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Frozen Shoulder Guide

An extremely detailed & readable guide to one of the strangest of all common musculoskeletal problems, for both patients and pros

Paul Ingraham, updated

Photo of woman holding her shoulder.

Sometimes shoulders just seize up, painfully and mysteriously: frozen shoulder. It comes with other diseases, usually diabetes, or it follows traumas or periods of immobilisation — hold the shoulder in one position for long enough, and it actually may get stuck there. The shoulder is the only joint that often “freezes” like this.1 Frozen shoulder is a biological puzzle, and a common one. It’s hard to define precisely, diagnose accurately, or treat effectively. In fact, frozen shoulder treatment is one the best examples of how musculoskeletal medicine is surprisingly primitive still.2

Sadly, the old idea that this is a self-limiting condition is flatly contradicted by modern evidence.3 There is hope — it can thaw spontaneously4— but many people will be frozen to some degree for a long time, measured in years.5

Adhesive capsulitis is the more formal term for frozen shoulder: it describes the characteristic stickyness that develops in the shoulder joint capsule. Sticky shoulder is probably a better name.

Range of motion fails, usually just on one side.6 Most patients first notice that they are having trouble reaching bra clasps, hip pockets, and back itches. About two thirds of patients are women.

How common is frozen shoulder?

The classic number is 2% of the population, but that’s not based on much, and it was challenged by Bunker in 2010:

The condition is also less common than the usually quoted figure of 2% of the population. This figure was arrived at 40 years ago when shoulder disease was ill understood and frozen shoulder was used as a waste‐bin diagnosis for any stiff and painful shoulder.

Bunker argues that the upper limit is probably 0.75% of the population for cases involving clear contracture.7 But that is still almost 1 in a 100 people. It’s not common-cold common, but it’s not rare either. It’s red-hair common.

Frozen shoulder is also linked to some extremely common health problems, like diabetes at 10% of the population, and diabetes is much more common than it used to be, a proper epidemic.8 The rising tide of diabetes may be bringing frozen shoulder with it.

Nature of the beast: frozen shoulder is a biological glitch

Getting into more detail now, frozen shoulder involves fibrosis and/or contracture of the tendons and joint capsule surrounding the glenohumeral joint, the main shoulder joint, specifically the rotator cuff interval.9 In severe cases, the rotator interval is “obliterated,” and the coracuhumeral ligament is “transformed into a tough contracted band,”10 like arthritis of soft tissues. This is more disease-like than most common musculoskeletal problems: a biological glitch, not a mechanical breakdown. Most notably, it is not a repetitive strain injury. In fact, if anything, it’s the opposite of an overuse injury: when it appears to have a “cause,” it’s more like an under-use injury, often triggered by a period of shoulder immobilization, like being stuck in a sling after a fracture or stroke. But it may also occur after a trauma to the area, even when there is no pronounced immobilization.

It is probably related to broader health problems. It mostly hits people over the age of forty, much more so if you have diabetes and/or cardiovascular disease.11 Frozen shoulder is extremely common in diabetics: more than 12% of them will get frozen shoulder, and about 30% of people with a frozen shoulder also have diabetes.12

Those problems are commonly associated with obesity, and what they have in common is “metabolic syndrome[NIH] — trouble with managing fats and sugars in the blood, and chronic low-grade inflammation everywhere.

Chronic low grade inflammation is increasingly seen as a part of other orthopaedic conditions such as osteoarthritis — once considered a ‘cold’ wear and tear problem (as opposed to the far more overt and ‘hot’ inflammation of rheumatoid arthritis).

~ Summer is coming — Frozen Shoulder, Cocks (Noijam.com)

No one knows why the shoulder joint capsule in particular would be the tip of this dysfunctional iceberg. Why such a dramatic point of failure? Why that tissue in particular? No one knows. But the relationship between frozen shoulder and metabolic syndrome is clear, as well as other glitchy biology like hyperthyroidism.13 It is one of many conditions that fall short of frank, diagnosable autoimmune disease like rheumatoid arthritis or lupus, but are still obviously autoimmune in character and characterised by inflammatory over-reaction.

General biological vulnerability

Carpal tunnel syndrome, just like frozen shoulder, is a surprisingly weird condition that is definitely more complicated than just using your wrist too much. People with median nerve compression have a significantly increased risk of … wait for it… heart disease.14 Since carpal tunnel syndrome itself pretty clearly doesn’t cause heart disease, it’s more likely that there’s something about the biology of these patients that leads to both carpal tunnel syndrome and heart disease.

This kind of thing is true of all chronic pain problems to some degree: general biological vulnerability is often just as important as whatever is specifically wrong with the tissue. Things like smoking, sleep deprivation, and being out of shape and several others are modifiable risk factors for any kind of chronic pain that, and typically neglected. See Vulnerability to Chronic Pain.

So that may be true for all chronic pain, but it seems to be more true of frozen shoulder. Of all common musculoskeletal conditions, frozen shoulder seems the most obviously linked to being unhealthy in other ways. Which makes it more interesting, for sure.

We know that smoking, for instance, is weirdly a major risk factor for shoulder problems,15 which likely includes frozen shoulder. Smoking contributes to the poor health that seems to make frozen shoulder more likely. Among it’s many notoriously harmful effects, smoking is also a factor in many kinds of chronic pain16 — but shoulders particularly tend to break down in smokers.

The good news is that general biological vulnerability is treatable. Most of the non-specific risk factors are modifiable (although it may be very tricky). I’ll return to the topic of general vulnerability when discussing treatment.

More more specific genetic vulnerability

There’s another weird link between frozen shoulder and another weird disease, both stronger and stranger than the diabetes link: roughly half of people with frozen shoulder also have a Dupuytren’s contracture — “frozen hand” — which is quite common and is probably caused by the same underlying problem with connective tissue seizing up.17 Although it causes such different symptoms that they seem more like pathological cousins than siblings, they are clearly related. Dr. Bunker: “This terrible triad of contracted shoulder, Dupuytren's contracture and diabetes pervades this whole area of scientific enquiry.”18

Or it could be an infection? Surgery and vaccination as causes of shoulder joint infection

You can hardly crack a medical journal open these days without stumbling on another example of how wee beasties are guilty of causing unexpected trouble, a factor in yet another condition we didn’t realize was infectious. The canonical example is the role of H. pylori in stomach ulcers.19 There are many other fascinating examples.20

Including some cases of… frozen shoulder?

Microscopic view of P. acnes bacterium.

Propionibacterium acnes, a bacterium we want in our pores, but not in our shoulders.

Apparently sticking a probe into a shoulder, despite antiseptic precautions, sometimes results in an alien invasion of the joint. By pimple bugs! “P. acnes was the most prevalent organism,” researchers reported in 2017.21 Yes, that’s the acne bacteria, Propionibacterium acnes (which may be wrongly blamed for acne22).

P. acnes is a “powerful nonspecific immune stimulant” which probably does trigger some cases of frozen shoulder, failures of prostheses, some arthritis, and perhaps even sciatica.23 Its role in post-operative infection is probably simply because it’s an endemic skin critter, nearly impossible to completely eliminate from the site of any puncture. Push just a few of them deep into a joint, and they find a new home and cause new kinds of trouble.

