PainScience.com Sensible advice for aches, pains & injuries
 
 

Frozen Shoulder Guide

A readable self-help manual for one the strangest of all common musculoskeletal problems, adhesive capsulitis

updated (first published 2016)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

Sometimes shoulders just seize up, painfully and mysteriously: frozen shoulder.[Mayo] 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 commonly “freezes” like this.1 Frozen shoulder is a biological puzzle, and yet common. It’s hard to define precisely, diagnose accurately, or treat effectively; it’s one the best examples of how musculoskeletal medicine is surprisingly primitive still.

Sadly, the old idea that this is a self-limiting condition that is flatly contradicted by modern evidence.2 There is hope — it can thaw spontaneously3— but many people will be frozen to some degree for a long time, measured in years.4

Adhesive capsulitis [Wikipedia] 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.5 Most patients first notice that they are having trouble reaching behind bra clasps, wallets, and back itches. About two thirds of patients are women.

About footnotes. There are 55 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942. ← That symbol means a link will open in a new window.
Try one!

Nature of the beast: frozen shoulder is a biological failure, not a biomechanical one

Frozen shoulder is more like a disease than most common musculoskeletal problems. It is a biological failure, not a biomechanical one. 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, frequently brought on by a period of shoulder immobilization, 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 probably is a symptom of broader health problems. It mostly hits people over the age of forty, much more so if you have diabetes and/or cardiovascular disease.6 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.7 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.

Revealingly, smoking is a major risk factor for shoulder problems,8 probably including frozen shoulder. Smoking probably contributes to the poor health that frozen shoulder is an expression of. Smoking is a well-known factor in many kinds of chronic pain.9

Someone in my personal life is a perfect example of the connection between metabolic syndrome and frozen shoulder. She is catastrophically diabetic today, with failing kidneys, but long ago, for about three years before her diabetes diagnosis, she suffered through a phase of obviously inflammatory problems that prompted a tentative diagnosis of lupus. Lupus is the autoimmune disease that usually gets diagnosed when no other autoimmune disease can be identified. Unsurprisingly, she got frozen shoulder during this period, but it was only one of several inflammatory over-reactions around her body — and diabetes itself may have been one of the consequences of that inflammatory period of her life.

Shoulder neglect? An evolutionary perpsective on frozen shoulder

An interesting theory is frozen shoulder occurs because “the human shoulder evolved for high speed projectile throwing” (Pietrzak 2016), 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,10 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.11 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 many or 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)?

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,12 but there is no compelling direct evidence of it. We mostly just have an accumulation of evidence that the usual suspectsaren’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.13 If it’s true, it’s going to be hard to prove. And it hasn’t been a focus of research because it’s so clear that most cases, and probably the worst ones, really are dominated by adhesion — that’s the bigger problem. 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 later on…

The possibility shouldn’t be completely ignored.

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 would functional stiffness work?

There are two main ways that a functional limitation of shoulder ROM would probably work, and we shouldn’t underestimate the power of either of them:

  1. the brain can “shut down” a joint with neurological inhibition
  2. the muscles can become unhealthy and 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 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. This is standard neurological procedure with severe traumas.

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. Although their nature is unexplained and controversial,14 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.”

Further on in the tutorial, I’ll discuss disinhibition strategies, and the (hopelessly imperfect) options for trying to treat trigger points.

A 150-year history of misleading names

The earliest medical description of frozen shoulder dates to 1872, when Simon-Emmanuel Duplay called it periarthritis of the shoulder,15 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.16 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.17

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:18 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 are 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 1995,1920 with virtually no confirmation, elaboration, or even contradiction from researchers since then. (I’ll continue looking.) Having 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, I’m not comfortable taking 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.21

Confirming the diagnosis: classic frozen shoulder symptoms

Frozen shoulder isn’t hard to diagnose — or rather, it shouldn’t be. 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.”22 There can be confusion with other conditions (reviewed below). The defining symptoms of frozen shoulder are:

Frozen shoulder bombshell: it ain’t self-limiting

The conventional wisdom for decades has been that frozen shoulder inexorably grinds through all three stages — freezing, frozen, thawing — on a fairly predictable timeline, finally resolving with or without treatment within a couple years at most for almost everyone, a self-limiting condition. This “natural history” of the condition has been repeated ad nauseum by countless experts for decades.

Too bad it’s bogus.

It turns out… not so much. In fact, while no evidence supported the natural history theory, evidence from multiple randomized control trials with longitudinal data directly contradict the theory of a recovery phase that leads to complete resolution for frozen shoulder. That the findings so starkly contradict the accepted view of frozen shoulder, as reflected by clinical reviews, research article introductions, textbooks, and reputable health websites has prompted reflection on how such an assumption made it into the medical knowledge base.

Dr. Christopher Kevin Wong, “Frozen shoulder: fact or fiction?”

In other words, how the #%!*& did this happen? Basically, it was a mistake that got repeated until it was entrenched. Once it’s in a few textbooks, it’s game over for the truth — hardly anyone even thought to question it. For a long, long time.

Frozen shoulder almost certainly does not consistently resolve on its own.2526 This is a bombshell, and a credible one, and rotten news. I’ve always thought frozen shoulder is an interesting mess of a topic, but it this makes it even more so. And how long will it be until most physiotherapists know about this? Start your timers. Bet it takes 20 years.

The dead giveaway symptom: a specific painful spot, on the coracoid process

Anatomical illustration showing the location of the coracoid process on a superficial dissection of the shoulder.

