Your Diagnosis

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 made incorrectly.

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.)

Frozen Shoulder Facts:

• 2-5% of the population.
• It is more common in women (60%)
• It is at least five times more common in diabetics
• It is slightly more common in patients with Dupytren’s contracture
  and shares some of the same pathology
• It may have a genetic component i.e./ it can run in the family
• It may well have an hyper responsive auto-immune component
• It seems to affect 40-70 year olds (in Japan it is known as 50’s shoulder)
• 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)

What is happening inside my frozen shoulder?

Inflammation

In a Frozen Shoulder Syndrome 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 is because 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 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 the duration 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 by The 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 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:

• Non-Steroidal anti-inflammatory 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 NSAID’s rarely improve things.
• 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.
• 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 et al. 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).
• Hydroplasty – involveing distention of the glenohumeral joint 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.
• 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<0.0001). But it should be noted that this is a surgical procedure and the evidence is not conclusive. Some authors have failed to identify any further beneficial affects from three hydrodilatations when included with steroid therapy compared to the steroid injections alone (Tveita EK. MBC Musculoskelet Disord 2008;9:53).
• A combination of Acupuncture 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).
• Physical Therapy – is of little or no use during the freezing or frozen phases but may help speed up recovery during the thawing phase¹. (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.
• Transcutaneous electrical nerve stimulation (TENS) machines are also commonly used to alleviate night pain.
• 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 the manipulation 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 injury¹ and the risks associated with anaesthesia.
• A series of three indirect bupivacaine supra scapula nerve blocks has been shown to be effective in reducing the pain from frozen shoulder within one month (64% Vs 13%) in the control group (Daha TH. J Rheumatol 2000;27:6:1464-9).

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 the cuff 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 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 chalk deposits 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 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 bit complex. 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 be improved 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  

• Night pain – sometime relieved by side-lying on the same side
• Weakness on certain movements – especially lifting and rotating the arm
• Catching pain on certain movements
• Able to lift the arm with the other one
• Pain on certain movements on the rear outside of the arm

Treatment

• NSAID’s – 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 for cuff injuries.
• 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.
• Physiotherapy – Several 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 technique® practitioners.
• 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:

• 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).
• 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. This operation can be peformed by key hole (arthroscopy) or by open surgery. It is often performed with a decompression

Advice

• We strongly advise icing the area morning and evening. For more information click here.
• To help reduce the swelling around the shoulder tendons we advise you use non invasive natural anti-inflammatory medication.
• 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 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

• Sharp spasms of pain
• Pain reaching for the back pocket
• Pain reaching for a seatbelt
• 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

• We strongly advise icing the area morning and evening. For more information click here.
• To help reduce the swelling around the shoulder tendons we advise you use non invasive natural anti-inflammatory medication.
• This problem responds well to The Niel-Asher technique®.
• Other treatment options include physical therapy, steroid injections (up to 3) and or surgery - if severe.

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 smooth joint 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. 

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

• Stiff shoulder (may appear like a frozen shoulder)
• Painful shoulder – related to movement
• Clicking, crunching or clonking sounds on movement
• Loss of shoulder movement
• (Not usually painful at night)
• Clearly identified on x-ray

Treatment

• Conservative treatment – include medication - pain relieving and anti-inflammatory, physical therapy and exercise. Sometimes steroid injections and or artificial joint fluid (synavistin) asre used.
• 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.
• 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 technique® and simple exercises. All of our excellent and highly qualified Practitioners have a good knowledge of arthritis and how to treat it.

Arthritis of the acromio-clavicular joint

Symptoms include

• Catching pain at the tip of the shoulder
• Painful shoulder – related to specific over head movements
• Painful clicking, crunching or clonking sounds on movement
• Pain may radiate to the back of the thumbt
• Reduction in certain shoulder movements (such as reaching behind the back)
• (Not usually painful at night)
• Can be identified on x-ray

Advice

• 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
• Physical therapy – usually with prescribed x-rays
• 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 technique® and simple exercises. All of our excellent and highly qualified Practitioners have a good knowledge of arthritis and how to treat it.

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 can become 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.

Advice

• We strongly advise icing the area morning and evening. For more information click here.
• To help reduce the swelling around the shoulder tendons we advise you use non invasive natural anti-inflammatory medication.

Treatment options include

• Medication – including steroidal or non steroidal - anti-inflammatory. These may have unwanted side effects.
• 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/or the….)
• 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 technique® and simple exercises. All of our excellent and highly qualified Practitioners have a good knowledge of arthritis and how to treat it.
• Acupuncture

Dislocation

The shoulder is designed for ‘mobility’ and allows a large range 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 the tissues 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 out as 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.

Some people don’t 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 than once, 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

• Pain – can be very severe
• Complete or partial loss of function
• Weakness

Treatment

• If you suspect a dislocation go straight to the emergency room

Painful arc/impingement

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 a frozen 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

• Crippling pain as the arm is raised to shoulder level
• Pain diminishes as push through this point
• Full range of motion
• Night pain especially lying on the same side
• Aching after the pain has gone
• Bursitis

Treatment

• NSAID’s – 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.
• 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.
• Physiotherapy – Several 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 technique® practitioners.
• The Niel-Asher technique® - employs a range of manouvres to sooth and relieve impingement long term – our practitioners look at the relationships between muscles which are not working properly and can offer you an alternative – non-surgical ‘hands-on only’ decompression technique which is highly effective.
• 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:

• 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 at www.shoulderdoc.co.uk

Reflex Sympathetic Dystrophy (RSD) or CRPS I– What’s that?

Severe cases of Frozen Shoulder Syndrome 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:

• We strongly advise icing the area morning and evening. This couldn’t be easier with our state of the art icepack. For more information click here.
• To help reduce the swelling around the shoulder tendons we advise you use non invasive natural anti-inflammatory medication.

Key features of RSD

Hands

• white-blue or reddish, cold, numb, stiff, swollen fingers
• painful & swollen knuckle joints

Other

• increased sweating and odour
• strange odour from arm pit
• 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 longer it 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

• Seek conventional medical advice
• The Niel-Asher Technique™
• Squeezing a squash ball for 5 minutes 10 times per day
• Putty and hand home exercise products
• Ginko Biloba
• Ruta Gravis & Rhus Tox
• MSM
• Specialized deodorants

More information is available on the following websites

• http://www.rsdhope.org/
• http://www.rsds.org
• http://www.emedicine.com/radio/topic596.htm

The sooner you seek advice and treatment the better. This is because if you leave RSD too long it can become irreversible. ALTERNATIVELY PLEASE CONSULT YOUR DOCTOR IF YOU THINK YOU HAVE ‘MAJOR RSD’ AS IT MAY REQUIRE SPECIALIST INVESTIGATION.