Amazing.

Rather than an infection that is dangerous and acute, the kind of thing we already know is a risk after surgery, it’s almost polite at first: barely detectable, in fact, just a little inflammation. But then? The inflammation caused by fighting the infection blossoms into frozen shoulder, and then it starts to suck to be you.

This is probably more common than we want to know about. In a 2015 survey, about 29% of people with persistent symptoms after surgery had an infection, and most of those had P. Acnes specifically growing in their joints. Only 3% of control group patients had P. Acnes growth (which is a lot less, but still strikes me as surprisingly high).24

Only surgery? Probably not

This seems to only apply to people who’ve had surgery, based on the data we have so far. But I don’t think we can actually rule out the possibility of infection with other mechanisms. Like many conditions involving inexplicable inflammation of tissue, it’s possible that it only looks like the immune system is attacking our own tissues for no reason. How many “autoimmune” diseases are responses to infections we don’t understand yet? Pure speculation on my part — but plausible, I hope, and certainly intriguing.

If surgery can do it, then there’s probably another way for P. acnes to catch a ride into the joint capsule…

Shoulder injury related to injections

The number one candidate for a non-surgical mechanism of infection is injection. While injections cause a lot fewer complications than surgery, anything that breaks the skin is still “invasive” and involves some infection risk. The most common injections are vaccinations, which is why this phenomenon is often referred to as “shoulder injury related to vaccine administration” (SIRVA) — a terrible term that seems to go out of its way to emphasize the wrong thing.25

Most injections are in the shoulder, because most injections are intramuscular, and the shoulder is convenient spot with a bunch of muscle. But sometimes shoulder injections miss: the needle goes into the joint capsule instead of the muscle tissue. Oops. Within a day or two, it becomes clear that the shoulder is much more sore than it should be. The symptoms may drag on and on: “Patients will often visit their physicians months later because they are not able to carry out daily tasks that were possible before the vaccination.”26 Wired magazine: “The prolonged pain and stiffness of SIRVA is distinct—in other words, much worse—than typical soreness from shots.”27 The conventional wisdom is that this is an ordinary minor injury, which is often mistaken for conditions like bursitis, rotator cuff tears, and adhesive capsulitis. Bancsi et al.:

During physical examination and on ultrasound scan, SIRVA will not appear to be any different from routine shoulder injuries. The only difference is that the shoulder symptoms will have started within days of a vaccination.

But is that the “only difference”? It’s not really normal for a minor physical trauma to drag on for weeks and months. It seems like something more might be going on here.

Unfortunately, it’s plausible that injections can trigger genuine adhesive capsulitis by the mechanism described above: the needle drags P. acnes into the joint capsule, just like a surgery can, and then excessive and prolonged inflammation ensues, more than minor physical trauma would ever cause, creating a genuine case of frozen shoulder.

Citation needed, but where there’s smoke…

Injection injuries are certainly a real thing, and frozen shoulder is a real thing, but do they overlap? Is there any evidence that injection injury specifically can cause frozen shoulder, via the mechanism of P. acnes infection? Not direct, evidence, no. This is the closest we’ve got: a 2015 paper reported three cases of injection injury followed by a confirmed diagnosis of frozen shoulder:28

But this is also about as where-there’s-smoke-there’s-fire as you can get. Infection as a complication of both surgery and injection are plausible, and there’s good evidence of the first. And it’s also plausible that such infection could lead to frozen shoulder, and there’s also both direct and indirect evidence for that (discussed above). From those premises, it’s just a short, reasonable hop to the hypothesis that injection injuries can cause frozen shoulder: far from proven, definitely possible.

Injection safety

The next time I get an injection — probably a vaccination, which I obviously will do, because the benefits dramatically outweigh the risks — I’m going to drown my shoulder in rubbing alcohol immediately beforehand. I want exactly zero surviving P. Acnes on my skin when that needle goes in!

“I say we take off & nuke the entire site from orbit. It’s the only way to be sure.”

~ Ellen Ripley, Aliens

Or just don’t get shots in the shoulder! Surgeon Dr. Michael Skyhar: “This is all avoidable by simply asking that the vaccine be placed in a different location, such as the upper/outer buttocks.”

Shoulder neglect? An evolutionary perspective on frozen shoulder

An interesting theory is that frozen shoulder occurs because “the human shoulder evolved for high speed projectile throwing,”29 and it suffers from neglect in modern living. Sedentary tissues can cause trouble, and be more vulnerable to biological failure. In particular, Pietrzak suggests, injury near the shoulder might trigger an inflammatory reaction that’s just waiting to happen.

I think it’s unlikely that the shoulder actually “evolved” for that purpose in the first place,30 and, even if it did, why would the shoulder be the only anatomy in the body with this problem? Surely many body parts tend to stagnate in modern living, and yet — as already noted — only shoulders “freeze” like this.

But there’s some strong support for Pietrzak’s idea. In 2013, Littlewood et al. made a detailed argument that the symptoms of rotator cuff tendinopathy — and the shoulder joint capsule is essentially just a bunch of rotator cuff tendons — can occur without any actual or impending tissue damage.31 First they make the case that explanations for pain based on “peripherally driven nociceptive mechanisms secondary to structural abnormality, or failed healing, appear inadequate” — at least in the context of rotator cuff tendinopathy (and probably much else). They’re on firm ground with that premise. So what is the problem? They propose that the brain may react to relative overuse of de-conditioned tendon — tendon that’s just been lazing around too much — with fearful avoidance of movement, a vicious cycle of painful inhibition of function. This is completely consistent with Pietrzak’s idea. And “functional freezing” is the next major topic …

Stiff but not “frozen”: the case for functional freezing

“Adhesive” capsulitis refers to a literal stuckness, and there’s no question that the most frozen shoulders are literally stuck in a limited range. But could some frozen shoulders be less literally stuck? Could that stuckness sometimes be more of a functional limitation than a physical one? Is it even possible that many cases are at least partially like this? What if, say, 60% of cases were 30% explained not by sticky joint capsule, but by an extreme reluctance to move (neurological inhibition)?

In a minor way, everyone’s joints “freeze” like this eventually. Joint stiffness, especially after being still for a while, is probably a non-specific reaction to practically anything that can go wrong with a joint. For many people, their first experience with this is after joint injuries in their youth — but it’s so obviously related to and in sync with recovery from the injury that it’s unremarkable. And then, years later, it’s usually the first symptom of arthritis. This stiffness is almost certainly protective and not a physical limitation, but neurological inhibition.32 Its purpose is to limit risk exposure for a joint the nervous system is “worried” about. In other words, it’s how the body says, “Careful now… no sudden moves…”

Any normal process in the body is usually represented by more extreme examples in some people, or in particular anatomy, and there definitely some more dramatic examples of joint inhibition: some people’s quadriceps muscles shut down after knee trauma, a well-described phenomenon known as arthrogenic muscle inhibition.33 The muscle just stops doing its job so completely that it starts to atrophy: “My quad is deflating daily, like a slow tire leak.”34

If it can happen to the knees, maybe it can happen to other joints — it’s not clear why it would be so well-known about knees and not at all about shoulders, but it could still be true.35

Not all frozen shoulders are contractured

When you open frozen shoulders up, not all of them have clear visible signs of disease. Dr. Tim Bunker believes that only about 50% of patients diagnosed with the condition actually have obvious signs of pathology in the shoulder.36

That suggests that quite a few cases are functionally frozen.

