• Good advice for aches, pains & injuries

Frozen Shoulder Guide

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

Paul Ingraham, updated

Photo of man grimacing, holding his shoulder.

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 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; 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 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.

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.6 But that is still almost 1 in a 100 people. It’s not common-cold common, but it’s not rare either.

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

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

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.7 In severe cases, the rotator interval is “obliterated,” and the coracuhumeral ligament is “transformed into a tough contracted band,”8 like arthritis of soft tissues. This 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.9 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.10

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 (

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.11 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.

There’s another weird link with another weird disease, even stronger 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.12 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.”13

Revealingly, smoking is a major risk factor for shoulder problems,14 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 pain.15

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.16 There are many other fascinating examples.17

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 2017.18 Yes, that’s the acne bacteria, Propionibacterium acnes (which may be wrongly blamed for acne19).

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.20 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.


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).21

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.22

MMost 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.”23 Wired magazine: “The prolonged pain and stiffness of SIRVA is distinct—in other words, much worse—than typical soreness from shots.”24 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: aA 2015 paper reported three cases of injection injury followed by a confirmed diagnosis of frozen shoulder:25

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,”26 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,27 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.28 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)?

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.29 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.30 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.31 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.32 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.

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 freezing work?

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.33 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.34

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,35 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

The earliest medical description of frozen shoulder dates to 1872, when Simon-Emmanuel Duplay called it periarthritis of the shoulder,36 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.37 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.38

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:39 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 1995,4041 with little other comment from other researchers, except notably Bunker in 2010, who is emphatically on “team contracture”:42)

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?


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!

Part 2

Diagnosis of Frozen Shoulder

Confirming the diagnosis: classic frozen shoulder symptoms

Frozen shoulder is technically a diagnosis of exclusion, 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.”44

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.

Do you need imaging? X-ray or ultrasound?

Imaging is not a bad idea. X-ray is mostly for ruling out other things, which probably isn’t necessary in most cases. Ultrasound might be more directly useful.

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.47 There is no evidence-based right answer to this.

Diagnostic ultrasound is cheaper and completely safe. In general, for new cases of other kinds of shoulder pain, it’s not very useful. A 2019 showed study showed that things turn out the same way whether ultrasound is used to help with diagnosis or not.48

But frozen shoulder stands out among shoulder conditions. Ultrasound probably can detect the condition. Better than that, it can probably confirm that a shoulder is truly “frozen” (contracture, fibrosis, adhesions) rather than just super stiff (functional freezing).49 When truly frozen, the joint capsule looks different on ultrasound: “hypoechoic echotexture.” In other words, it looks dark with ultrasound. And that ability, in turn, could actually inform treatment choices.

Ultrasound can also usually identify a thickened corachumeral ligament,50 which is strongly linked to shoulder capsule distress. More on that coming right up.

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

Frozen shoulder may be a diagnosis of exclusion, but it does have one particularly strong defining symptom, almost “pathognomonic” (absolutely defining, a symptom that can only mean a specific diagnosis). If it was a sure thing, frozen shoulder wouldn’t be a diagnosis of exclusion!

But it’s not quite a sure thing, just a very strong clue. 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.51 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.

And, again, the poor state of the corachumeral ligament can also usually be confirmed by diagnostic ultrasound.52 When it’s unhappy, it gets thicker.

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 when there’s an “obvious” problem on an X-ray or MRI, it ain’t necessarily the problem.53 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. This joint can also be sprained (as I learned the hard way in 2008), usually by a fall on the outstretched arm, the kind of accident that might also break the collarbone. It’s conceivable that the pain of a mild sprain of this joint could strongly resemble frozen shoulder, but I think even a minor strain would involve a fairly obvious “oh shit” moment of injury.

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.

Part 3


Depressing 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 may be bogus. Someone looked into the basis for the conventional wisdom, and found “no evidence” to support it:

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.5455 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.

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 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.

