the frozen shoulder

8/7/2019 The Frozen Shoulder

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The Frozen Shoulder (Adhesive

Capsulitis)

This condition has traditionally been considered a medical

enigma! It is considered to be the worst of all shoulder

problems and is often the end-point of other problems. It is

also, unfortunately a waste can diagnosis, often madeincorrectly.

Frozen shoulder syndrome is a very painful and debilitating

condition of the shoulder characterized by pain and severe

stiffness. It is a clinical diagnosis and is only very rarely the

result of an underlying disease. Fortunately (and curiously)

once cured it (almost) never comes back on the same

shoulder. It often comes on for seemingly no reason at all

(primary) but may follow a trauma or shoulder surgery (also

following breast re-construction.)


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Frozen Shoulder Facts:

y 2-5% of the population.

y

It is more common in women (60%)y It is at least five times more common in diabetics

y It is slightly more common in patients with Dupytrens

contracture

and shares some of the same pathology

y It may have a genetic component i.e./ it can run in the family

y It may well have an hyper responsive auto-immune

component

y It seems to affect 40-70 year olds (in Japan it is known as

50s shoulder)

y About 15% of people get it on both sides

How long does it last for?

Symptoms lasts an average of thirty months (some say

longer)

There are four phases to frozen shoulder, (which lasts an

average of 30 months).

Pre-Freezing (0-1 week)

Freezing (1 - 8 months)

Frozen (9 - 16 months)Thawing (12 - 40 months)


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What is happening inside my frozen

shoulder?

Inflammation

In a Frozen ShoulderSyndrome the lax capsular

sack becomes sticky and can sometimes though not always

form adhesions; hence the name of the condition. The

stickiness is brought on through inflammation; research has

pinpointed the source of this is in the rotator interval, in our

experience this inflammation often starts in the groove

behind the biceps tendon. (This can occur after a small

injury, like reaching for the back seat of the car but often you

may not remember anything). Once established this

inflammation spreads into other shoulder soft-tissues and

can cause swelling in other shoulder sacks (bursae). This isbecause the muscles, ligaments and bursae within the

shoulder are very much interconnected.

Stiffness

The stiffness is due to an overreaction of the body to the

inflammation (within the rotator interval/biceps groove). The

body then seems to switch off muscles in a co-ordinated

sequence; this sequence is the same for everyone and we

call it the capsular pattern. In less than a week the arm

movements start to diminish, and within a few weeks the


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arm literally becomes frozen and for many, can not be

raised more than 40 in any direction. The muscles of the

rotator cuff become weak and start slowly to waste away,

leaving the arm to hang stiff and immobile.

Treatment for the frozen shoulder

Until now the current orthodox and alternative medical

approaches to treatment have not proven to reduce theduration of symptoms or reliably improve the range of

motion. Several treatment options exist but they are very

much hit and miss. The good news is that Frozen Shoulder

syndrome can be treated simply and effectively byThe Niel-

Asher technique. This unique hands-on, drug-free

approach is evidence based and works with the body to help

dramatically speed up recovery, even in very severe cases.

It has been shown by independent research to significantly

reduce the duration of symptoms, reduce pain and

significantly improve strength and power above and beyond


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traditional physical therapy. This technique is now being

used successfully by therapists all over the world, a list of

these can be found here.

The Niel-Asher technique works by reducing

inflammation in and around the shoulder capsule and

tendons and then re-programming the muscles which have

switched off click here for more information. You can even

start working on it yourself from home with our self help

products. Better still, all of our excellent and highly qualified

Practitioners have an excellent knowledge of the various

types of Frozen Shoulder syndrome and how to treat it.

Conventional approaches to treating the frozen

shoulder and the evidence for them:

y

Non-Steroidalanti-inf

lammatory medications these are

mainly ineffective. This type of medicine is good for reducing

acute pain and swelling but because frozen shoulders are

full of chronic inflammation NSAIDs rarely improve things.

y Oral Steroids Short courses of high doses of intravenous

steroids (500mgs of prednisolone IV for three consecutive

days) appear to improve the pain relief. A three week course

of 30mgs prednisolone daily has shown significant short

term benefit in adhesive capsulitis, but the benefits did not

persist beyond 6 weeks(Buchbinder R. Ann Rheum Dis

2004;63:11:1460-9). It must also be remembered that Oral

steroids can have significant and unwanted side-effects.


