Frozen Shoulder

[gerry the neck]

Frozen Shoulder.

Because there seems to be many contradictory opinions on what causes ‘Frozen Shoulder’, I’m going to add my opinion to further confuse, or resolve, our understandings. Firstly, I believe the terms ‘Frozen Shoulder’ and ‘Adhesive Capulitis’ are misleading, and only help to add to the confusion by directing attention to the fallacy that it is solely a shoulder problem. In my opinion, it’s not, and here’s why…….


The most common vulnerability to the nervous system, and how it distributes itself throughout the body, occurs where the nerves exit the cervical spine, between the C1 and C7 vertebrae. Because of possible degeneration or regeneration, whether due to an underlying arthritic condition (such as Osteoarthritis) or an injury based condition (such as whiplash), and because of the full range of flexibility allowed to the neck structure, the risk of a compressed nerve, or even the ‘threat’ of such a risk, becomes a greater possibility than would normally be the case.

Where an actual compression has occurred, there would be obvious indicating symptoms manifested in the hand, at the extremity of that particular nerve’s field of influence. These symptoms are usually self explanatory and point to a direct cause i.e. trapped nerve in neck area. Where there is just a ‘threat’ of nerve compression, the nervous system is capable of reading this vulnerability, and, in order to protect from such an event, it can instigate certain muscular reactions to help protect itself. So, the shoulder (which is the next flexible joint along the nerve route) muscles are instructed to restrict the arm’s movement. This is achieved simply by introducing pain for any arm movements which might refer their effects back to the neck, and thus increase the threat to the nerve.

Unfortunately, this process can enter a cycle, perhaps due to ‘muscle memory’ issues, and can take many months to resolve itself. The actual initial threat to the nerve may have already resolved itself, but the shoulder effects carry on regardless. If that initial threat didn’t resolve for any reason, then the frozen shoulder would keep repeating itself endlessly. This doesn’t happen normally…it does resolve with no obvious lingering damage. In fact, there was never any tissue or structural damage in the shoulder, and it returns to normal painfree flexibility in time, usually about 10 to 12 months. It can be very painfull for first 3 to 4 months, and then gradually reduces in pain intensity until eventually it disappears.

So, to summarise, the painful shoulder is just the nervous system’s way of restricting arm movement so that it can better protect a vulnerability to itself as it exits the cervical spine. Any manipulations of the shoulder, especially painful manipulations, are likely to increase that vulnerability in the neck, and thus lengthen any recovery timespan. Any surgical intervention in the shoulder, where no obvious damage is apparent, is even more questionable. Frozen Shoulder is caused by protective nerve behaviour, and it only resolves itself when the threat to the nerve eases off by itself..

I believe that a lot of confusion, particularly regarding a patient’s understanding, is caused by the use of the terms ‘Frozen Shoulder’ and ‘Adhesive Capulitis’. Perhaps it should just be renamed ‘Referred Shoulder Spasm’ to ease patient anxiety.

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[neurospast]

A nice idea, as you say let's get some confusion!. When it comes to joint integrity: the joints blood supply is most likely estabished by the orthosympathetic pathways thus it could well have nothing to do with C1-C7 since these pathways come from the Thoracic area. Mobilisations of e.g. T1-4 can have dramatic effect on the pain as well as mobilisation rib1-4 9 (in between lie the orthosympathetis nodules) and in case the frozen shoulder is not well established the ROM as well. One should though ask why the shoulder and not other joints? Because the arm has it's nerve connection e.g. dermatomes, sclerotomes from C3-T2 and only the shoulder is affected? What makes the shoulder so special? the golfball on the T: an extremely unstable joint with via the Scapula only 1 bony connection the Clavicula.
Frozen shoulder does show intra articular changes as shrinking of capsula which is not explained by the explanation given by gerry the neck. Taking in account the possibility of reduction of bloodflow due to orthosympathetic changes here might lie also a clue. again why only the shoulder and no other joint?

[gerry the neck]

Sorry for late reply.

"Why only the shoulder"?.......good point. In my opinion, it's only the shoulder because the goal is only to restrict arm movement so it doesn't affect the neck. And, it's usually only one shoulder because that arm is the one causing the referred muscle reaction in the neck area. If there were other joints involved we would have to be looking at arthritic condition connections. Also, there is the question of inflammatory reactions in the shoulder leading to some temporary tissue damage. This might be explained by the cyclical pain eventually causing tissue inflammation and anything resulting from that. It doesn't mean that the inflammation or tissue damage caused the pain ! Everything returns to normal functionality fairly consistently within the same time frame for most patients, and that suggests to me that the cause was referred cyclical pain with a source other than the shoulder.

[Dr Damien]

Dear Gerry the neck

I have heard of this new insight to frozen shoulder syndromes too however if there is a direct relationship between the neck and frozen shoulder symprtoms perhaps treating the neck shhould automatically relieve the frozen shoulder symptoms. Have you ever had this dramatic result in your practice? In my experience, most patients that present with frozen shoulder that i have seen have not often showed neck symptoms that would make me personally want to investigate the neck. yes there is some restriction in neck range of motion that at best are mildly non capsular but they rarely complain of neck issues. secondly, the range of motion that would effectively cause some movement at the neck would be well over 90 degrees only because by that time the scapular would have moved a great distance to tug on the cervico scapula muscles. this does not explain why in severe frozen shoulder the shoulder limitation can be as low as below 30 degrees. In addition, the end feel one gets with frozen shoulder is usually a very firm and/or hard endfeel...this is not often the case in the neck as a rule of thumb. i would expect that is the neck theory stands, then there should be a precise capsular limitation of the neck as well. finally, why is it then that treatingn the shoulder directly sometimes improves the condition and why is it that the condition is self limiting? Does the neck suddenly realise its actually safe to be moved in a certain range after a while on its own?
I agree that this new insight is worth researching further however we shouldnt jump into conclusions on it being the real reason for frozen shoulder syndromes. I can understand how thiscould be a possiblity in a stroke patient.

[gerry the neck]

Hi Dr Damien
Just a quick reply for now. I have to say that your descriptions/ analysis etc seem to me to be pretty faultless. I don't often encounter this. Will study what you comment on and reply anon.

Gerry