Other than the slow-but-steady loss of mobility, there’s one particularly strong defining symptom (“pathognomonic”) that’s good to know about, but you might never notice if you don’t go looking for it. It occurs in more than 95% of cases, but only in 10-15% of other kinds of shoulder pain. It’s sensitivity on a specific spot on the front of the shoulder, on the tip of a bone called the coracoid process.27 This odd little bone points forward like a finger, just below the end of the collar bone. If you feel around in the tissue there, it’s hard to miss — and if it hurts quite a bit (more than 3 on a scale of 10, say), that’s the sign you’re looking for.

Other shoulder problems that could be 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:

Rotator cuff tendinopathy or tear. The rotator cuff is a group of four muscles that surrounds the shoulder joint like a “cuff,” and that cuff is anatomically overlapping the joint capsule that gets inflamed in frozen shoulder — which is why rotator cuff problems can be difficult to distinguish from frozen shoulder. Confusing things even more, rotator cuff trouble might make movement uncomfortable, as with frozen shoulder, but not necessarily. Rotator cuff abnormalities and lesions increase steadily later in life, like arthritis, but are also amazingly common in pain-free younger people — in other words, even there’s an “obvious” problem on an X-ray or MRI, it ain’t necessarily the problem.28 But the rotator cuff can hurt, and when it does, it mostly limit active movement, whereas frozen shoulders are frozen even when you are relaxed and someone else tries to moves your shoulder for you (passive movement). And tears tend to happen suddenly with exertion, a clear “oh shit” moment of injury. And with tears or tendinitis, the pain is usually limited to more specific spots and movements than with frozen shoulder.

Subacromial and subdeltoid bursitis are closely related to rotator cuff tendinitis, but instead of tendons they affect bursae (the anatomical padding between tendons and other structures).

Arthritis of the big shoulder joint mostly occurs beyond middle age, and usually develops more slowly-but-steadily, and isn’t as severe. An X-ray will show clear signs of joint degeneration that won’t be seen with adhesive capsulitis. Shoulder arthritis often involves a history of injury.

Acromioclavicular arthropathy is degeneration of the joint at the outside end of the collar bone. It does not really affect shoulder range of motion, the pain is more specific to that superficial joint, and it’s usually associated with a history of overuse and injury, usually athletic.

Tendinitis of the biceps tendon. Tenderness sticks to the front of the shoulder with this condition. Biceps contraction is painful, but other movements are normal.

Cervical disk degeneration, basically arthritis of the spine, can cause pain, weakness, and numbness that spreads out into the shoulder and can make it seem “frozen,” but this problem usually also spreads further: symptoms in the hand and wrist will usually be more prominent with this problem.

Autoimmune diseases like lupus or rheumatoid arthritis can affect many joints in the body, including the shoulder — but they usually do affect multiple joints, and cause several other health problems that obviously set them apart.

Cancer is one of the least likely causes of frozen-shoulder-ish pain, but a tumour in or near the joint is a possibility. Watch out for other signs of failing health, especially night sweats and weight loss and shortness of breath.

Do you need a shoulder x-ray?

It’s not a bad idea, but the “need” part can be debated. An x-ray is potentially helpful for excluding shoulder joint arthritis or scary causes of pain like a tumour, but some professionals will sensibly advise against it because frozen shoulder is quite distinctive clinically, because it’s rare for a sinister condition to masquerade as frozen shoulder, and because x-ray isn’t exactly a foolproof method of detecting other causes anyway. Other pros think an x-ray is a no-brainer and well worth the minor (radiation) risks of a single x-ray to check for surprises before proceeding with therapy.29 There is no evidence-based right answer to this.

Frozen shoulder treatment: it can’t be “cured,” but it probably can be managed and minimized

Management is controversial & depends on the phase of the disease.

Nagy et al, 2013, Open Orthop J

Every professional seems to have their own take on frozen shoulder treatment, even doing nothing at all: some believe it should just be left alone to run its course, and it’s an understandable position. A huge 2009 survey of almost 2,400 physical therapy patients found that no one got better, at least by one way of reckoning.30 In a 2004 test with 77 patients, “supervised neglect” actually worked (slightly) better than “intensive physical therapy”!31 Why even go on? It sounds like nothing works! But these studies were looking at the tip of an iceberg of possibilities32 hardly the last word — just good perspective. It might be unwise to spend a bunch of time and money on basic physiotherapy.

At one of the scale, there’s the “do nothing” crowd. At the other, there there are many different kinds of more dramatic cure claims, as there is for any difficult condition. Despite too-good-to-be-true promises, there really is no known effective treatment for frozen shoulder [NHS] — nothing that actually prevents the capsule from adhering, nothing that can free it up without doing more harm than good, nothing that clearly, reliably makes the ordeal shorter or easier for most patients.

However, range of motion can probably be preserved to some degree by early use-it-or-lose-it interventions. And the pain can be helped (which in turns helps with the “using”). Pain can almost always be helped.