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y Streroid injections Your GP may initiate a course (up to

3) of hydrocortisone injections into the shoulder, these can

take away some of the acute pain but the effect seems to be

short-term and they are rarely useful on their own. (Bal A etal. Effectiveness of corticosteroid injection in adhesive

capsulitis. Clinical Rehabilitation 2008;22:6:503-12). They

also may have serious unwanted side effects such as facial

flushing and changes in sugar metabolism (especially in

diabetics).

y Hydrop

lasty

involveing distention of the glenohumeraljoint with an injection of 10mgs of combined bupivacaine

(Marcaine), lidocaine (Xylocaine) and corticosteroid followed

by injection of 30mls of chilled sterile normal saline (Callinan

N. J Hand Ther 2003;16:3:219-24). This is a surgical

procedure and s not risk free it is more effective when

combined with physical therapy and may also need to be

repeated.y Hydrodilatation involves inflating the capsule with

between 10 and 50mls of saline. Has shown to be

significantly better than manipulation under anaesthesia at 6

monts (p


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y A combination ofAcupuncture and physical therapy may

lead to a better outcome than using one method alone (Ma

T. Am J Chin Med 2006;34:5:759-75).

y Physical Therapy is of little or no use during the freezingor frozen phases but may help speed up recovery during the

thawing phase. (Vermeulen H. Phys Ther 2006;86:3:355-

68). Patients may have well over a dozen physical therapy

sessions and modalities include ultrasound, mobilization

and exercise regimens.

y

Transcutaneous electrica

lnerve stimu

lation(TENS) machines are also commonly used to alleviate night

pain.

y Manipulation under anaesthesia (MUA) followed by

several months of intensive physical therapy, or if severe,

more invasive surgery. Manipulation under anaesthesia

does not add effectiveness to exercise program with only a

small difference in the range of movement in favour of themanipulation group (Kivimaki J. J Shoulder Elbow Surg

2007;16:6:722-6). The risks associated with MUA include

fracture of the humerus, tendon rupture and brachial plexus

injury and the risks associated with anaesthesia.

y A series of three indirect bupivacaine supra scapula

nerve bl

ocks has been shown to be effective in reducingthe pain from frozen shoulder within one month (64% Vs

13%) in the control group (Daha TH. J Rheumatol

2000;27:6:1464-9).


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Other type of shoulder problems:*

Rotator Cuff Tendinopathy & the

Supraspinatus

The rotator cuff is made of four muscles

Supraspinatus, Infraspinatus, Subscapularis and Teres

Minor (see Anatomy). These muscles join together and

blend to form a muscular cuff at the top and back of the arm.

The job of the rotator cuff is to stabilize the ball and socket

joint of the shoulder pulling it down and back and holding it

into position; this affords a stable base for us to use the

arms and hands in manipulating our environment.

The cuff is vulnerable for a number of reasons, especially if

you have got a round-shouldered posture. Muscles of thecuff are prone to ware and tear (peri-arthritis) and the

tendons can be trapped and damaged (usually under the tip

of the acromion), sometimes leading to actual tears and

sometimes ruptures. The most common of the cuff muscles

to be injured is the Supraspinatus. This is because it sits on

top of the shoulder blade and its tendon drops down onto

the upper outside of the arm at an angle. The tendon can

get rubbed and inflamed, also variations in the under

surface of the arch of the shoulder blade (such as

osteophytes) can dig into it and sometimes cause tares in


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the tendon. Another common problem for the Supraspinatus

is that the muscle itself is vulnerable to ware and tear.

During the day, the weight of the arm shuts off the blood

supply to the muscle and at night, when the arm is off-stretch any damage that has occurred is repaired. This

leads to low grade aching and night pain. The area of the

muscle most vulnerable to damage (other than the tendon)

is in the middle of the belly. Damage and repair to this area

can cause a series of repetitive micro-bleeds which when

repaired leave behind calcium (chalk) deposits. These chalkdeposits can cause a wide range of low-grade problems

such as aching and pain and occasionally/rarely the chalk

can form a boil within the muscle which can burst causing

agony. There are two types of chalk soft and hard, and

depending on which one you have, there is a different

treatment plan.

Because of the inter-related nature of the rotator cuff

muscles injury in one can lead to changes, compensation


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and eventually failure in the others. The tendons blend

together to form a joint conjoined tendon.

The terminology for rotator cuff injuries can be a bitcomplex. We talk of partial tears, full thickness tears and

ruptures. This terminology refers to the scenario when one

of the individual tendons tears off from the bone and retracts

but the others in the conjoined tendon remain intact.

Unfortunately there is a scenario where the tears

progressively work their way through all of the tendons until

the whole cuff ruptures.