And could functional limitation be more prevalant in cases that are dragging on and on? Do some people slowly climb out of the frying pan of a sticky joint capsule and into the fire of a shoulder that’s just too uncomfortable to move? What if the door of shoulder movement stealthily transitioned from welded shut to just being rusted shut?

There’s hope in them thar hills, because a functional stiffness might be easier to loosen up (with massage, say, or carefully planned exercise). And yet the opportunity might be tragically missed! How would a patient even know that the situation had changed? There’s no easy way to tell that something badly stuck is less badly stuck that it used to be.

I’ve used a lot of questions to introduce this topic because — surprise surprise — no one actually knows. It’s a popular idea.37 There’s an accumulation of clues that the usual suspects aren’t cutting it, evidence that we’re missing something (which is what Littlewood et al is all about). And we have clinical stories that seem to suggest it.38 And some recent evidence.

Well that’s interesting: “stuck” shoulders not so stuck when unconscious

In 2015, someone finally did a nice science experiment on this, simple and directly relevant.39 Five capsular release surgery patients were checked before and after being put under general anaesthesia. All five of them had “significantly more passive shoulder abduction” when they were knocked out … which would be impossible if their capsules were actually contractured or adhered or full of cement or any physical limitation. The improvement in ROM ranged from a minimum of 44˚ all the way up to a 110˚ boost (all the way back to normal). The researchers reasonably concluded:

Passive range of motion loss in frozen shoulder is not fully explained by a true capsular contracture alone. Passive shoulder abduction ROM assessed in awake patients with frozen shoulder does not accurately reflect the true available ROM of the affected shoulder. It appears that active stiffness or muscle guarding is a major contributing factor to reduced ROM in patients with frozen shoulder.

If I was the surgeon, I might have found it ethically hard to justify operating on these shoulders after seeing that.

Case closed? No, not yet. It’s really a shame it was such a small study. We really need someone to do the same thing with five times as many patients. But it is quite suggestive, innit? Things that make you go, “Hmmmm!”

The worst cases probably really are dominated by adhesion. Worrying about a functional limitation, especially in the earlier stages of freezing, may be like trying to sweep up the ashes while the fire is still raging. But the possibility really shouldn’t be ignored, especially later on. It just might be the most important thing anyone can learn about this bizarre condition, mainly because it suggests several treatment options that are much more useful if there’s functional freezing, like strengthening, massage, or even Tiger Balm.

A diagram depicting the hypothetical relationship between functional and adhesive restriction of movement in frozen shoulder.

Over time, it’s possible that a functional limitation gradually becomes responsible for a larger share of the immobility & pain of the condition. It probably wouldn’t sustain the full ferocity of the condition, so I’ve depicted a slope downwards representing a general decline in severity — but of course the mixture over time could vary a lot from patient to patient.

How does “functional freezing” cause frozen shoulder?

There are three main ways that a functional limitation of shoulder ROM would probably work, and we shouldn’t underestimate their potential power:

  1. The brain can “shut down” a joint with neurological inhibition.
  2. The brain might do that to the joint because it has become sensitized.
  3. The muscles may have gotten rotten with “knots” (trigger points)

The brain is the boss of all function, and when it decides that a joint shouldn’t move, then it’s not going to move — and because your conscious mind isn’t included in the decision, the limitation can feel externally imposed. Your shoulder might as well be in a vice. Inhibition doesn’t feel “functional”: it just feels like you can’t move. Will power doesn’t come into this. Your brain is protecting you from yourself (or so it hopes). This is standard neurological procedure with severe traumas.

Why would a brain lock a joint down this? It might do it if the pain has become like an oversensitive alarm that’s always going off when there’s nothing really wrong. “Sensitization” is well-described, and it’s what puts the “chronic” in chronic pain.40 It is the main mechanism by which pain gets stubborn and unrealistic, a neurological over-reaction. Pain is all about detecting threats and changing behaviour to avoid them. If your brain is convinced that your shoulder is is more danger than it really is, it will both hurt more and get shut down. And there are couple reasons why the inhibited movement might be more obvious than the pain in this particular joint.41

Trigger points are a tough topic, because no one really knows exactly what they are, but there’s no question that people often develop sensitive spots in soft tissue, and there’s usually more of them in troubled areas. Although their nature is unexplained and controversial,42 the usual way of explaining them seems like a great fit for frozen shoulder: “tiny cramps” in the muscle would make it uncomfortable, weak, and less stretchy, like a knotted bungie cord. If the rotator cuff and other shoulder muscles were full of trigger points, perhaps the net effect would feel an awful lot like literal “freezing.”

I’ll discuss dis-inhibition and de-sensitization strategies below, as well as the (hopelessly imperfect) options for trying to treat trigger points.

Shrunk, not stuck: a 150-year history of misleading names for frozen shoulder

The earliest medical description of frozen shoulder dates to 1872, when Simon-Emmanuel Duplay called it periarthritis of the shoulder,43 and for a while various shoulder problems were (incorrectly) attributed to the idea of “periarthritis,” and for a while Duplays Disease was used to describe several shoulder problems.

The term “frozen shoulder” was coined by a Boston surgeon, Ernest Amory Codman, in 1934, in his book about the shoulder.44 Codman was the first to more thoroughly and precisely describe the condition, and he gave its popular name which still in wide use today — although perhaps it shouldn’t be, as we’ll see. (Codman was also the first American doctor to systematically track patients through recovery, which is pretty cool: he was ahead of his time.)

The term “adhesive capsulitis” arrived in 1945 when Dr. Julius Neviaser described the texture of the joint capsule as “adhesive,” comparing it to a sticking plaster — an archaic term for a small medical dressing, AKA a bandage.45

These days, adhesive capsulitis is usually seen as the most modern and precise descriptive jargon for the condition, but perhaps its no better than “periarthritis.”

“Adhesive” may be the wrong word: shrunk, not stuck

There is no detail of this condition that isn’t controversial and mysterious, and what shows it better than a challenge to its name? Nagy et al (among others) argue that “adhesive” is inaccurate:46 it’s not an adhered joint capsule, but rather a contractured one. Contracture [Wikipedia] is the shortening or hardening of tissue. In more familiar words, they’re saying the joint has been “shrink wrapped” by a joint capsule that has tightened, rather than surrounded by loose layers of joint capsule that have gotten stuck together.

What’s in a name? Maybe a lot in this case: this difference could be extremely important to treatment. Sticky layers can be pulled apart; contracture is an issue that’s probably a lot harder to force.

So, what’s really going on? It’s probably impossible to call this one. We can infer from the partial successes of some surgical procedures that contracture probably isn’t the whole story, so that’s one decent clue. But the main problem with the theory is that there’s not much information about this adhesion versus contracture business. It seems to have originated with a couple papers way back in 1989 and 1995,4748 with little other comment from other researchers, except notably Bunker in 2010, who is emphatically on “team contracture”:49)

Finally we can appeal for a new name for this common, painful and protracted condition and call it what it is, a contracted shoulder.