Only a few scientific reviews of frozen shoulder treatments have been published, but they suffer badly from the “garbage in, garbage out” problem: there’s not enough good quality research to review. And so there’s a strong theme in their conclusions: no one really knows what works yet, and most of the better evidence we do have is either unimpressive or outright disappointing. “Despite over a hundred years of treating this condition the definition, diagnosis, pathology and most efficacious treatments are still largely unclear.”33

In a typical example, Maund et al reviewed 31 studies in 2012, “many” of which were “at high risk of bias,” concluding after great effort that were is “limited clinical evidence on the effectiveness of treatments for primary frozen shoulder.”34 The authors of a big 2014 review sounded particularly underwhelmed: they concluded that hardly anything seems to work, and nothing works for long.35 Out of 32 trials, not one “compared a combination of manual therapy and exercise versus placebo or no intervention” — in other words, a total lack of evidence on what is probably the most important treatment topic.

Favejee et al is one the more optimistic reviews, somehow finding — in the same literature Maund et al and Page et al looked at! — some moderate to strong evidence for the short term benefits of some treatments.36 But emphasis on the short term: “most of the included studies reported short-term results” only.

This unhelpful mess of mediocre evidence and “more study needed” conclusions is a good demonstration how musculoskeletal medicine is still surprisingly primitive.37 Frozen shoulder seems worthy of considerably more and better research attention than it has gotten!

Use it or lose it: movement therapy to prevent the capsule from adhering too much too soon

If you believe you are in the early stages of frozen shoulder, immediately begin a campaign of mobilizations: gently, thoroughly use as much of your range of motion as you can without excessive discomfort.38 This a nice collection of exercises for the shoulder, with good illustrations: “7 stretching & strengthening exercises for a frozen shoulder.” [Harvard Health]

Give your range of motion a little helping hand, too. For instance, use a wall to support the weight of your arm while “walking” up the wall with your fingers. Such tactics are a good way to take safe baby steps into the outer limits of your comfortable range.

Emphasize any activity you enjoy that requires extensive shoulder range of motion. If you have none, consider taking one up: tennis, for instance. You may find it difficult, but making movement challenges fun is a really valuable rehab principle.

What if you can’t move it? Then imagine moving it. Seriously! A very large component of movement is neurological. When we lose range of motion, it’s both a physical and a neurological loss. If you can’t preserve the physical, keep working on the neurological!

The Meakins method: eccentric loading + “let it go”

In my experience manual therapy and traditional physiotherapy methods for frozen shoulder do very, very little. I have tried them all, pulling and pressing people with painful frozen shoulders, here, there, and everywhere, all with little effect, and all too no avail. However, there is a “different” method for treating frozen shoulders that I have been using more and more over the years…

Frozen shoulder? Let it go, Let it go…., Meakins (TheSportsPhysio.wordpress.com)

Physiotherapist Adam Meakins has a novel idea idea about how to treat frozen shoulder. Although it’s not clearly evidence based, it is an educated guess from a particularly good guesser about shoulders, with some strong theoretical foundations.39 It involves progressively challenging range of motion, putting it firmly in the “use it or lose it” category of treatment approaches. Adam put’s another spin on that, teaching his patients to use it specifically with eccentric contractions: that is, contracting muscles while they lengthen.

Why use “contraction” here at all, if frozen shoulder isn’t a muscle problem? The complex rotator cuff muscle group is seamlessly blended with the joint capsule, and to stimulate one is to stimulate the other… and eccentric contraction is an interesting stimulus, well known to have unusual and potentially rehabilitative effects on connective tissue. It is often used as a tendinitis treatment.

Another consideration is the on-going debate about how much of a role muscle tension may play in frozen shoulder, either greatly complicating or actually mimicking an adhered capsule: functional freezing. To the extent that the freezing is functional, then it does make a lot of sense to work with the shoulder muscles.

So what exactly do you do? You slowly lower a small weight into a manageable stretch into your most limited movements. You make it as easy as possible at first, and you up the ante every few days. You tolerate a little discomfort, but not too much. You don’t want to push hard through pain, but you do want to strive to ease through any muscle tension holding you back: “let it go,” as Adam puts it…referencing the song, of course. 😃 And you do all of this with the confidence that your shoulder tissues are probably not as raunchy as they feel.

See his article for full details with pictures: Frozen shoulder? Let it go, Let it go….

Over-the-counter pain killers for frozen shoulder

Some pain relief may be possible with the use of a topical analgesic like Voltaren®. The medication may not soak in deeply enough for a significant effect, unfortunately. The inflamed tissue is quite well buried under thick shoulder musculature. But it’s worth trying, because topical delivery is much better than dosing your entire system with edible pain-killers, which have a dizzying array of side effects.

Many people can probably get some additional relief from short-term, cautious use of NSAIDs, the non-steroidal anti-inflammatory drugs,40 which are:

My advice is to strictly reserve these for occasional “emergency” use, for taking the edge off when it’s most desperately needed. This is treating the symptoms only, of course, but that’s fine to a point: masking symptoms is under-rated. Just do it sparingly and reluctantly. Treat it like the lesser-of-evils that it is.

At any dose, these drugs can cause heart attacks and strokes41 and they are “gut burners” (they can badly irritate the GI tract, even taken with food, and especially with booze). Aspirin is usually best for joint and muscle pain — which may or may not mean it works better for frozen shoulder — but it’s the most gut-burning of them all.

Or how about squirting anti-inflammatory medication right into the joint?

Corticosteroid injections for frozen shoulder

Corticosteroids are potent anti-inflammatory agents. Wherever pain is caused by inflammation, corticosteroid injections are likely to produce substantial temporary pain relief — at the cost of an invasive procedures with some risks. In the case of frozen shoulder, it’s clear that these injections function as a kind of super pain-killer — they can reduce pain.42 However, it’s equally clear that the benefits don’t last, and the freezing of the joint proceeds. The main use of corticosteroid injections for frozen shoulder is probably to facilitate ROM-maintaining exercise through pain relief.