It is essential that a proper diagnosis is made to see which

of the cuff muscles is damaged and, if possible what is the

underlying cause for this damage. In most cases there is an

element of poor posture and/or occupational or sports

trauma. Often the mechanics of the shoulder can beimproved by conservative management. The good news is

that many of the most common Rotator Cuff problems can

be treated by a combination of The Niel-Asher

technique and simple exercises. All of our excellent and

highly qualified Practitioners have a good knowledge of

Rotator cuff problems and how to treat them.

Signs and Symptoms of Rotator Cuff

Tendinopathy


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y Night pain sometime relieved by side-lying on the same

side

y Weakness on certain movements especially lifting and

rotating the army Catching pain on certain movements

y Able to lift the arm with the other one

y Pain on certain movements on the rear outside of the arm

Treatment

y NSAIDs Anti-inflammatory medication can be useful forreducing the acute swelling around an injured tendon.

These are, however, rarely useful as a long-term treatment

for cuff injuries.

y Steroid injection this involves injected a cortico-steroid

+/- anesthetic into one of the inflamed rotator cuff tendons.

The technique is most effective when performed under

guided ultrasound (Ekeberg et al BMJ Vol 338 Jan 2009

p 273).Studies have shown this approach to very be useful

for reducing the acute swelling around swollen tendons

and/or bursae. There are, however, side effects and

injections are rarely useful on their own as a long-term

treatment for cuff injuries.

y Physiotherapy Several studies have shown that specificexercises which target the cuff muscles may be as effective

as surgery These exercises are incorporated into the

training programme for all Niel-Asher

technique practitioners.


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y Surgery Several types of surgical procedures have been

used to treat rotator cuff pathologies. Results vary for many

reasons, including. The health of the underlying tissues pre-

surgery, the age and health of the patient, occupation,activity/sport, post operative rehabilitation programme - to

name but a few. Some authorities report that up to 70% of

cuff repairs go on to fail again!

The two most common operations are:

y Decompression This is the procedure used if the tendondamage is due to arthritic changes on the under surface of

the acromion or due to their being insufficient space for the

tendons to run through. It is usually performed by key-hole

(arthroscopy) as an out-patient procedure. An electric burr

drill is used to remove (abride) up to 1cm of the acromion

bone thus creating more space for the tendons to runthrough. It is sometimes accompanied by steroid injections

and usually by several sessions of post operative physical

therapy. Results of this operation vary dramatically; it does

risk complications (including a frozen shoulder).

y Surgical Repair This operation is used to re-attach the

two part of a torn tendon either to each other, to a bone or

both; most commonly the Supraspinatus tendon. Thisoperation can be peformed by key hole (arthroscopy) or by

open surgery. It is often performed with a decompression

Advice


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y We strongly advise icing the area morning and evening. For

more information click here.

y To help reduce the swelling around the shoulder tendons we

advise you use non invasive natural anti-inflammatorymedication.

y We are not saying there is not a place for surgery as it can

be effective but our practitioners are trained to offer

alternatives. The Niel-Asher technique offers a non-

operative decompression programme which, along with

specific exercises can be highly effective in pain reduction,increased mobility and long-term relief.

Biceps tendinopathy (long head)

The biceps tendon (long head) is vulnerable to injury in

certain positions especially under its retaining transverse

ligament. Because of its unique anatomical strain it can


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sometimes tear, rupture and/or slip out of its ligamentous

fixation. Furthermore the biceps tendon often acts

(incorrectly) as a stabilizer in a range of shoulder problems

to prevent external rotation.

Symptoms include

y Sharp spasms of pain

y Pain reaching for the back pocket

y Pain reaching for a seatbelt

y Night pain - localized

An inflamed (long head) Biceps is often very involved in

many shoulder problems such as a frozen shoulder, so it is

important to get it treated. The biceps tendon lies in a

groove running up the humerus bone of the shoulder.

Advice




advise you use non invasive natural anti-inflammatory

medication.

y This problem responds well to The Niel-Asher technique.

y Other treatment options include physical therapy, steroid

injections (up to 3) and or surgery - if severe.


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Arthritis of the gleno-humeral (ball and

socket) joint

Recent medical research suggests that it is NOT just bones

that can get arthritis, but muscles and tendons too this is

known as Peri (or soft tissue) Arthritis and results from

injury, aging, posture, occupation, sports and ware and tear.

Osteoarthritis is a progressive weakening of the smoothjoint cartilage that is designed to allow the joint to move

fluidly. The smooth joint surfaces of the ball and socket joint

begin to become rusty. Most of the time the cause is not

known, but overuse and injuries can lead to the

development of osteoarthritis over time.

