. If the fluid leaks out, there is no backpressure against the syringe, then the capsule could be torn, or the technique of injection is poor. Normal strengthening exercises can be prescribed post procedure, weith a graduated increment of 10 to 15 %, no more.
Hope this helps
MrPhysio

[Muneerad]

First of all, a comlpete assessment of the shoulder girdle is of utmost importance. In case of severe restriction in range, along with mobilization, you should concentrate on correcting the shoulder protraction and Tx kyphosis -- by starting the pt on scapula strenghtening exs. Care should be taken to avoid muscle soreness---that can lead to an increase in pain.
Manual Therapy --maitland's/mulligan's is helpful -- Mulligan's is more helpful in the acute/subacute stage.
In later stages, for strengthening the muscles around the shoulder, theraband is better than cuff weights, as here the pt can monitor the resistance.

[Moonraker 5]

Hi,

well i feel that current research does not support the use of physiotherapy for the frozen shoulder, that is Maitlands mobilisation or manual therapy. But please ensure it is a frozen shoulder and all other possible reasons for reduced ROM have been exhaused, however the "gold standard" for diagnosing a frozen shoulder is via arthroscopic evaluation of the capsule.

exercise prescription is important as an atempt to reduce further adhesions and complications whilst giving the patient some self control of the symptoms. Again research is foggy due to various types of exercise and lack of monitoring complience. There is little evidence to support mobilisation, of the few studies, one was impingement and the other was end-stage at about 12 months. In theory it should work based on Maitlands claims but as yet no research to my knowledge that has proved this theory in the shoulder capsule.

The real treatment for frozen shoulder is an MUA, when time and physio have been exhausted, and it is here that physiotherapy plays its biggest role, that is post surgery.

Hydrodilation or capsular distention is as discribed above, and i know it has been used as a diagnostic tool where fluid capacity has found to be reduced from a "normal", however ethics wont allow injections into the good shoulder for comparison!

The best treatment for frozen shoulder is patient education, pain management and a home exercise programme for at least 6/12. If symptoms are same or worse then refer for an MUA, by the time they see the consultant, and theatre waiting times, they will have probably got better :\

[docamrita]

hi,
as already stated by our friends,it is importatnt to throughly asess the subject by exposing the shoulder and the scapular region as well,as most of the cases of frozen shoulder go misdiagnosed.pain relief will occur as soon as the GH capsule is stretched ,so cryotherapy will cover the pain prior to stretching.Start gradual strethcing of the capsule in flexion,abbduction and in lateral rotation(90-90 stretches),start strengthening the deltoids,ssp,isp in the available ranges.(therabands preferred to free weights) and examine for scapular stabilisation,strengthen muscles around scapula as the entire GH rhytm is altered following GH range restrictions.Pain relieving modalities better if used SOS.

[GAJENDRA]

I have been suffering from frozen shoulder for last 1 year. In the past 3-4 months the pain has become very severe. The motion of the right arm is restricted in thr front straight direction only. I had diabetes, but sugar level is very normal now. I searched net. There are big claims about Prosero but I don't know how far it is effective. I have been taking PHYSIOTHERAPY but improvement is very less.

Please guide me with the effective treatment for this condition!!

[ginger]

The so called "frozen shoulder" problem used to confuse and worry me also, till about twenty years ago when I began to treat the cervical spine instead of the shoulder . The method i now call Continuous Mobilisation , when applied to the lower cervical facet joints , will release those joints from their protective tone . When this occurs ( within one to three minutes in most cases for each joint ) it will be noted that referred pain and a pattern of altered recruitment within the specific myotome of that joint/nerve , will be affected . Immediate and lasting resolution of the symptoms of this shoulder pain problem are resolved . If severe , this may take up to three treatments. I have not come across a frozen shoulder /adhesive capsulitis/"impingement" problem that has not had a significant ( and usually 100% ) contribution from spinal joints/nerves since the late eighties.
The alert therapist will immediately note , with carefull examination, that the facet joints C456 on the side of the complained of shoulder , will invariably be tender to deep palpation and attempts at passive movements unilateraly. Further information on the CM method can be posted if any wish to explore this method further. This problem ( and many like it ) are no longer the mystery once thought of , though the information about this minor revolution ( for some at least ) appears not to have filtered through in many quarters. Treatments of the shoulder are a waste of time , cruel and produce poor results at best. CM to the cervical spine however , done with skill and persistance , will permanently resolve this problem in a short time .