This encouraging evidence contrasts starkly with what happens with rotator cuff tendinopathy, which is almost nothing at all: brief, minimal relief in only about 1 in 5 patients, according to a witheringly negative 2017 review.43 The difference is probably attributable to different pathology. Tendinitis is often incorrectly regarded as inflammatory, when in fact it is much more clearly degenerative, so it’s not much of a surprise that a powerful anti-inflammatory medication does not have much effect on it. But the painful freezing stage is much more truly inflammatory in character, and therefore responds more clearly to steroids. It’s a nice demonstration of the power of actually understanding the biology of a problem.

Treating frozen shoulder with diet

An anti-inflammatory diet — also known as a healthy diet, with a few specific features — might reduce the severity and duration of frozen shoulder.

As explained above, frozen shoulder is strongly associated with metabolic syndrome, which in turn is strongly associated with poor fitness, obesity, aging, a typical modern junky diet, genetics (of course), and maybe chronic stress, anxiety, and fatigue as well.44 One of the main biological consequences of metabolic syndrome is a lot of subtle inflammation, which can to all kinds of trouble in time, especially cardiovascular disease … and even frozen shoulders. An “anti-inflammatory” diet is not magic: it’s just eating to minimize metabolic syndrome and its consequences, the kind of diet that practically everyone everywhere should be eating anyway.

There is no evidence at all — zip, zero, zilch — that eating this way will specifically help a condition like frozen shoulder. By the time your shoulder is freezing, it could be way too late for your diet to make any difference. Or maybe it’s not! Maybe this is one of the reasons why some people take much longer to recover than others. No one knows, but all of this is very reasonable speculation, and it’s well worth trying, for obvious reasons: it’s good for you otherwise, even if it has no effect on frozen shoulder.

There’s a more extreme dietary option to consider…

Treating frozen shoulder with a ketogenic diet (a longshot that might be worthwhile)

Diets that force you to mainly burn fat for energy, instead of carbohydrates — a ketogenic diet [Wikipedia], like the infamous Atkins diet — have some well-established benefits and might be anti-inflammatory and de-sensitizing.45

This is a completely experimental treatment. However, like a standard anti-inflammatory diet (AKA “healthy”), it has a non-crazy rationale, and it’s safe and inexpensive to dabble in. As long as you don’t get extreme, the worst case scenario is putting up with a fussy and unpleasant change in eating habits. Nevertheless, I am obliged to suggest that you run this by your physician and/or a nutritionist.

Fasting is another option, but it might work (and perhaps simply because it includes a ketogensis), but it’s harder and less safe — so I’m less inclined to actually recommend it. But if you are keen on the idea fasting for whatever reason, it’s another possibility to consider.

I have a separate article devoted to this topic which suggests some other possible strategies for reducing systemic inflammation. To the extent that any of them work at all (quite unknown), they would likely support recovery from frozen shoulder, especially (or perhaps exclusively) in the first and most inflammatory phase

Massage therapy for frozen shoulders: symptom relief at least, possibly more

Although the adhesions in the shoulder joint capsule cannot be broken by massage — not safely at any rate — it probably is possible for massage to relieve some of the discomfort that usually develops in the area. That’s an opinion. The totally inadequate scientific evidence may even suggest the opposite. For instance, in 2009 Jewell et al found that use of massage in the context of physical therapy “reduced the likelihood of a favorable outcome”!46 Uh oh. But that’s not remotely the same thing as a well controlled trial of the efficacy of professional therapeutic massage… which has literally never been done!

Massage for frozen shoulder is too unstudied for an evidence-based recommendation, and so all of my recommendations about massage are based on experience and educated guessing.

Many patients crave massage therapy for this condition. In the best case scenario, the discomfort of frozen shoulder may just be a symptom that can be treated by massage. At least a little, at least temporarily. And we should never knock a little symptom relief.

But massage might have more profound relevance to frozen shoulder. As discussed earlier in the tutorial, some shoulders may be more functionally than literally frozen, and this is more likely in chronic cases. If true, then massage may could theoretically treat the root of the problem. If it works, here’s how it might work…

Reducing neurological inhibition with massage

The stimulation of massage, probably combined with slow passive movements, might encourage and reassure the nervous system that it’s okay to move the shoulder again, such that it can reconsider the shoulder “lockdown” policy it may be entrenched in. Any reduction of neurological inhibition would create an opportunity for more movement, but that window opportunity might be narrow, especially at first. If there’s any increase in range of motion following massage, that’s a great sign that should be exploited by gently exploring the improved ROM as much as possible for as long as it lasts.

The massage treatment itself should be low key as well: this is all about convincing the nervous system that there’s no danger. Excessively intense massage could actually backfire.

A major disadvantage of this approach is that it could be slow and therefore expensive. How good is massage at facilitating the resolution of neurological inhibition? Can it do it at all? No one knows. It’s probably not worth pursuing if there’s no noticable improvement within roughly 6 half-hour massages of the shoulder and area (and even that’s getting to be quite a costly experiment). However, note that there are also other, less expensive ways to “reassure” nervous systems about shoulders.

Treating trigger points with massage

Drawing of a thumb pressing downwards on a target, suggesting trigger point therapy.