I suspect these authors are correct, but I have also watched similar scientific controveries about other problems go back and forth for many years, with new studies over-turning old ones as often as I change my socks, so I won’t take a position on this one. For now I’ll just point out that there’s an interesting question mark here.

Posture: is frozen shoulder the tip of a misalignment iceberg?

No.50

See also: Betteridge’s Law of Headlines strikes again.

Case study: an interesting example of a biological X-factor

Tanya Augustine teaches high school biology, anatomy and physiology and exercise physiology in Cambridge, Mass. She kindly sent me her interesting frozen shoulder story, and granted permission to use it here. I think it will be of interest to many readers.

I had an experience similar to your wife’s experience in that I have an extremely high tolerance with pain and when I tripped or someone bumped into me, a few times I fell to the ground writhing in pain. I was in tremendous pain, couldn’t get my sports bra on/off, write on the board while teaching, comb my hair and was having great difficulty sleeping.

I was 39 at the time. I’m now 50. I have been extremely active my entire life. I taught “aerobics” for decades and was a sergeant in the US Army in my early 30’s for 4 years. I’ve never been overweight, a smoker, diabetic, or any of those things. The only risk factor I had was my sex and approximate age (around 40).

I could no longer take the pain and after some steroid shots and physical therapy opted for surgery. I had my surgery at Mass General Hospital in Boston MA. The surgeons told me that as soon I was under general anesthesia that they attempted to mobilize my shoulder to see if it was frozen from pain, and nope, that wasn’t it: they couldn’t move it at all when I was unconscious. Then when they went to insert the arthroscopic equipment, they couldn’t get it in without great difficulty due to all the scaring in the joint.

I had never had a shoulder injury that I could remember. No accident, baseball pitching career, etc. I had gotten into doing pull-ups at the gym at that time, but I’ve always been very strong. It just gradually crept in for no obvious reason. Also, it was in my dominant side (left) which I guess is less common.

The rehab and physical therapy for the shoulder surgery was brutal, but I instantly regained a ton of ROM and was back to about 90% in 2 months and was discharged from PT. I am so grateful I had the surgery, although I had been advised that it would “eventually” unfreeze on its own (a year or two!?!).

A couple of years later my right shoulder started developing pain, and I freaked out and saw a sports doctor at Tufts Medical. She juiced me up with a lot of cortisone in the joint capsule, I did zero PT, and felt better a few weeks later. The pain has not returned in either shoulder.

So this is about as cryptic a case of frozen shoulder as there could possibly be. But would some kind of biological disposition to this condition eventually reveal itself? Indeed it would.…

So fast forward 10 years later. I had surgery this past June for Dupuytren’s contracture in my right hand. Again, no obvious risk factors. Not old (for this disease), male, diabetic, Parkinson’s, etc, etc. My hand was so contracted I could no longer type on my computer or open jars. The surgeons again reported that I had a great deal of scar tissue and had to cut more than originally planned to break it up. My mother had the surgery in her 50s, and when visiting my father this past summer, I realized he has it as well (he thought it was arthritis, he’s 81), so clearly there’s a genetic component.

A point of interest: I had a very bad bike accident about 8 years ago which involved me landing on my palms and scraping deep wounds off filed with pavement and glass into them. I didn’t get any medical treatment for those, just washed them out (sort of) and bandaged them up. Within months, I thought I had pebbles stuck in my palms from the accident. I waited a year or two and saw a hand specialist who looked at my hands and replied “not pebbles, Dupuytren’s.” The hand specialists are skeptical there's a link between my bike accident and the disease onset, but at that time I started noticing hard bumps which eventually progressed to my advanced disease.

So I think I have an over active immune system, at least as far as my joints and tendons go. Also, I’m extremely happy with my choice in both circumstances for surgery, rather than months of other therapies. I had to get my regularly, active, pain-free, lifestyle back and the surgeries were extremely effective both times. I am not a big proponent of surgery or general medical practices for things that will resolve on their own (or even diagnositcs such as MRIs) but in these cases, I am glad this is how I handled it.

Like everyone, I’m searching for an explanation for these things, and have to settle for “it’s not well understood”, which is frustrating, since I don’t want either condition to return. However, I have made zero lifestyle changes, as I don’t think there is anything I can do to prevent them.

I think Tanya’s theory is sound. Autoimmune diseases are as varied as the inhabitants of a zoo, such a wide spectrum of severity that it’s a near certainty that they often exist in a subtle disease, with consequences that fall well short of frank disease but still change lives. So this is a dramatic example of a shoulder that was obviously not functionally frozen. This was true freezing, a joint capsule that was stuck, stuck, stuck. And what a strong testimonial for surgery!

Part 2

Diagnosis of Frozen Shoulder

Confirming the diagnosis: classic frozen shoulder symptoms

Frozen shoulder is technically a diagnosis of exclusion[Wikipedia], which means that it can only be diagnosed by eliminating all other possibilities. There is no standard clinical test for frozen shoulder, nothing that can clinch it.

That said, it shouldn’t be hard to diagnose by exclusion — or rather, it shouldn’t be. In practice, there is often confusion with other conditions (reviewed below). Physical therapist and shoulder guy Adam Meakins sees “a lot of frozen shoulders,” but also “many who have been told they have frozen shoulder who clearly do not.”51

The defining symptoms of frozen shoulder are:

But, in principle, it’s important to understand that any/all of those symptoms could in theory be caused by other problems.

Shoulder issues that get confused with adhesive capsulitis

These are presented roughly in order of how much they can seem like frozen shoulder, briefly explaining them and highlighting the major differences…

END OF FREE INTRODUCTION

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Plus …

The trouble with Dr. Google and why this book matters

In the many years since I’ve been writing about painful problems like frozen shoulder, there has been an explosion of shabby information about everything condition. Shockingly, this has not resulted in patients or health care professionals being better informed. Most of the information that you can find out there repeats the same oversimplified conventional wisdom … much of which is just wrong. A particularly good example is the way “adhesive” capsulitis is probably the wrong name for the condition, a mistake based on early, incorrect assumptions about the pathophysiology that almost no one seems to know about yet.

Scientists have actually proven that “Dr. Google” is incompetent — just in case you needed any convincing.+In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al.

I’ve been obsessively updating this tutorial for about 3 years now. By 2018, it was the largest and best of its kind as far as I could tell. I had already mined the best ideas I could find from the most detailed sources, and surpassed them — more information, more fun, and more rigorous. And then I kept going, while everything else seems to have stood still. Blog posts that haven’t been updated. Myths repeated ad nauseum for decades now. Big medical publishers that haven’t added anything to their shallow frozen shoulder summaries in years, and you wouldn’t enjoy reading it if they did.

So what can I do for you?

There is no cure for frozen shoulder syndrome. Of course not! Wouldn’t it be great if there were a proven treatment with minimal cost, inconvenience, or side effects? But we’re nowhere close to this for frozen shoulder. This book wouldn’t need to exist if there were.