Part 4

Treatment of Frozen Shoulder

Reviews of all the major treatment options

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

~ Nagy et al, 2013, Open Orthop J

Most cases of frozen shoulder can’t be “cured,” but any case can be managed and minimized.

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.56 In a 2004 test with 77 patients, “supervised neglect” actually worked (slightly) better than “intensive physical therapy”!57 Why even go on? It sounds like nothing works! But these studies were looking at the tip of an iceberg of possibilities58 hardly the last word — just good perspective. It might be unwise to spend a bunch of time and money on basic physiotherapy.

At one end 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 at least a little.

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.”59

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.”60 The authors of a big 2014 review sounded particularly underwhelmed: they concluded that hardly anything seems to work, and nothing works for long.61 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.62 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.63 Frozen shoulder seems worthy of considerably more and better research attention than it has gotten!

Use it or lose it: movement therapy to try to maintain function and slow down the capsule’s adhering/contracturing, or speed up recovery

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.64 And if you are somewhere the middle of the condition? Same thing, but with the goal of trying to prevent further range loss or regain it quicker.

This can include easy stretching and strengthening exercise as well: anything that requires your shoulder to do any kind of shoulder job, as long as it is tame enough to avoid making it more painful during the painful phase, which is a serious risk with frozen shoulder. I’ll discuss more “assertive” strengthening/stretching a little more below. Here’s a nice collection of miscellaneous 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! Literally just visualize movement, no joke. 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!

Strengthening for frozen shoulder

Building up muscle tissue is generally a much healthier activity than most people realize, and far more efficient too — even a small amount is a lot better than nothing. This is why there’s a saying that you “can’t go wrong getting strong”… but with frozen shoulder you can go wrong.

Strength training basically involves exhausting muscles enough to force them to adapt and get stronger. Although strengthening can be done relatively gently, there is a minimum level of intensity required for it to actually achieve the goal. Below that level, you’re just … moving with slight resistance. But above that level there’s a real risk of aggravating frozen shoulder.

Weakness is not the problem with frozen shoulder, so more strength is not therapeutic in itself. If there’s any hope for strength training to actually help frozen shoulder, it’s that the stimulation of the activity will somehow alter the course of the biology. This is not a foolish hope in theory, and there’s exactly zero direct scientific evidence about it. AFAIK, literally no one has ever tested this rigorously.

However, in practice, I wouldn’t expect much from it: strengthening is the bedrock of mainstream, conventional physical therapy and very widely prescribed … and yet frozen shoulder marches on for nearly everyone.

And then there’s that risk of aggravation …

My recommendation: Avoid strength training during the painful freezing stage — the risk of making a bad situation worse is just too great, and ain’t nobody got time for that — but do it any time after that, because it’s a lot less likely to be a problem, and it might just work.

What exercises? Literally anything with a barbell or weight machine that involves the shoulder. I think there’s no justification for any specific instructions — there’s not much reason to think that any specific approach is better than any other. As long as you are cautiously wearing out your muscles a little bit, 2 or 3 times per week, you’re providing a stimulus that might be therapeutic.

But here’s a more specific approach to consider anyway …

Strengthening with 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 (

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,65 especially that 2015 science experiment that showed that frozen shoulders un froze substantially under anaesthesia.66 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 … .

Stretching for frozen shoulder

Stretching is generally over-rated as a therapeutic tool: it doesn’t do most of what people usually assume it does (e.g. “prevent injury”), and flexibility is less important than people think (see Quite a Stretch). But it does increase flexibility, for whatever that’s worth … and frozen shoulder is a condition of decreased flexibility. So it seems like it could be a natural fit for this condition.

However, it’s super unlikely that pulling on the adhered/contractured capsule is going to change it. That tissue is exceedingly tough, and contracture makes it even tougher — we know stretch cannot change contracture.67 You might as well try to stretch a truck tire. Even without taking it easy to prevent aggravation of the condition, there’s probably little hope.

