Frozen Shoulder
Pathology
The greatest range of motion of any joint in the body occurs in the glenohumeral joint. While freedom of movement is necessary in performing various actions of the shoulder, there is increased potential for soft-tissue injury. Without stabilization from the bony structures of the joint, much of the structural support must come from soft-tissue support. Thus, muscles, tendons, ligaments and the joint capsule make up the primary support for this joint.
The joint capsule's fundamental role is in restricting excess motion. However, because there is such a great range of motion in the shoulder joint, the capsule must be able to allow a wide range of movement before it restricts that motion. The glenohumeral joint capsule is looser than many other joint capsules in the body in order to accommodate this greater range of motion.
The pathology in adhesive capsulitis develops when a portion of the capsule (usually the underside) adheres to itself and prevents full movement. The joint capsule is richly innervated, so when the adhesions pull on the capsular tissues, it is very painful.
There are two categories of adhesive capsulitis: primary and secondary. In primary capsulitis, there is no easily apparent cause for the condition. It is frustrating for many health-care providers because they aren't able to identify what created the problem and help the patient/client better understand why it happened. It is difficult to avoid the aggravating factors of the condition without understanding what triggered the problem.
What can make primary capsulitis more challenging is that, in some cases, there seems to be a correlation between significant emotional trauma and the development of adhesive capsulitis. While there is not a clear cause/effect relationship, this correlation can lead some health-care practitioners to presume the condition is primarily psychological in nature. However, the seriousness of the problem should not be minimized simply because a structural or mechanical cause cannot be found.
In this case, the capsular adhesion occurs as a result of some other pathology. For example, in the glenohumeral joint, secondary capsulitis will often develop as a result of rotator-cuff tears, arthritis, bicipital tendinosis (an abnormal condition of the tendon when no inflammatory cells are present), shoulder trauma, surgery or other problems. There appears to be a process of fibrosis that is initiated by these other conditions. Consequently, the individual is usually limiting motion in the shoulder at the same time that fibrous proliferation is occurring. As a result, the fold on the underside of the joint capsule never gets fully elongated, and the fibrous proliferation causes the two sides of the fold to adhere to each other. A vicious cycle then follows. The adhesion causes pain and limitation to movement, thus worsening the problem.
Another possible cause of secondary capsulitis is the presence of myofascial trigger points. There is an indication that trigger-point activity in the subscapularis muscle can set off a cascade of adhesion in the capsule. This may result from irritation of the attachment site of the subscapularis, which is very close to the joint capsule. Local inflammation at the attachment site will then cause fibrous adhesion in the capsule.
Adhesive capsulitis can be a stubborn condition and last for many months. In fact, it is not unusual for the problem to last 18 months or more. The severity of the problem and its recuperation time depend upon how early in its development it can be halted.
The problem is often divided into three different stages:
Freezing: Onset is usually between 10 and 36 weeks. This stage is characterized by a gradual decrease in range of motion and an increase of pain.
Frozen: This period occurs between four and 12 months after initial onset. Motion is likely to remain limited though a gradual decrease in pain may be occur.
Thawing: This period is characterized by a gradual return of range of motion and decreased pain. This stage may be as short as several months, but it is not uncommon for it to last for years.
Assessment and evaluation
Adhesive capsulitis is commonly evaluated through client history and physical examination. The condition affects women more often than men, and occurs more frequently in women age 45-65. A detailed client history is important to establish any characteristic patterns that indicate either a primary or secondary capsulitis.
The most prominent symptoms are pain and loss of range of motion. Dysfunctional biomechanics and motion compensations.
An important approach to distinguishing adhesive capsulitis from similar shoulder problems is to evaluate the way in which motion is restricted at the shoulder joint. Most synovial joints of the body are enclosed in a joint capsule. When there is pathology, there is a characteristic pattern to the range-of-motion limitation in that joint. The pattern of limitation is unique to each joint. In the glenohumeral joint, the capsular pattern is for motion to be limited first in external rotation, then in abduction, and finally in medial rotation.
To understand how to apply the concept of the capsular pattern, lets look at a common shoulder complaint where the client has trouble bringing the arm up in abduction . A person with this motion restriction could have adhesive capsulitis; however, if the client has no problem externally rotating the shoulder from a neutral position with the arm at the side. Because the capsular pattern indicates that motion restriction will first be observed in external rotation, it is unlikely this person has a capsular pathology.
However, other conditions, such as sub-acromial impingement, calcific tendonitis or bursitis, are all likely to produce restriction in abduction. Assuming this problem to be adhesive capsulitis can lead to faulty methods of addressing the problem. This underscores the importance of a thorough assessment, and diagnosis from a physician.
In addition to active and passive range-of-motion evaluations, a special orthopedic test for measuring functional range of motion in the shoulder, called the Apley scratch test , is useful. In this procedure, the shoulder of the arm being held overhead is in abduction and external rotation while the shoulder of the lowered arm is in adduction and internal rotation (with a slight degree of extension). You should have the client perform this test with both sides in the upper and lower positions to compare the available range on each side.
Massage techniques
Techniques that encourage relaxation of the muscles surrounding the shoulder girdle are a mainstay for massage approaches. Simple techniques, such as effleurage and broad cross-fiber sweeping strokes, are useful. Because the muscles often become fibrous and shortened due to the limited range of motion in the shoulder, restoring their proper movement is an important aspect of addressing this problem.
When muscles are unable to move through their full range of motion, restoring proper movement can be challenging. In this case, active engagement techniques work well for the pectoralis major, which often becomes restricted in adhesive capsulitis. The client is instructed to hold an isometric contraction (horizontal adduction) in the pectoralis major and then slowly let it go. As the client releases the contraction, the practitioner performs a longitudinal stripping technique on the pectoralis major fibers.
Myofascial trigger points in muscles such as the subscapularis may also play a role in the perpetuation of capsular adhesion.
These trigger points can be treated with static compression methods or compression with active movement. During compression with active movement, the practitioner maintains pressure on the trigger point while the client moves through as much of the range of motion as possible (internal and external shoulder rotation).
Another goal for the massage therapist is to encourage elongation of the adhered capsular tissues. This is accomplished with various stretching procedures.
However, do not expect results to come quickly. In addition to - or in conjunction with - massage techniques, stretching methods should emphasize the motions of external rotation and abduction, and will get the best results when performed slowly to stretch the adhered tissues. For example, with a passive stretch in lateral rotation, the client is taken just to the point where discomfort starts and then held there . While in this position, the client is encouraged to breathe deeply and relax the shoulder as much as possible. After holding the stretch for 20 seconds or more, the client is slowly brought back to the neutral position. The procedure can be repeated several times.
Conclusion
Adhesive capsulitis can be debilitating and cause long-term impairment. Proper treatment can mean the difference between a several-months-long disability or one of several years. Even with therapeutic results, this condition may require a long rehabilitation. As a result, the client may get depressed about the lack of improvement in his/her condition. Positive statements regarding even small amounts of improvement will go a long way toward encouraging active participation in the rehabilitation process. This is also where your knowledge of the condition will be highly valuable, as your clients attempt to learn more about their own bodies and what they can do to return to optimum health.