What I can do is explain and review all the imperfect options so that you can prioritize them. I can help you confirm your diagnosis and debunk bad ideas. Some people will finally enjoy a breakthrough after reading this tutorial, and get partial or complete relief of their symptoms, sometimes temporary, sometimes lasting. And maybe that is kind of miraculous!

Just reading it might help. Online tutorials like this one might actually be able to directly help people with chronic pain — the evidence supports that, at least a little+Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902. 

Researchers tested a series of web-based pain management tutorials on people who had been suffering for more than six months. No matter how much (or little) help they had from doctors and therapists, they all experienced significant reductions in disability, anxiety, and average pain levels, for at least three months.
Basic knowledge is fine for basic cases, but more and better information is important for the tough ones. And even if you only recently developed frozen shoulder for the first time, how long do you want to spend following poor quality advice or muddling about with partial understanding? Get started on the right foot.

All of that is hopefully worth more than several sessions of physical therapy, at a fraction of the cost.


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Part 2.2

Appendices

Related Reading

Why Does Pain Hurt? — The inflammation of frozen shoulder is exasperatingly mysterious. This article explains how inflammation can be “glitchy” — an interesting perspective that might help make sense of frozen shoulder.

Muscle Pain as an Injury Complication — The story of a difficult shoulder rehab. Although not a case of adhesive capsulitis, there’s lots of relevant detail about how any shoulder pain can get stubborn.

Repetitive Strain Injuries Tutorial — Frozen shoulder isn’t an overuse injury, but it is often mistaken for one, and most of the RSIs are just as odd and surprising as frozen shoulder is, in their own ways. This article explores five surprising and important facts about conditions like carpal tunnel syndrome, tendinitis, or iliotibial band.

Dupuytren’s Contracture — Frozen shoulder is probably in the same pathological family as this common hand condition that slowly causes the hand to flex into a claw. The palm “shrinks” much like the shoulder joint capsule.

What’s new in this article?

Seventy-nine updates have been logged for this article since publication (2016). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets PainScience.com apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.

I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

NovemberNew section: No notes. Just a new section. [Section: The cannabinoids: marijuana and hemp, THC and CBD — “it’s complicated!”.]

NovemberMinor improvement: Minor but interesting: a couple new paragraphs about joint stiffness as a the non-specific protective mechanism that may be analogous to functional freezing of the shoulder. [Section: Stiff but not “frozen”: the case for functional freezing.]

NovemberMajor update: Added a lot more detail, especially about psychoactive “muscle relaxants,” and many new references. [Section: Muscle relaxants (Robaxin, Robaxacet, etc), psychoactives, and sedatives.]

NovemberNew chapter: [Section: Muscle relaxants (Robaxin, Robaxacet, etc), psychoactives, and sedatives.]

OctoberNew chapter: [Section: Whole lotta shakin’ going on: vibration therapy.]

OctoberScience update: Added an interesting reference about a link between carpal tunnel syndrome and heart diease, for context and comparison. [Section: Nature of the beast: frozen shoulder is a biological glitch.]

SeptemberExpanded: Added Reiki and magnet therapy, plus a bunch of other minor improvements. [Section: Hall of treatment shame: the most bogus frozen shoulder treatments.]

SeptemberExpanded: Added discussion of general health benefits of massage therapy. [Section: Massage therapy: can everyone’s favourite therapy help?]

SeptemberAddition: Added facioscapulohumeral muscular dystrophy, a particularly good example of a condition that causes diagnostic confusion in the shoulder. [Section: Shoulder issues that get confused with adhesive capsulitis.]

AugustBook launch: The frozen shoulder guide has been free since I first introduced it in the summer of 2016. Two years and hundreds of hours of development later, I am putting it behind the paywall, the first addition to my inventory of ebooks in many years. It is for sale for $20 USD. All existing boxed set customers will get access automatically — someone who bought a set in 2009 is getting a new book out of that purchase a decade later.

AugustExpanded: Added a fascinating cautionary tale of surgery gone wrong. [Section: Forcing the issue with manipulation under anesthesia (MUA).]

AugustNew section: No notes. Just a new section. [Section: Confirm the contribution of functional freezing (maybe).]

JulyNew section: No notes. Just a new section. [Section: Aquatic therapy: water exercise, floatation therapy, and Epsom salts.]

JulyNew section: No notes. Just a new section. [Section: Woo! “Windows of opportunity” might be important in frozen shoulder rehab.]

JulyExpansion: Added a detailed overview of all the treatment options reviewed in this tutorial. [Section: Treatment of Frozen Shoulder: Reviews of all the major treatment options.]

JulyNew section: No notes. Just a new section. [Section: Tiger Balm, A535, and friends: unfreezing shoulders with mild chemical burns.]

JulyNew section: No notes. Just a new section. [Section: Hall of treatment shame: the most bogus frozen shoulder treatments.]

JulyClarification: Made it clear that frozen shoulder is a particularly strong example of an important phenomenon, the importance of non-specific risk factors in chronic pain. [Section: Nature of the beast: frozen shoulder is a biological glitch.]

JulyNew section: No notes. Just a new section. [Section: Reducing vulnerability: tackling the things that make all kinds of pain worse.]

JuneNew chapter: Before the update: just a couple of paragraphs about self-massage of trigger points. After: now there’s a concise but complete 2000-word whirlwind tour of the world of trigger point therapy, spelling out the relevance to frozen shoulder and plenty of specific advice for frozen shoulder patients. [Section: Trigger point therapy: trying to “release” those sore spots.]

MayNew sub-topic: Fascinating addition to the tutorial: “Shoulder injury related to vaccine administration.” [Section: Or it could be an infection? Surgery and vaccination as causes of shoulder joint infection.]

AprilExpanded: Imaging is now discussed in its own small section, and I beefed it up with information about the role of diagnostic ultrasound. [Section: X-ray, MRI, or ultrasound for diagnosing frozen shoulder.]

MarchScience update: Added information and citations on the condition of the joint in severe cases, and the link to Dupuytren’s contracture. [Section: Nature of the beast: frozen shoulder is a biological glitch.]

FebruaryNew section: No notes. Just a new section. [Section: Or it could be an infection? Surgery and vaccination as causes of shoulder joint infection.]

JanuaryMinor science update: Added support from another researcher (Bunker) for abolishing the term “adhesive capsulitis.” [Section: Shrunk, not stuck: a 150-year history of misleading names for frozen shoulder.]

JanuaryScience update: Added information about the prevalence of frozen shoulder in the general population and in diabetics. [Section: Nature of the beast: frozen shoulder is a biological glitch.]

JanuaryClarification: Made it clear that frozen shoulder is a diagnosis of exclusion. [Section: Diagnosis of Frozen Shoulder: Confirming the diagnosis: classic frozen shoulder symptoms.]

JanuaryAddition: Defined the condition more precisely and thoroughly. Added a substantive footnote about the exact anatomy affected. [Section: Nature of the beast: frozen shoulder is a biological glitch.]

2018Upgrade: Added table of contents.

2018New section: No notes. Just a new section. [Section: Hacking the neurology of pain: desensitization and disinhibition.]