If a frozen shoulder is functionally frozen, muscle “knots” or trigger points may be one of the causes of the tightness. Rubbing trigger points seems to ease them! No one knows how well this works, or even if it works at all, but it is a safe treatment to experiment with, often pleasant if done well, even cheap if you learn to do some yourself, and it’s not hard to dabble in. Trigger point treatment is covered in great detail elsewhere on this site. I have a basic trigger point self-treatment guide, and a huge trigger point tutorial for the toughest cases, for both patients and professionals.

But basically… just rub the sore spots. Somehow I’ve written about a quarter million words about “just rub the sore spots.” 😮

Although massaging nearly any muscle tissue in the area may be useful, there is one that’s worth some special consideration: Perfect Spot No. 14, The Most Predictable Unsuspected Cause of Shoulder Pain.

For what it’s worth, many massage therapists do claim to have cured cases of frozen shoulder.47 It’s not hard to see why. I have my own highly relevant treatment story — the one about my uncle-in-law, near the beginning of that page — worth a detour if the massage angle interests you.

Forcing the issue: ripping the adhesions to increase range of motion

Warning! Please do not allow a health care professional to attempt to forcefully increase your range of motion! This can cause extreme pain from the rupture of adhesions, which quickly get sticky again. Also, resistance from muscles protecting the joint can be so substantial that it is impossible to apply force effectively to the actual joint capsule, and muscles may tear instead of adhesions. There is no proven benefit to this therapeutic approach, and substantial risk.

Doing the same thing under anaesthesia, although hardly safe, is much more promising…

Manipulation Under Anesthesia (MUA) and related methods (surgery and pseudo-surgeries)

The shoulder can be paralyzed by injecting anaesthetic into a thick web of nerves emerging from neck (brachial plexus), which greatly reduces muscular tone (but probably doesn’t actually eliminate it.48) A doctor can then apply force much more directly and precisely to the adhesions in the joint capsule, without fighting through much muscular resistance.

Unfortunately, this is only an option for desperate patients, because there are substantial risks to this procedure.49 Some people go straight from the freezer to the frying pan of a serious manipulation injury or — ironically — permanent hypermobility with recurrent disclocations. There’s also a substantial rehab process after the surgery — things are a bit wonky afterwards, even if it goes well, and it takes time. (And it’s not an option at all for patients with past dislocations, fractures, or bone loss.)

Does it work? If only we knew! This is a pseudo-surgery, and like many surgeries,50 it is understudied and based more on seeming to make sense than any hard evidence. There are a few mediocre scientific tests, but there’s just not enough good quality data yet. It’s important to bear in mind that many orthopedic surgeries have been proven ineffective, even though they too seemed liked good ideas.51 This one might actually work, or it might not. It’s just a gamble.

Photo of a scalpel on a uniform blue background. The word “hope” is engraved on the blade.

Arthroscopic capsular release

Another way to force the issue, and likely safer that MUA, is arthroscopic or “keyhole” surgery. The goal is exactly the same, but the method is much less brutish: instead of tactical wrenching of the joint until the adhesions tear, a surgeon goes in with a tiny camera through a tiny incision and cuts things free.

Although we don’t have good data on whether manipulation or cutting actually work, we do know that each one is roughly as good as the other.52 All other things being equal, I’d prefer not to get wrenched around.

Joint capsule inflation (arthrographic distension, hydrodilatation injections)

When you blow up a balloon, it is often stuck to itself, and slightly adhered layers of rubber peel away from each other as you force them apart with air pressure. The same principle is used in hydrodilation injections, only the ballon is the shoulder joint capsule, and it’s inflated with saline solution (maybe with some steroids as well, to help with the inevitable spike in inflammation). Like blowing up a ballon, the pressure is supposed to inflate the capsule.

In no other way is the shoulder joint capsule like a balloon, and simplistic analogies like this are often misleading in medicine. Adam Meakins calls distension “highly dubious.” It has barely been tested, but the conclusion of a 2008 scientific review of just five studies makes it sound almost promising:53

There is "silver" level evidence that arthrographic distension with saline and steroid provides short-term benefits in pain, range of movement and function in adhesive capsulitis. It is uncertain whether this is better than alternative interventions.

Still, “uncertain” is an understatement there!

Fortunately, there is some more encouraging evidence from 2013 trial, only the second one ever to produce long term results (and it also included diabetic patients).54 And still more in 2017! Sinha et al. also concluded that it worked, based on over a hundred patients (although the size of the benefit was not very impressive).55

This is all far from proof, but it’s better than nothing.

Despite that evidence, this procedure is based mostly on “common sense” of the doctorly sort: it seems like a good idea. Maybe it helps and maybe it doesn’t. As with arthroscopic release, I’d certainly try this before manipulation under anaesthesia, for the safety. But I certainly wouldn’t bet on the outcome. Remember that there’s no way this treatment method can work (in principle) if the joint is actually contractured rather than adhered (see above, “Adhesive” may be the wrong word: shrunk, not stuck).

My (wife’s) frozen shoulder story

On this website, I often write about conditions I have some personal experience with. In this case, it’s not my own experience, but my wife’s: a rip-roaring case in the aftermath of a very serious car accident, adding injury to injury.

She says the shoulder was the worst pain she had in the entire recovery experience (and she broke several bones, including her skull, spine and pelvis). We have a rather vivid memory of walking down the street together one day, near the peak of the problem, and she tripped a little and reflexively tried to stabilize herself with the bad shoulder. WOW. Never seen her react like that to anything, before or since!