What if it’s stiff, not frozen? What if the problem is “more of a functional limitation than a physical one,” a possibility discussed extensively above? In that case, I think there’s quite a bit more hope that stretching could be useful.

So what does the evidence say? Stretching is such an obvious therapeutic option that it actually has been studied … but very little. One of the only noteworthy trials I can find was decent quality at least, and certainly appeared to have a happy ending.68 They used a “static progressive stretch device,” in other words a gadget for applying a slowly-but-steadily intensity of stretch, and the thirty stretched patients did better than patients who got “conventional physical therapy” on all measures, both after a month and a year later. Not bad … but it’s also hard to trust a single study.

My recommendation: As with strengthening, I recommending taking it so easy with stretch during the painful freezing stage that you might as well not bother, just don’t risk the aggravation, stick to doing exercises within your pain-free range of motion. But after that? I think it’s worth trying. Just find the end of your range of motion and push up against it. Push lightly and less frequently at first, and if it causes no trouble, start ratcheting up the frequency and intensity.

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,69 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 strokes70 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 a (minimally) 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.71 However, it’s equally clear that the benefits don’t last, and the freezing of the joint proceeds relentlessly.

How temporary are those benefits? Several weeks, maybe four months at the outside. A 2007 review concluded that “up to three injections were beneficial, with limited evidence that four to six injections were beneficial.”72 And beyond six? Uncharted waters! But it’s very likely the returns diminish, disappear, and then backfire. Steroids are crazy potent and have well-known corrosive effects on connective tissue. You don’t want to go overboard, and it’s unlikely that any doctor would let you. Many doctors won’t do steroid injections at all.

With potent short term benefits, the main use of corticosteroid injections for frozen shoulder should probably be to facilitate ROM-maintaining exercise through pain relief. If anything.

This encouraging evidence contrasts starkly with what happens with rotator cuff tendinopathy, which is almost nothing at all: brief, minor relief in only about 1 in 5 patients, according to a witheringly negative 2017 review.73 The difference is probably attributable to different pathology. Tendinitis is often incorrectly regarded as inflammatory, when in fact it is probably more 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 classically inflammatory in character, and therefore responds better to steroids. That’s a nice demonstration of the power of actually understanding the biology of a problem.

Treating frozen shoulder with … diet? Yeah, it’s a long shot, but it’s an interesting long shot

Fifty-nine updates have been logged for this article since publication (2016). All 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 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.

An anti-inflammatory diet — also known as a healthy diet, with a few specific features — could conceivably reduce the severity and duration of frozen shoulder. And the worst case scenario is that you’re eating better for general health.

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.74 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.75

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 shoulder: 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 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”!76 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.77 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.

Ultrasound for frozen shoulder

Ultrasound therapy is the use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries (sprains, tendinitis, bursitis). And frozen shoulder. It has been a popular therapy for decades, its use so widespread that it almost defines physical therapy. Unfortunately, although mainstream, it is not as scientific a treatment as most people assume. It has been condemned by one scientific review after another for a quarter century. Scientists seem to have almost nothing good to say about ultrasound. Conclusions like this one are the rule: “As yet, there seems to be little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders.”78 Some modern variants of ultrasound are expensive, hyped, and totally unproven for any or many conditions.

Ultrasound for frozen shoulder has barely been studied, but what little research has been done concluded that it couldn’t out-perform a sham.79 Ultrasound is particularly easy to compare to a sham, because you just need an ultrasound device that isn’t actually doing anything. That’s quite a persuasive negative trial, alas, and there isn’t really any promising science to contradict it.80

With ultrasound, there’s always the faint hope that just the right settings (amplitude, frequency, duration, and so on) might make an important difference. The big idea with ultrasound is — this will blow your mind! — that cells and tissues somehow respond “well” to being shaken (not stirred). It’s not clear to me why anyone thinks that, but it’s an entrenched idea. In the case of frozen shoulder, tissue is clearly misbehaving in some profound way, much worse than simply being hurt, so maybe being vibrated will convince them to behave? The possibilities have never been explored for frozen shoulder, but they have for fractures, and it’s not good news.81 If it doesn’t work for fractures (a simple traumatic lesion in tissue with amazing innate capacity for healing), it probably isn’t going to work for mysteriously contractured joint capsules.