2018New section: Predictably gloomy conclusions! But it’s now here for thoroughness. [Section: Super ultrasound! Shockwave therapy.]

2018Science update: Cited and analyzed Jewell et al with regards to the poor results from physical therapy overall, and massage specifically. [Section: Treatment of Frozen Shoulder: Reviews of all the major treatment options.]

2018Improved: Significantly improved the answer to the question “How would functional freezing work?” by including sensitization. [Section: How does “functional freezing” cause frozen shoulder?]

2018Science update: A small but important update: cited Hollmann et al, who demonstrated in a small study that at least some people with frozen shoulder aren’t frozen when anaesthetized, strongly suggesting that at least some cases are not caused by capsular contracture. Cool and promising. [Section: Stiff but not “frozen”: the case for functional freezing.]

2018New section: No notes. Just a new section. [Section: Stretching.]

2018New section: No notes. Just a new section. [Section: Getting stronger as a therapy.]

2018New section: No notes. Just a new section. [Section: Forcing the issue with MUA lite, the Oolo-Austin Trigenics® Procedure (OAT).]

2018New section: Very “negative”: there’s almost no hope that it works. [Section: Maybe sound waves will help? Ultrasound.]

2018Science update: A couple new citations and details about steroid injections. [Section: Corticosteroid injections.]

2017Improved: Beefed up information on over-the-counter medications. [Section: The basic pain killers — aspirin, ibuprofen, acetaminophen, etc.]

2017New section: No notes. Just a new section. [Section: Posture: is frozen shoulder the tip of a misalignment iceberg?]

2017Science update: Cited new evidence on the limited benefits of steroid injections for rotator cuff tendinopathy (Mohamadi) — an interesting contrast with the effects of steroids on frozen shoulder. [Section: Corticosteroid injections.]

2017New section: Important revisions and a new section based on important new evidence (Wong et al) that frozen shoulder is not a self-limiting condition as everyone has assumed for decades. [Section: Prognosis: Depressing frozen shoulder bombshell: it ain’t self-limiting!]

2017New section: No notes. Just a new section. [Section: Corticosteroid injections.]

2017Improvements: Added more movement recommendations. [Section: Use it or lose it: movement therapy.]

2017New section: No notes. Just a new section. [Section: Shoulder neglect? An evolutionary perspective on frozen shoulder.]

2017Improved: Added some history, which is nice new context for this topic. [Section: Shrunk, not stuck: a 150-year history of misleading names for frozen shoulder.]

2017New section: A substantial and interesting reader-submitted case study plus a little commentary. [Section: Case study: an interesting example of a biological X-factor.]

2016Publication.

Acknowledgements

Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends (see the origin story). Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

Notes

  1. Other joints do freeze like the shoulder, but much less often. For instance, there is such a thing as a frozen hip (see de Sa et al), but it’s so rare and hard to diagnose that we don’t even know how rare it really is. (Byrd et al argues that it’s “more common than suggested in the published literature,” but still much rarer than frozen shoulder.) Some other joints in the body can probably freeze to some extent as well — frozen ankle! frozen wrist! — but the shoulder is by far the most prone to it.

    There’s also an interesting connection to Dupuytren’s contracture — “frozen hand” disease — which is fairly common and may be more similar than it seems. More on that below.

    BACK TO TEXT
  2. Weirdly, musculoskeletal pain is a bit of a backwater, simply because medicine has had much bigger fish to fry, like trying to cure major infectious diseases and so on (see A Historical Perspective On Aches ‘n’ Pains). Medical training is certainly better than the competition, but family doctors lack the skills and knowledge to treat most chronic pain and injury problems, especially the tricky, stubborn ones (see The Medical Blind Spot for Aches, Pains & Injuries). Even sports medicine is only beginning to really get going properly, despite the serious money involved in elite athletics (see Grant et al). BACK TO TEXT
  3. Wong CK, Levine WN, Deo K, et al. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy. 2017 Mar;103(1):40–47. PubMed #27641499. 

    Evidence from seven reviewed studies suggests that frozen shoulder does not resolve on its own without treatment, contrary to the entrenched conventional wisdom (which isn’t supported by any evidence). On the contrary, what the evidence supports is that frozen shoulder prognosis is highly unpredictable, and may resolve much sooner than average… or not at all.

    BACK TO TEXT
  4. Eljabu W, Klinger HM, von Knoch M. Prognostic factors and therapeutic options for treatment of frozen shoulder: a systematic review. Arch Orthop Trauma Surg. 2016 Jan;136(1):1–7. PubMed #26476720.  “Spontaneous recovery to normal levels of function is possible.” BACK TO TEXT
  5. Clement et al paints quite a grim prognosis, with as many as 40% experiencing “persistent symptoms and restricted movement beyond 3 years,” and a troubling 15% left with “permanent disability.” Fortunately, that’s probably a bit alarmist, and those numbers are supported by citations to only two small old studies. Much more recently, Hand et al looked at many more cases (223) after about 4 years on average. Although they confirmed that 40% still had symptoms, almost all of them were mild (94%), and “only 6% had severe symptoms with pain and functional loss.” BACK TO TEXT
  6. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg. 2008;17(2):231–6. PubMed #17993282.  About 15-20% of patients develop the disease in both shoulders. BACK TO TEXT
  7. Bunker T. Time for a new name for frozen shoulder—contracture of the shoulder. Shoulder & Elbow. 2009;1(1):4–9. PainSci #52392. 

    Bunker believes that capsular contracture only accounts for 5% of all shoulder disease, “and since shoulder disease only affects 15% of the population, then it would be reasonable to suggest that the real incidence of capsular contracture is about 0.75% of the population.”

    I will be referencing Bunker's papers again and again in this tutorial.

    BACK TO TEXT
  8. Danaei G, Finucane MM, Lu Y, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants. Lancet. 2011 Jul;378(9785):31–40. PubMed #21705069. 

    Almost 10 percent of all adults globally have diabetes and that number is rising fast. Increased obesity and inactivity are the primary causes. Danaei et al predict an enormous burden of disability and medical costs if the trend continues.