But there’s a peculiar wrinkle in her story: she actually already had a full-blown case of frozen shoulder when the accident happened. It cleared up completely for several months during the the initial stages of rehab. And then it returned! It’s like the accident hit the “pause” button. What can we make of this? It’s hard to interpret for sure, but I think one possibility is that it means that the first phase of her frozen shoulder was functional: not an adhesive capsulitis, but a neurological ban on movement which was lifted when the accident changed her “priorities,” and then re-imposed when her body started to recover from the severe injuries.

Case study: an interesting example of a subtle 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!


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

Related Reading

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

Into the Fire — 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?

Thirty 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.

DecemberBeefed up information on over-the-counter medications. Added some related reading recommendations. A few other miscellaneous minor improvements.

OctoberUpdated the article abstract. Cited and analyzed Jewell et al with regards to the poor results from physical therapy overall, and massage specifically.

AugustNew section, “Posture: is frozen shoulder the tip of a misalignment iceberg?” (Hint: no.)

JulyCited 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.

JuneImportant revisions and a new section — “How long do those stages last?” — based on important new evidence (Wong et al) that frozen shoulder is not a self-limiting condition as everyone has assumed for decades.

FebruaryNew section, “A 150-year history of misleading names,” a nice segue into the “shrunk, not stuck” discussion added back in November.

JanuaryAdded a substantial reader-submitted case study and a little commentary.

2016Added a new section: “Adhesive” may be the wrong word: shrunk, not stuck, based mainly on Nagy and Ozaki for now. Several other minor improvements, most notably a revised treatment introduction, citing Diercks as an interesting example.

2016Added a mobile-only article summary.

2016Science update: Littlewood et al now provides some more substantive support for the theory of functional freezing and related rehabilitation methods.

2016Minor updates. Polishing of the massage section. Added an interesting clarification about my wife’s strange experience with frozen shoulder. Several other miscellaneous, minor improvements.

2016Significant expansion. Added much more information about trying to treat frozen shoulder with massage therapy.

2016Minor science update. Brief discussion of rotator cuff abnormalities in asymptomatic people.

2016Minor upgrades. Editing of “stiff but not frozen” topic. Made a diagram of the hypothetical relationship between adhesive and functional freezing.

2016Minor upgrades: some revisions to the discussion of treating systemic inflammation with diet, and added an important link out to a new article on that topic.

2016Major upgrade: added a new section, “Stiff but not frozen: the case for tightness,” and started beefing up the massage section as well.

2016Added a couple footnotes to the introduction about prognosis and worst case scenarios. Added a footnote about hyperthydroidism as a risk factor. And there’s enough footnotes on this page now (31) that I added a footnote demo to the intro.

2016Added “The Meakins Method” treatment suggestion — eccentric loading of the rotator cuff muscles. Added interesting new evidence about arthrographic distension.

2016Added more general evidence about treatment efficacy. Added a new section about joint capsule inflating.

2016Several clarifications about diagnosis, and some new citations and expert quotes. Added a paragraph about x-rays.

2016Added more information about range of motion and reliability of assessment of ROM. Added new sections on manipulation under anaesthesia and arthroscopic capsular release.

2016Added footnote about other frozen joints, like frozen hips. Added a little about smoking as a risk factor. Expaned the introduction to treatments and added several new citations.

2016Added section about anti-inflammatory (AKA “healthy”) diet. Added short paragraph about fasting. Added a case study. Miscellaneous editing. Article is now substantive enough for removal of “half-baked” disclaimer, and a title change from frozen shoulder “primer” to “guide.”

2016Added full description of symptoms, edited diagnostic section, and added a picture showing where to find the coracoid process.

2016Added first draft of differential diagnosis section.

2016Added diagnosis section, starting with a clear pathognomonic sign, coracoid process sensitivity.

2016Added links to several authoritative/useful sources. General editing to clean up and clarify recent additions. More descriptive headings. Started adding related reading recommendations.

2016Added recommendation to try a ketogenic diet.

2016Added basic information about corticosteroid injections; discussion of Pietrzak’s evolutionary perspective; more movement recommendations.

2016Added “Nature of the beast” section, cited Pietrzak, plus a few other miscellaneous details.

2016Publication.

Notes

  1. Dupuytren’s contracture — “frozen hand” — is quite common and may be caused by the same underlying problem with connective tissue seizing up, but it causes such different symptoms that they seem more like pathological cousins than siblings.

    Other joints freeze more like the shoulder, but not commonly. For instance, there 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.

    BACK TO TEXT
  2. 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 studies shows 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, frozen shoulder may resolve early or not at all.