Ultrasound for frozen shoulder does not look like a solid investment, based on the scientific information we have to date. About the only thing that can be said for it is that it’s harmless and not very expensive.

Super ultrasound: shockwaves

Extracorporeal shockwave therapy (rESWT) is a form of high-energy ultrasound. It has no obvious specific relevance to frozen shoulder — there’s just no particular reason to think it would work. The main story shockwave mongers are telling their customers is that shockwave therapy “breaks up” the adhesions in adhesive capsulitis … but we know better. We know that adhesive capsulitis is not “adhesive” but contractured. How are high-intensity sound waves going to help with that? It’s not inconceivable, but it would be a surprising and rather exotic biological effect, and that seems like a reach.

Another standard claim is that shockwave therapy will “speed up the healing process” because stimulation something something mumble … it’s so vague it’s meaninglessness, an idea that has already been tested and found wanting in the context of ordinary therapeutic ultrasound (and other electrotherapies, like TENS).

But shockwave therapy is a trendy treatment option for many musculoskeletal conditions — and there’s good evidence of efficacy for some of them — so of course people are doing it. And some scientists are testing it. To date, I am aware of just three tests, all recent, which is like trying to play baseball with three people. Without even looking at them, I could guarantee they aren’t going to be enough to conclude anything. But I will trudge through the data anyway …

My conclusion for now: there’s no particular reason to think shockwave therapy helps frozen shoulder, and no compelling evidence that it does. Shockwave providers that are citing Hussein et al to help sell their wares are irresponsibly opportunistic and ignoring (or ignorant of) what constitutes adequate evidence.

Desensitization and disinhibition

As discussed above, a functional freezing of the shoulder may be driven by neurological sensitization and subsequent inhibition. The brain thinks it’s dangerous to move, whether it actually is or not. It expresses its concern by making the shoulder hurt to discourage movement, or just outright refusing to allow movement. If this idea is any good, then obviously we want to desensitize and disinhibit. How is that done?

I have a Nobel prize for anyone with a straight answer to that.

But there’s good news: not only are there lots of reasonable approaches to this, but we’ve already been going over them in most of the sections above. Most of the treatment options covered so far involve building up confidence that you can, in fact, still use your shoulder. Anything that is soothing and encouraging, like making a little bit of progress with exercise, is a step towards convincing your brain that your shoulder is okay.

It’s okay, brain. Shoulder okay. See? I just moved it more than yesterday, and nothing terrible happened!

Brains are stubborn, unfortunately. Being soothed and reassured is rarely enough in and of itself. “Brain hacks” are not exactly well-known for curing any kind of chronic pain, let alone notoriously stubborn problems like frozen shoulder. But it is worth trying.

The basic template for all rehab is to “calm shit down” and then “build shit up,”86 also known as avoidance and exposure therapy. That is, first you rest, soothe, comfort, reassure, protect … and then you gradually introduce easy, artificial challenges, and then more difficult functional ones, slowly “demonstrating” to your brain that, actually, it is okay to use your shoulder.

This recalibration process is complex, slow, and uncertain — there are lots of ways it can get de-railed — but the principle is very sound. It should always be in your mind as you plan your rehab.

For much more detailed discussions of sensitization and what to do about it, see Sensitization in Chronic Pain and Pain is Weird.

Forcing the issue manually: joint capsule release with manipulation

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 …

Forcing the issue with manipulation under anesthesia (MUA)

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.87) 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.88 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,89 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.90 This includes other shoulder surgeries that seem like no-brainers, like decompression for impingement — more or less completely shot down by a 2017 trial.91

So any untested surgery for frozen shoulder 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.