[hussain_whosayin]

hi,
you should have detailed assessment done, physical therapy is directed at symptoms. Try to prevent further damage and preserve the ROM and strength of shoulder complex by effective means of mobilization and stretch techniques. As many of text says condition to be self limiting, try to be preventive rather than curative. most important factor considered is activity and function, try to give modifications in activities for use of shoulder in pain free ways.

[stephandriver]

Hi Simon,

Below there is a plethora of replies and it seems we are all on the same page with this one. Frozen shoulder, often referred to as Adhesive Capsulitis and often quoted as going through 3 distinct stages is truly a mystery to date to the Mx world. SO don`t panic as I did in your place 30 years ago.

The facts remain that the etiology is still unknown and suggested treatments are simply that, suggested. Evidence shows that there is no effective treatment of it. I would guide you to "The Journal of Bone and Joint Surgery" Vol 89B, No 9, September 2007, "Thawing of the Frozen Shoulder by Quraishi et al.. Here you will find a comparison between dilatation and MUA.

I am qualified in spinal manipulation, human movement, acupuncture and physiotherapy. I have used these approaches for the last 20 years and have many colleagues all over the world. I have not had any consistent success with this complaint nor have any of my colleagues. Nor have I seen any "Evidence Based" information to the contrary. And if you think about, for such a common complaint, if such a treatment existed it would be mainstream and frontline news around the world. If it has been I havent seen it.

However, I note that Ginger, below, is in possession of information/techniques to the contrary. Please Ginger, could you please make this evidence based information public so we and our patients can all benefit from it. I genuinely do look forward to hearing from you soon.

Hope this helps alleviate your anxiety Simon and is helpful.

Cheers
Scooba.

[ginger]

scooba, Frozen shoulder was a mystery to me too, till I discovered it to be a referred event , along with many other MSK pain and dysfunction problems that have confused physios and others for many years. I have mostly been working in isolation and have had little interest in putting my work into the mainstream published media , till the internet allowed me access to blogs and forums such as this one .
I have posted many pieces of explanatory and technique related work on Rehab Edge , over the past few years. Should you be interested in reading further I suggest you begin there.
Cheers
G.

[linbin]

hi friends
as we all know for any shoulder pathology cervicothoracic screening is amust along with shoulder girdle assessment.as frozen shoulder is concerned i agree with physios that its a vague diagnosis.we should find out the primary cause too.our management will be based on that.i felt koltenborn technique of shoulder mobilization with intermitent longitudinal traction,capsular stretches,rotator strengthening helps a lot.in diabetes healing process will be disturbed,so we should be gentle in their handling and proper joint care advises should be given

[Physioindeed]

ginger,
just had a look at the website you suggested.
There are 10 thousands of messages in the forum. How are we supposed to find your previous entries about your fantastic method?
I think that if you want to help and have something to say: just say it here and now. Or give us a defenitiv link. Otherwise to claim that you have the ultimative answer but to not make it easy for everybody else to access it is a little unhelpful and frustrating.