    BACK TO TEXT
  3. 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
  4. 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
  5. About 15-20% of patients develop the disease in both shoulders. BACK TO TEXT
  6. 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
  7. 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
  8. 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
  9. PS Ingraham. Smoking and Chronic Pain: We often underestimate the power of (tobacco) smoking to make things hurt more and longer. PainScience.com. 1180 words. BACK TO TEXT
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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. 3698 words. BACK TO TEXT
  15. 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
  16. Codman, E. The shoulder. Boston: Todd. 1934. BACK TO TEXT
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. TheSportsPhysio.wordpress.com [Internet]. Meakins A. Frozen shoulder? Let it go, Let it go….; 2016 July 27 [cited 17 Oct 26]. BACK TO TEXT
  23. TheSportsPhysio.wordpress.com [Internet]. Meakins A. Frozen shoulder? Let it go, Let it go….; 2016 July 27 [cited 17 Oct 26]. 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
  24. 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). BACK TO TEXT
  25. Wong 2017, op. cit. BACK TO TEXT
  26. Clement 2013, op. cit. BACK TO TEXT
  27. Carbone S, Gumina S, Vestri AR, Postacchini R. Coracoid pain test: a new clinical sign of shoulder adhesive capsulitis. Int Orthop. 2009 May. PubMed #19418052. BACK TO TEXT
  28. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014 Dec;23(12):1913–21. PubMed #25441568. BACK TO TEXT
  29. Hanchard NC, Goodchild L, Thompson J, et al. A questionnaire survey of UK physiotherapists on the diagnosis and management of contracted (frozen) shoulder. Physiotherapy. 2011 Jun;97(2):115–25. PubMed #21497245. “The value of X-rays in differential diagnosis was under-recognised.” BACK TO TEXT
  30. Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009 May;89(5):419–29. PubMed #19270045. PainSci #55683.

    An interesting study of 2,370 frozen shoulder patients who received physical therapy: rather than a controlled trial of a specific treatment, it was a statistical analysis of the relationship between common treatments and outcomes. The therapists reported the treatments they used in each case, the patients took surveys before and after, and the researchers calculated the relationship between the treatments and the results.

    Notably, literally no patients at all achieved clinically meaningful improvement by one method of measuring. So they just eliminated those measurements from their analysis, and worked with three other scoring systems that did detect some improvements.

    This study will come again as I discuss other treatments.

    BACK TO TEXT
  31. Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg. 2004;13(5):499–502. PubMed #15383804. BACK TO TEXT
  32. In Diercks et al, intensive physical therapy treatment consisted of “passive stretching and manual mobilization,” which might have been “intensive” but it certainly wasn’t comprehensive, just a couple of rehab staples for a notoriously stubborn condition. And it was compared to “supportive therapy and exercises within the pain limits,” which I’m not sure counts as “neglect” — exercises within pain limits may actually be quite important. So if the physical therapy had been a little more interesting, and the neglect had been more total, the results might not have been so disappointing. BACK TO TEXT
  33. Uppal HS, Evans JP, Smith C. Frozen shoulder: A systematic review of therapeutic options. World J Orthop. 2015 Mar;6(2):263–8. PubMed #25793166. PainSci #53286. BACK TO TEXT
  34. Maund E, Craig D, Suekarran S, et al. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2012;16(11):1–264. PubMed #22405512. PainSci #53309. BACK TO TEXT
  35. Page MJ, Green S, Kramer S, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;(8):CD011275. PubMed #25157702. “The overall impression gained from [32] trials is that the few outcome differences between interventions that were clinically important were detected only up to seven weeks.” BACK TO TEXT
  36. Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: the effectiveness of conservative and surgical interventions — systematic review. Br J Sports Med. 2011 Jan;45(1):49–56. PubMed #20647296. BACK TO TEXT
  37. PS Ingraham. A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta. PainScience.com. 1897 words. BACK TO TEXT
  38. Too much discomfort means inflammation… and inflammation is what drives the stickyness of the capsule in the first place. You must strike a balance: only just enough movement to slow down the adhesions. BACK TO TEXT
  39. Littlewood 2013, op. cit. This is basically the scholarly version of Adam Meakins article about his methods. From their conclusions: “If pain is regarded as a sign of de-conditioning rather than actual or impending tissue damage then an alternative process of CNS scrutiny might result in an active output, for example engagement with a structured exercise regime, with the potential to recondition peripheral (tendon) and central tissue. Additionally, active engagement and ‘permission’ to resume normal activity without fear of causing harm to self might facilitate an improved outcome in contrast to existing approaches.” BACK TO TEXT
  40. Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015;6:CD007402. PubMed #26068955. BACK TO TEXT
  41. Bally M, Dendukuri N, Rich B, et al. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ. 2017 May;357:j1909. PubMed #28487435. PainSci #53592.

    Taking any dose of common pain for as little as a week is associated with greater risk of heart attack, according to a this meta-analysis, and the risk is greatest in the first month of use. This is probably primarily of concern for people already at risk for heart attack, but this data doesn’t address that question, and it’s a lot of people regardless.

    BACK TO TEXT
  42. Song A, Higgins LD, Newman J, Jain NB. Glenohumeral corticosteroid injections in adhesive capsulitis: a systematic search and review. PM R. 2014 Dec;6(12):1143–56. PubMed #24998406. PainSci #53477. From the abstract: “Corticosteroid injections offer rapid pain relief in the short-term (particularly in the first 6 weeks) for adhesive capsulitis. Long-term outcomes seem to be similar to other treatments, including placebo.” BACK TO TEXT
  43. Mohamadi A, Chan JJ, Claessen FM, Ring D, Chen NC. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017 Jan;475(1):232–243. PubMed #27469590. PainSci #52902.

    Do steroid injections reduce the pain of rotator cuff tendinosis? How many people do you have to inject to get a good result? Does more than one injection help? This review sought the answers in eleven mostly small studies of 700 patients (including three studies that included multiple injections). The answers were disappointing, other than confirmation of minor temporary pain relief. There was there was no effect for most patients at three months, multiple injections made no difference, and five patients need to be treated to get good results for one. The conclusion of the study is an articulate indictment:

    Corticosteroid injections provide—at best—minimal transient pain relief in a small number of patients with rotator cuff tendinosis and cannot modify the natural course of the disease. Given the discomfort, cost, and potential to accelerate tendon degeneration associated with corticosteroids, they have limited appeal. Their wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient's drive toward physical intervention, or for remuneration, rather than their utility.