Forcing the issue with MUA lite, the Oolo-Austin Trigenics® Procedure (OAT)

This is a branded treatment method named after founder Dr. Austin Oolo (formerly Dr. Oolo-Austin), a chiropractor and osteopath. He has a few clinics around the world. Since the rise of the popularity of this article, I have gotten more inquiries about Trigenics and OAT than any other single treatment. For (obvious) legal reasons,92 I will offer no direct opinion on the value of the technique; I will highlight some features of the treatment method, as presented on, the Trigenics website, and let readers judge for themselves as best they can.

The conventional treatment most similar to OAT is manipulation under aneasthesia (MUA, discussed above), but OAT is done with local anaesthetic instead of anaesthesia, which has alleged advantages. It is also “interactive” and during the procedure “the patient is actually contracting specific muscles heavily.” Although the shoulder is “now frequently anesthetized” during OAT, “patients do still experience some pain briefly.” Apparently so, because OAT also may involve injection of corticosteroids to “prevent post-procedural inflammation,” and “risks such as fractures or dislocations could exist.”

Dramatic results are claimed by the seller. It is “revolutionary” and “ensures a fast return to functional ability for frozen shoulder sufferers.” And, “Other than the OAT Procedure, there is NO treatment which can boast of a cure in only one visit.” Those are bold claims.

No independent studies of OAT have been conducted to verify these claims. A section of the website is devoted to testimonials, but only a single scientific citation is presented as of 2018,93 for a 2012 study conducted by Dr. Allan Oolo-Austin himself, based on patient data collected in his own clinic, and allegedly published in the suspiciously mysterious “Russian Journal of Manual Therapy.”94 Predictably, the study claims to show “a 98% restoration of arm raise ability (abduction) within 2 days.” The risk of bias in such a study is, of course, as high as it gets. As the authors themselves note, “it is recommended that further studies be conducted.” Understatement.

What are the odds that the “secret sauce” of contractions makes all the difference from MUA? What are the odds that this chiropractor is succeeding where everyone else is failing? I’m just asking questions here.

Forcing the issue surgically with arthroscopic capsular release and inflation

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.95 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:96

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).97 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).98

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).

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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 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.

Part 5


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?

Fifty-nine updates have been logged for this article since publication (2016). All 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 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.

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: Do you need imaging? X-ray or ultrasound?]

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 failure, not a biomechanical one.]

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.]

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 failure, not a biomechanical one.]

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 failure, not a biomechanical one.]

2018Upgrade: Added table of contents.

2018New section: No notes. Just a new section. [Section: Desensitization and disinhibition.]

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

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 would functional freezing work?]

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 for frozen shoulder.]

2018New section: No notes. Just a new section. [Section: Strengthening for frozen shoulder.]

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: Ultrasound for frozen shoulder.]

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

2017Improved: Beefed up information on over-the-counter medications. [Section: Over-the-counter pain killers for frozen shoulder.]

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 for frozen shoulder.]

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 for frozen shoulder.]

2017Improvements: Added more movement recommendations. [Section: Use it or lose it: movement therapy to try to maintain function and slow down the capsule’s adhering/contracturing, or speed up recovery.]

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.]

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

2016New section: No notes. Just a new section. [Section: Shrunk, not stuck: a 150-year history of misleading names.]

2016Science update: Revised introduction to treatments, citing Diercks as an interesting example. [Section: Treatment of Frozen Shoulder: Reviews of all the major treatment options.]

2016New section: No notes. Just a new section.

2016Science update: Littlewood et al now provides some more substantive support for the theory of functional freezing and related rehabilitation methods. [Section: Stiff but not frozen: the case for functional freezing.]

2016Clarification: Added an interesting clarification about my wife’s strange experience with frozen shoulder. [Section: My (wife’s) frozen shoulder story.]

2016Improvements: Many miscellaneous improvements.

2016Expanded: Added much more information. [Section: Massage therapy for frozen shoulder: symptom relief at least, possibly more.]