[ginger]

As much as I would like to enroll you and others here into a more elegant and successfull method and perspective , on shoulder and other MSK issues , I have been doing this very thing on Re for some years and feel somewhat reluctant and time pressured at the moment to go over this territory from the beginning. It is possible , with careful orientation to the RE site , to find previous posts under headings. I suggest you begin with key words , such as Continuous Mobilisation ( CM ) , frozen shoulder, Ginger etc .
I have also posted many times with similar p.o.v. on somasimple.
I am happy to contribute to your considerations on shoulder pain here , though cannot commit to a exhaustive and detailed response. Should you be willing to follow my guidance and sugestions, I am certain you will find access to a quiet revolution in the manner to which shoulders ( and other MSK) problems are easily solved.
I have just returned from a lecture series I conduct twice a year here in victoria on these matters and am just a little exhausted. A few days in the hammock watching cricket should see me back on top. Go the aussies.
Ask questions by all means, I'll do my best for you.
Cheers

[Physioindeed]

had a nother look on rehab edge.
first tried to type in key words on their home page, which is why I didn't get anywhere. you of cours need to go to the forums first, then in manual therapy, scroll down and type in key words. there is also an option to look for entries by one specific user. I guess the threat "Mobilisation of facet joints, the continuous method - July 2, 2006 7:34:00 PM " is the one I was looking for.
sorry for being impatient and a bit slow...
now bussy reading in there. thanks ginger

[estherderu]

dear colleagues,
to add to the confusion....
how about this one??

Some, not all, but some of the patients I have treated ( especially if they were woman in their late 40´s and 50´s ) reacted very well to magnesium supplements.
I learned this from a chinese physician (who was also trained in western medicine and especially complementary medicine ).

Do not ask me why....
esther

[nasde]

Personally, I've never found too much success with much physio treatment for a "true" frozen shoulder. I say "true" because in my experience, a lot of stiff shoulders with full capsular movement (or almost full passive movement) - have been referred over as "frozen shoulder".

IMO Mobs and stretching exercises seem to irritate the capsule, and not provide much in the way of improvements (esp when compared to the amount of pain/irritation it causes). I find that educating a patient to use their shoulder (pain free range), not sleep on it, timeframes to recovery etc, to be the most effective. Soft tissue stuff is good short term.

Ginger - I'm also quite interested to hear more about this CM type stuff. I've searched your posts on those websites you suggested, but the whole topic is very vague - except for the fact that it works, it's very simple and effective etc ... What lectures do you do and where did you speak at? Are any of these talks coming up? What university do you lecture at? Is it at physiotherapy conferences that you talk at? Do you teach at a university, lecturing to physiotherapy students?

If you would prefer not to say on the forums as a matter of privacy or whatever, send me a PM.

Thanks

[Laura01]

A colleague of mine has just worked on a review of the literature in relation to Physio Mx of adhesive capsulitis. The finding of which swayed neither way basically supervised neglect showed the same outcome 2 years on so all the aggressive mobs to the shoulder- theres no point! The evidence was in agreement with the scapular stability and pain relieving modalities however.

[soranidinesh]

hi ginger
i think i agree to your thought on spinal mobs for frozen shoulder
what i have seen in a few patients is thoracic spinal mob (at the level of around t567) may help to improve extension with medial rotation
although this is not seen in every one
i would like to try your trick on my patients
some new things i ve heard is that the pain on shoulder may be due to suprascapular nerve irritation and is resolved by block by injection of analgesic TENS over shoulder...
can u give a hint on this

[estherderu]

like Ginger,
I also had problems working on the "frozen-shoulder" when I started, having been trained to look and work locally. I have since then made it a point to ALWAYS look at the whole spine when treating people with shoulder (upper & lower extremity) disorders. More often than not, treating the cervical and thoracic spine gave much better results than treating the shoulder only.
I also used the german(massage) technique called bindegewebsmassage a lot to help treat many so-called musculoskeletal problems.

It really helps to look at the whole picture, the patients posture, his/her response to pain and most importantly, what is happening/has happened in his/her "muscle train and/or meridiaan.

the more you learn, the more you realize you know so little

Esther

[mIrAge]

I believe the most recent inclination to manage adhesive capsulitis is early steroid injection (during painful phase) and exercise therapy, which yield a siginficant improvement in short term functional outcomes and pain level, and some long term benefit over steroid only and exercise therapy only group.

[112inky]

u shout undr go for the shoulder mobilasation treatment