Although this condition is more common in other joints

(especially the knees and hands), shoulders can become

affected by osteoarthritis.


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Although we can not cure arthritis, the good news is that the

pain and mobility can be helped a great deal by a

combination of The Niel-Asher technique and simple

exercises. All of our excellent and highly

qualified Practitioners have a good knowledge of arthritis

and how to treat it.

Symptoms include

y Stiff shoulder (may appear like a frozen shoulder)

y Painful shoulder related to movement

y Clicking, crunching or clonking sounds on movement

y Loss of shoulder movement

y (Not usually painful at night)

y Clearly identified on x-ray

Treatment

y Conservative treatment include medication - pain

relieving and anti-inflammatory, physical therapy and


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exercise. Sometimes steroid injections and or artificial joint

fluid (synavistin) asre used.

y Surgical options include full shoulder replacement

(Arthroplasty) or partial shoulder replacement (Hemi-arthrotomy) and sometimes replacing the ball joint at the top

of the arm (humerus) with a larger artificial ball. Depending

on the state of the joint other operations may be performed

at the same time such as a decompression.

y The Niel-Asher technique - Although we can not cure

arthritis, the good news is that the pain and mobility can behelped a great deal by a combination of The Niel-Asher



arthritis and how to treat it.

Arthritis of the acromio-clavicular joint

Symptoms include

y Catching pain at the tip of the shoulder

y Painful shoulder related to specific over head movements

y Painful clicking, crunching or clonking sounds on movement

y Pain may radiate to the back of the thumbt

y Reduction in certain shoulder movements (such as reaching

behind the back)


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y (Not usually painful at night)

y Can be identified on x-ray

Advice

y Steroid injection up to 3 injections may be performed

directly into the joint these are best performed guided

under x-ray or ultrasound they rarely provide more than

symptomatic relief

y Physical therapy usually with prescribed x-rays

y The Niel-Asher technique- Although we can not curearthritis, the good news is that the pain and mobility can be

helped a great deal by a combination of The Niel-Asher




Bursitis

The body has many folded bursae throughout. These fluid

filled structures are designed to stop tendons rubbing on

muscles or bones. Under certain circumstances these canbecome inflamed and swollen and this inflammation can

linger on and on this is called chronic inflammation. Once

this type of inflammation has occurred it generally requires

treatment of some kind.


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Advice





medication.

Treatment options include

y Medication including steroidal or non steroidal - anti-

inflammatory. These may have unwanted side effects.

y Steroid injection it is not uncommon to have up to 5

steroid injections for this problem. These may improve the

situation but often provide only short term relief they are

best performed in combination with physical therapy (and/orthe.)

y The Niel-Asher technique- Although we can not cure

arthritis, the good news is that the pain and mobility can be

helped a great deal by a combination of The Niel-Asher


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y Acupuncture

Dislocation

The shoulder is designed for mobility and allows a largerange of movement, this freedom of motion is however at

the expense of stability. The shoulder is vulnerable in

certain ranges of motion and the ball can sometimes slip

out of the socket. The shoulder can dislocate anteriorly

(forward), posteriorly (backward) and superiorly (upward).

Unfortunately once you have had one or two bad

dislocations the there is often irrevocable damage of thetissues inside the ball and socket joint and the shoulder will

require surgery. A truly dislocated shoulder often needs to

be put back in by a doctor at the A & E department.

Some people are born with anomalies within the joint which

makes dislocation more likely, they can pop them in and outas a party trick. Also the socket joint of the shoulder has a

small cartilaginous cup which holds the ball in place which

can be too short and stubby leading to dislocation.


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Some people dont fully dislocate the shoulder but instead,

sublux their shoulders in what we call a-traumatic

dislocation. This type of dislocation often pops itself back in

spontaneously. If the dislocation has occurred more thanonce, there is a strong chance of some permanent internal

damage and stabilizing surgery is to be advised.

Although we can not promise to cure subluxation, the

unique sequence of manipulations performed in The Niel-

Asher technique have been shown to increase

the strength and power of the shoulder muscles. The

technique is especially effective as part of a post-operative

regime.