    BACK TO TEXT
  9. The rotator cuff interval (space) is a wedge of complex anatomy roughly between the top of the humerus and the clavicle, filled with part of the shoulder joint capsule and some tendons and ligaments. Its “roof” is the coracohumeral ligament, a major structural ligament that the arm hangs from. It contains the subscapular recess, an outpouching of the glenohumeral joint capsule, basically sticking right into the rotator cuff interval. Other notable inhabitants of the interval: the long head of biceps tendon, and the superior glenohumeral ligament. See Petchprapa et al [free full text] for extreme detail on all of this. BACK TO TEXT
  10. Omari A, Bunker TD. Open surgical release for frozen shoulder: surgical findings and results of the release. J Shoulder Elbow Surg. 2001;10(4):353–7. PubMed #11517365.  In this study, the authors treated 75 shoulders over a five-year period. Nine improved without surgery. Of the remainder, 66 improved with manipulation under anaesthesia, but 25 did not and “open surgical release” was attempted with those patients: cutting the shoulder free, basically. And those patients “showed a consistent alteration in the rotator interval and coracohumeral ligament. The rotator interval was obliterated, and the coracohumeral ligament was transformed into a tough contracted band.” BACK TO TEXT
  11. Pietrzak M. Adhesive capsulitis: An age related symptom of metabolic syndrome and chronic low-grade inflammation? Med Hypotheses. 2016 Mar;88:12–7. PubMed #26880627.  BACK TO TEXT
  12. Neviaser AS, Hannafin JA. Adhesive capsulitis: a review of current treatment. Am J Sports Med. 2010 Nov;38(11):2346–56. PubMed #20110457.  BACK TO TEXT
  13. Huang SW, Lin JW, Wang WT, et al. Hyperthyroidism is a risk factor for developing adhesive capsulitis of the shoulder: a nationwide longitudinal population-based study. Sci Rep. 2014;4:4183. PubMed #24567049.  PainSci #53252.  “The results of our large-scale longitudinal population-based study indicated that hyperthyroidism is an independent risk factor of developing adhesive capsulitis.” BACK TO TEXT
  14. Fosbøl EL, Rørth R, Leicht BP, et al. Association of Carpal Tunnel Syndrome With Amyloidosis, Heart~Failure, and Adverse Cardiovascular Outcomes. Journal of the American College of Cardiology. 2019;74(1):15––23. PainSci #52255. 

    This study is focussed on an increased risk of heart failure in carpal tunnel syndrome patients, but, as a musculoskeletal medicine guy, I am more interested in the reverse implication: that CTS is probably partially or entirely triggered by some underlying biology that makes things harder for hearts.

    BACK TO TEXT
  15. Bishop JY, Santiago-Torres JE, Rimmke N, Flanigan DC. Smoking Predisposes to Rotator Cuff Pathology and Shoulder Dysfunction: A Systematic Review. Arthroscopy. 2015 Aug;31(8):1598–605. PubMed #25801046.  BACK TO TEXT
  16. PS Ingraham. Smoking and Chronic Pain: We often underestimate the power of (tobacco) smoking to make things hurt more and longer. PainScience.com. 1358 words. BACK TO TEXT
  17. Smith SP, Devaraj VS, Bunker TD. The association between frozen shoulder and Dupuytren's disease. J Shoulder Elbow Surg. 2001;10(2):149–51. PubMed #11307078.  BACK TO TEXT
  18. Bunker 2009, op. cit. BACK TO TEXT
  19. Helicobacter pylori was famously hunted down in 1983 by Australian scientists Barry Marshall and Robin Warren. Although its link with ulceration was initially met with much skepticism, science came around relatively quickly — convinced by evidence, just like it’s supposed to work. By the mid-90s it was widely accepted that H. pylori infection causes ulcers, and Marshall and Warren got a Nobel prize in 2005 (acceptance speech). BACK TO TEXT
  20. A much, much fresher example than the H. Pylori story is the idea that the infamous “plaques” of alzheimer’s disease are, in fact, a form of immune reaction to an invader — “nets” of sticky protein tendrils intended to stop an infection, but which also cause collateral damage. Really amazing science. See: Have researchers been wrong about Alzheimer's? A new theory challenges the old story. BACK TO TEXT
  21. Khan U, Torrance E, Townsend R, et al. Low-grade infections in nonarthroplasty shoulder surgery. J Shoulder Elbow Surg. 2017 Sep;26(9):1553–1561. PubMed #28359693.  BACK TO TEXT
  22. This explanation from Arthritis Micropia:

    Propionibacterium acnes is a skin bacterium which grows well in an anaerobic (low oxygen) environment. The species populates skin pores and hair follicles and feeds on sebaceous matter. This is a fatty substance produced in glands to keep the skin waterproof. P. acnes is a benign skin bacterium which can help the skin by stopping harmful bacteria getting into the pores.

    It was long thought that P. acnes caused spots. This was because the number of P. acnes bacteria increases enormously during puberty, together with the number of spots. Recent research has shown, however, that P. acnes actually helps in the fight against spots. Harmful bacteria cannot get a foothold because the pores and hair follicles are already occupied.

    However, other sources contradict this (such as Knobler et al), or, this review much more recently, which explains: “Over the last 10 years our understanding of the taxonomic and intraspecies diversity of this bacterium has increased tremendously, and with it the realisation that particular strains are associated with skin health while others appear related to disease.” BACK TO TEXT
  23. The Infectious Etiology of Chronic Diseases: Defining the Relationship, Enhancing the Research, and Mitigating the Effects. National Academies Press (US); 2004.

    One of the great ironies of this organism is that it is a powerful nonspecific immune stimulant that resides naturally in the skin; its role as an immunostimulant in humans is appreciated when cases of severe acne also develop adjuvant-type arthritis.

    Some investigators have gone so far as to suggest that severe acne, by virtue of the nonspecific immunostimulatory effects of P. acnes, might have played a role in natural protection against life-threatening diseases such as malaria and plague. In contrast, the acquired immune response to P. acnes has received little attention in humans.