    BACK TO TEXT
  44. Prolonged chronic stress might contribute to metabolic syndrome (Gohil et al) by messing with the hormonal balance of the hypothalamic-pituitary-adrenal axis (HPA-axis). BACK TO TEXT
  45. Masino SA, Ruskin DN. Ketogenic diets and pain. J Child Neurol. 2013 Aug;28(8):993–1001. PubMed #23680946. PainSci #53476.

    Ketogenic diets are well-known to treat epilepsy in some children. The biology of ketogenesis may also have an effect on some kinds of inflammation and pain, especially neuropathic pain. Although highly speculative, there are some reasons to think it might work, and some indirect (animal) evidence that it does. Like seizures, some kinds of pain may involve overexcited neurons, and can be treated with anticonvulsant drugs. Ketone metabolism “produces fewer reactive oxygen species,” a contributor to inflammation; and it produces adenosine signalling, which is a suspected pain-killer in other contexts (exercise, possibly acupuncture).

    BACK TO TEXT
  46. Jewell 2009, op. cit.

    The design of this study was described above. Basically they surveyed thousands of patients before and after receiving physical therapy to try to statistically link treatments given with outcomes. They found that improvement was more likely in patients who were mobilized and given exercises to do, but they less likely to improve if they were given massage, iontophoresis/phonophoresis (methods of “injecting“ medicines through the skin), or ultrasound — which doesn’t mean that no one given those treatments improved, just that fewer did.

    This data is suggestive and interesting, but it’s a very different sort of data than what a controlled trial produces, and inferior in many ways. For instance, the “massage” provided to these patients was not standardized in any way, and mostly very different from what a patient would receive from a profession massage therapist. We might conclude from this not that “massage” is ineffective, but rather that physical therapy that includes massage is of dubious value, for any number of reasons: maybe physical therapists aren’t very good at massage, or maybe the kind of physical therapists that employ massage tend to favour passive methods that are collectively inferior to prescribing exercise.

    BACK TO TEXT
  47. It’s not not worth much, unfortunately! experience is not evidence. There are a countless ways that clinicians exaggerate their success rates in their own favour — most of them unconscious. Remember that every quack in history has claimed to cure people, no matter how ludicrous or even dangerous the treatment. BACK TO TEXT
  48. It is a myth that muscles are actually paralyzed by anaesthesia. “There is a constant battle to relax the muscles during some procedures,” explains Dr. Steven Levin. Even a supposedly relaxed muscle shrinks about 20% when cut. The tone is mediated by the brain and spinal cord. Some believe there is some intrinsic regulation of tone — that is, the muscle sets its own tone — but Dr. Levin directly refutes this with some pretty sound logic: “Curare works at the neuro-muscular synapse, so it is the CNS that maintains the muscle tone, including the resting muscle tone (RMT). In my many years of doing surgery, I have never cut a muscle that did not retract unless it was curare-ized (and even then there is some contraction), so the tone has to be a primitive function, maybe some of it spinal, present even in deeply anesthetized creatures.” That’s from this page, a bit hard on the eyes and heavy reading, but neat stuff. BACK TO TEXT
  49. The shoulder joint and other adjacent joints can be dislocated, and bones broken. The brachial plexus can be damaged by the injected, or by tearing from the force of manipulation, causing nerve palsy (probably temporary, but sometimes more serious). The rotator cuff can be torn. The joint can fill with blood. The ring of cartilage that forms the lip of the shoulder socket can break. The joint can become permanently hypermobile BACK TO TEXT
  50. Harris I. Surgery: The ultimate placebo. NewSouth Publishing; 2016. BACK TO TEXT
  51. Louw A, Diener I, Fernández-de-Las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2016 Jul. PubMed #27402957. PainSci #53458. BACK TO TEXT
  52. Grant JA, Schroeder N, Miller BS, Carpenter JE. Comparison of manipulation and arthroscopic capsular release for adhesive capsulitis: a systematic review. J Shoulder Elbow Surg. 2013 Aug;22(8):1135–45. PubMed #23510748. “The quality of evidence available is low and the data available demonstrate little benefit for a capsular release instead of, or in addition to, an MUA. A high quality study is required to definitively evaluate the relative benefits of these procedures.” BACK TO TEXT
  53. Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2008;(1):CD007005. PubMed #18254123. BACK TO TEXT
  54. Clement RG, Ray AG, Davidson C, Robinson CM, Perks FJ. Frozen shoulder: long-term outcome following arthrographic distension. Acta Orthop Belg. 2013 Aug;79(4):368–74. PubMed #24205764. This was a study of 53 frozen shoulders, including 12 diabetic patients, and tracked results at 2 days, 1 month, and then once more 8-26 months later, finding that clinically significant improvements were maintained. On the other hand, this study has significant methological limitations: it “presents the work of a single radiologist” and it’s a case series with “no randomisation and no blinding of the patients, surgeon, radiologist or assessors.” BACK TO TEXT
  55. Sinha R, Patel P, Rose N, et al. Analysis of hydrodilatation as part of a combined service for stiff shoulder. Shoulder Elbow. 2017 Jul;9(3):169–177. PubMed #28588657. PainSci #52791. BACK TO TEXT