Symptoms of dislocation

y

Pain

can be very severey Complete or partial loss of function

y Weakness

Treatment

y If you suspect a dislocation go straight to the emergency

room

Painful arc/impingement


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This condition is easily confused with a frozen shoulder as

there are similarities; however, they are very different

problems. Painful arc describes the symptom of pain, when

the arm is lifted up to shoulder level and then has a severe

crippling spasm of pain. The pain causes immediate

weakness and the arm often feels like it needs to be

dropped by the side. The MAJOR difference between this

and a frozen shoulder is that the arm can actually be raised

all the way up once it goes through the painful arc. In afrozen shoulder the stiffness is there in all directions even

when someone else tries to lift the arm. The pain is usually

caused by inflamed tendons being pinched between the

narrow top of the ball and the under surface of the collar

bone. This is usually the supraspinatus tendon but bursitis,

arthritis of the acromioclavicular joint and/or several other

problems may present as impingement.

Symptoms

y Crippling pain as the arm is raised to shoulder level


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y Pain diminishes as push through this point

y Full range of motion

y Night pain especially lying on the same side

y Aching after the pain has goney Bursitis

Treatment

y NSAIDs Anti-inflammatory medication can be useful for

reducing the acute swelling around an injured tendon.

These are, however, rarely useful as a long-term treatment.y Steroid injection this involves injected a cortico-steroid

+/- anesthetic into one of the inflamed rotator cuff tendons.

The technique is most effective when performed under

guided ultrasound (Ekeberg et al BMJ Vol 338 Jan 2009

p 273).Studies have shown this approach to very be useful

for reducing the acute swelling around swollen tendons

and/or bursae. There are, however, side effects and

injections are rarely useful on their own as a long-term

treatment for cuff injuries.

y PhysiotherapySeveral studies have shown that specific

exercises which target the cuff muscles may be as effective

as surgery These exercises are incorporated into the

training programme for all Niel-Asher techniquepractitioners.

y The Niel-Asher technique- employs a range of

manouvres to sooth and relieve impingement long term

our practitioners look at the relationships between muscles


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which are not working properly and can offer you an

alternative non-surgical hands-on only decompression

technique which is highly effective.

y Surgery Several types of surgical procedures have beenused to treat rotator cuff pathologies. Results vary for many

reasons, including. The health of the underlying tissues pre-

surgery, the age and health of the patient, occupation,

activity/sport, post operative rehabilitation programme - to

name but a few. Some authorities report that up to 70% of

cuff repairs go on to failagain!

The two most common operations are:

y Decompression This is the procedure used if the tendon

damage is due to arthritic changes on the under surface of

the acromion or due to their being insufficient space for the

tendons to run through. It is usually performed by key-hole(arthroscopy) as an out-patient procedure. An electric burr

drill is used to remove (abride) up to 1cm of the acromion

bone thus creating more space for the tendons to run

through. It is sometimes accompanied by steroid injections

and usually by several sessions of post operative physical

therapy. Results of this operation vary dramatically; it does

risk complications (including a frozen shoulder).

For more information about a range of other shoulder

problems, I suggest you visit my colleagues

atwww.shoulderdoc.co.uk


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Reflex Sympathetic Dystrophy (RSD) or CRPS I

Whats that?

Severe cases of Frozen ShoulderSyndrome can be

associated with Reflex Sympathetic Dystrophy; now also

called complex regional pain syndrome I (CRPS I). This can

be a serious and unwelcome complication or it may precede

the Frozen Shoulder. It can come on after fracturing the

shoulder and or splinting it. It is also associated with

shoulder surgery (including manipulation under

anaesthetic).

Mostly on the affected side, the massive inflammation in a

Freezing Shoulder can spread to a nerve bundle at the

base of the neck that regulates blood flow to the wrist and

hand. This causes a host of more unwelcome symptoms in

the hands and fingers:

y We strongly advise icing the area morning and evening.

This couldnt be easier with our state of the art icepack. For




medication.

Key features of RSD

Hands

y white-blue or reddish, cold, numb, stiff, swollen fingers


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y painful & swollen knuckle joints

Other

y increased sweating and odour

y strange odour from arm pit

y severe cramping in shoulder, elbow, wrist, hand

The RSD associated with frozen shoulder syndrome can be

effectively addressed with The Niel-Asher Technique; it

usually improves in tandem with the shoulder, but the longerit has been there, the longer it takes to get better. If you

think you have RSD you really should consult your doctor

and or a qualified Niel-Asher Technique practitioner (for a

list of practitioners click here).

Advice

y Seek conventional medical advice

y The Niel-Asher Technique

y Squeezing a squash ball for 5 minutes 10 times per day

y Putty and hand home exercise products

y Ginko Biloba

y Ruta Gravis & Rhus Tox

y MSM

y Specialized deodorants

the frozen shoulder

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