    BACK TO TEXT
  24. Horneff 3, Hsu JE, Voleti PB, O'Donnell J, Huffman GR. Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain. J Shoulder Elbow Surg. 2015 Jun;24(6):838–43. PubMed #25979553.  BACK TO TEXT
  25. This is about needles, not what’s in them, and the last thing the world needs now is more demonization of vaccinations. So let’s not call it SIRVA, because that’s a bullshit term that seems to go out of its way to emphasize the wrong thing. BACK TO TEXT
  26. Bancsi A, Houle SK, Grindrod KA. Shoulder injury related to vaccine administration and other injection site events. Can Fam Physician. 2019 Jan;65(1):40–42. PubMed #30674513.  PainSci #52264.  BACK TO TEXT
  27. www.wired.com [Internet]. Zhang S. Why Are Cases of Shoulder Injuries From Vaccines Increasing?; 2019 May 21 [cited 19 Aug 7]. BACK TO TEXT
  28. Saleh ZM, Faruqui S, Foad A. Onset of Frozen Shoulder Following Pneumococcal and Influenza Vaccinations. J Chiropr Med. 2015 Dec;14(4):285–9. PubMed #26793041.  PainSci #52474.  “Although vaccines are of tremendous importance in the prevention of serious illness, we emphasize the importance of administering them at the appropriate depth and location for each patient.” Indeed. BACK TO TEXT
  29. Pietrzak 2016, op. cit. BACK TO TEXT
  30. Stone-throwing hardly seems like a decisive reproductive advantage. And biologically modern humans were around for tens of thousands of years at least before we were using spears and slings to great effect. BACK TO TEXT
  31. Littlewood C, Malliaras P, Bateman M, et al. The central nervous system--an additional consideration in 'rotator cuff tendinopathy' and a potential basis for understanding response to loaded therapeutic exercise. Man Ther. 2013 Dec;18(6):468–72. PubMed #23932100.  BACK TO TEXT
  32. This phenomenon would have its roots in local inflammation as well as top-down modulation of movement. This inhibition might even be so basic that it’s regulated largely by spinal reflexes, no brain-imposed inhibition at all. BACK TO TEXT
  33. Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum. 2010 Dec;40(3):250–66. PubMed #19954822.  BACK TO TEXT
  34. LauraOpstedal.wordpress.com [Internet]. Opstedal L. WTH Happened To My Quads?  Arthrogenic Muscle Inhibition Explained; 2019 March 16 [cited 19 Jul 26]. BACK TO TEXT
  35. After more than two decades of writing about this stuff, I am no longer surprised to learn about weird knowledge gaps, and it seems plausible to me that AMI is well-known when it occurs in the knee only because the muscles are so huge and vital. Losing 20% of a huge muscle is more obvious than losing 50% of a tiny muscle. Would you know if you lost half of your subscapularis muscle mass? Admit it: you don’t even know how to check! Even for those of us who know how to check, it would be hard to tell, and the loss of mass would have to be dramatic for me to even suspect it. So it could certainly be happening to the rotator cuff muscles without being remotely clear. It’s less likely that the big shoulder movers — biceps, deltoid, triceps — would atrophy without being noticed, but they do not need to be the muscles that are inhibited. BACK TO TEXT
  36. Bunker 2009, op. cit. “Contemporary arthroscopic studies have shown that only 50% of patients diagnosed as having frozen shoulder actually had visual/tactile evidence of the disease.” Bunker doesn’t cite specific independent sources on this, but he has extensive direct experience and is obviously extremely familiar with the literature. I’m happy to take his word for it. BACK TO TEXT
  37. Many profesionals therapists use it as a basis for presumptive treatment — treating as if a diagosis is true, to see what happens. Massage therapists in particular are fond of this theory, because it would make their skills much more relevant to the condition. 😃 And they want to help, of course! BACK TO TEXT
  38. See the appendix at the end of the article, about my wife’s experience with frozen shoulder. Basically, it magically went away when she was seriously injured in a car accident, and then returned when she healed from the worst of her injuries. That does not seem like the natural history of adhesive capsulitis! Of course, the diagnosis could have been wrong in the first place — although it appeared to be a textbook case, misdiagnosis is always a possibility. It’s also possible the accident could have ripped the adhesions apart: a traumatic manipulation without the anesthesia. But this also seems unlikely to me, as it probably requires precise force to break adhesions without also breaking other things — and her shoulder was otherwise uninjured. BACK TO TEXT
  39. Hollmann L, Halaki M, Haber M, et al. Determining the contribution of active stiffness to reduced range of motion in frozen shoulder. Physiotherapy. 2015 2018/06/19;101:e585. PainSci #53197.  BACK TO TEXT
  40. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15. PubMed #20961685.  PainSci #54851. 

    Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. That sensitization is called “central sensitization” because it involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. Victims are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people.

    For a much more detailed summary of this paper, see Sensitization in Chronic Pain.

    BACK TO TEXT
  41. I’m just spitballing here, but the shoulder is an incredibly mobile joint — it is, in fact, the most mobile joint in the body. There’s quite a lot of range of motion to maneuver in. The pain system is mostly designed to protect us by detecting threats and then avoiding them. The brain may develop the “opinion” that your shoulder is just fine — relatively limited pain — as long as you stay within a narrow range of motion. After a while, the brain may decree that a pain-warning is no longer required as long as you stay in the safe range. If you try to leave it, it just inhibits the motion instead. By contrast, in many other joints, there’s much less range of motion, too little for their to be a “safe range” that your brain is content to let you mess around in. If this is correct, we should see a fairly obvious pattern: chronically painful joints with more natural mobility tend to hurt more at first but then transition to more “frozen,” while joints with minimal range just hurt and don’t “freeze” nearly so much. BACK TO TEXT
  42. PS Ingraham. Trigger Points on Trial: A summary of the kerfuffle over Quintner et al., a key 2014 scientific paper criticizing the conventional wisdom about trigger points and myofascial pain syndrome. PainScience.com. 4130 words. BACK TO TEXT
  43. Duplay, S. De la peri-arthrite scapulo-humerale et ces raideurs de l’epaule qui en sont la consequence. Arch Gen Med. 1872;20:513. BACK TO TEXT
  44. Codman, E. The shoulder. Boston: Todd. 1934. BACK TO TEXT
  45. Neviaser J. Adhesive capsulitis of the shoulder: a study of the pathological findings in periarthritis of the shoulder. J Bone Joint Surg. 1945; 27:211–22. BACK TO TEXT
  46. Nagy MT, Macfarlane RJ, Khan Y, Waseem M. The frozen shoulder: myths and realities. Open Orthop J. 2013;7:352–5. PubMed #24082974.  PainSci #53682.  “Neviasier, in 1945, described “adhesive capsulitis” using the term ”adhesive” to describe the texture and integrity of the inflamed capsule, which he thought was similar to sticking plaster. The term is also inaccurate, as this condition is not associated with adhesions of the capsule, but rather is related to synovitis and progressive contracture of the capsule.” BACK TO TEXT
  47. Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am. 1989 Dec;71(10):1511–5. PubMed #2592391.  “The contracture of the coracohumeral ligament and rotator interval appears to be the main lesion in chronic adhesive capsulitis.” BACK TO TEXT
  48. Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br. 1995 Sep;77(5):677–83. PubMed #7559688.  “Our histological and immunocytochemical findings show that the pathological process is active fibroblastic proliferation, accompanied by some transformation to a smooth muscle phenotype (myofibroblasts). The fibroblasts lay down collagen which appears as a thick nodular band or fleshy mass. … The contracture acts as a check-rein against external rotation, causing loss of both active and passive movement.” BACK TO TEXT
  49. Bunker 2009, op. cit. BACK TO TEXT
  50. One reader with frozen shoulder reported that her physical therapist told her that “whole body has been out of alignment and it is showing up in the shoulder.” Bullshit! This is a common but awful idea. It has no basis in reality, and therapy based on it is unethical. Any professional using this kind of explanation to justify treatment should be fired immediately. It’s a classic example of structuralism, the tendency to attribute common painful problems to structure (biomechanics, alignment, and especially posture). Structuralism is prevalent because it sells: it’s an emotionally appealing problem that seems fixable, and freelance therapists can sell the solution to it. BACK TO TEXT
  51. TheSportsPhysio.wordpress.com [Internet]. Meakins A. Frozen shoulder? Let it go, Let it go … .; 2016 July 27 [cited 19 Aug 7]. BACK TO TEXT
  52. TheSportsPhysio.wordpress.com [Internet]. Meakins A. Frozen shoulder? Let it go, Let it go … .; 2016 July 27 [cited 19 Aug 7]. More: “All ‘true’ frozen shoulders are extremely painful, extremely limiting, and extremely disabling. When I hear females telling me the pain in their shoulder is worse than child birth, I know I am dealing with a very, very painful condition.” BACK TO TEXT
  53. Range of motion is limited to at least 25% in at least two dimensions (often more), and usually the most limited are shoulder abduction (lifting the arm away from the side) and external rotation (turning the biceps outwards). These limitations can be reliably assessed by a professional, which is noteworthy: it has been debated, and many diagnostic assessments are not reliable (see Is Diagnosis for Pain Problems Reliable?), but I think this one is fairly settled (Tveitå 2008, Hollmann 2015). BACK TO TEXT

There are 111 more footnotes in the full version of the book.


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