2016Science update: Added brief discussion of rotator cuff abnormalities in asymptomatic people. [Section: Other shoulder problems that could be confused with adhesive capsulitis.]

2016Improvements: Editing, and added a diagram of the hypothetical relationship between adhesive and functional freezing. [Section: Stiff but not frozen: the case for functional freezing.]

2016Revision: Some revisions to the discussion of treating systemic inflammation with diet, and added an important link out to a new article on that topic. [Section: Treating frozen shoulder with … diet? Yeah, it’s a long shot, but it’s an interesting long shot.]

2016Expanded: Added more information. [Section: Massage therapy for frozen shoulder: symptom relief at least, possibly more.]

2016New section: No notes. Just a new section. [Section: Stiff but not frozen: the case for functional freezing.]

2016Expanded: Added information about joint capsule inflating. [Section: Forcing the issue surgically with arthroscopic capsular release and inflation.]

2016Expanded: Added interesting new evidence about arthrographic distension. [Section: Forcing the issue surgically with arthroscopic capsular release and inflation.]

2016New section: No notes. Just a new section. [Section: Strengthening with the Meakins method: eccentric loading + “let it go”.]

2016Expanded: Added recommendation to try a ketogenic diet. [Section: Treating frozen shoulder with … diet? Yeah, it’s a long shot, but it’s an interesting long shot.]

2016Science update: Added more general evidence about treatment efficacy. [Section: Treatment of Frozen Shoulder: Reviews of all the major treatment options.]

2016Improvements: Several clarifications about diagnosis, and some new citations and expert quotes. Added a paragraph about x-rays. [Section: Diagnosis of Frozen Shoulder: Confirming the diagnosis: classic frozen shoulder symptoms.]

2016New section: No notes. Just a new section. [Section: Forcing the issue surgically with arthroscopic capsular release and inflation.]

2016New section: No notes. Just a new section. [Section: Forcing the issue with manipulation under anesthesia (MUA).]

2016Science update: Added more information about range of motion and reliability of assessment of ROM. [Section: Diagnosis of Frozen Shoulder: Confirming the diagnosis: classic frozen shoulder symptoms.]

2016Improvements: Expanded and added several new citations. [Section: Treatment of Frozen Shoulder: Reviews of all the major treatment options.]

2016Minor addition: Added a little about smoking as a risk factor. [Section: Nature of the beast: frozen shoulder is a biological failure, not a biomechanical one.]

2016Minor addition: Added footnote about other frozen joints, like frozen hips. [Section: Introduction.]

2016New section: No notes. Just a new section. [Section: Treating frozen shoulder with … diet? Yeah, it’s a long shot, but it’s an interesting long shot.]

2016Upgraded: Article is now substantive enough for removal of “half-baked” disclaimer, and a title change from frozen shoulder “primer” to “guide.”

2016New section: No notes. Just a new section. [Section: Diagnosis of Frozen Shoulder: Confirming the diagnosis: classic frozen shoulder symptoms.]

2016New section: No notes. Just a new section. [Section: The dead giveaway symptom: a specific painful spot, on the coracoid process.]

2016New section: No notes. Just a new section. [Section: Other shoulder problems that could be confused with adhesive capsulitis.]

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

2016New section: No notes. Just a new section. [Section: Nature of the beast: frozen shoulder is a biological failure, not a biomechanical one.]



  1. Other joints do freeze like the shoulder, but much less 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.

    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.

  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.

  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. He 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.” BACK TO TEXT
  7. 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. It’s “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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. Bunker T. Time for a new name for frozen shoulder—contracture of the shoulder. Shoulder & Elbow. 2009;1(1):4–9. PainSci #52392.  BACK TO TEXT
  14. 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
  15. PS Ingraham. Smoking and Chronic Pain: We often underestimate the power of (tobacco) smoking to make things hurt more and longer. 1227 words. BACK TO TEXT
  16. 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
  17. 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
  18. 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
  19. Good 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). BACK TO TEXT
  20. 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.

  21. 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
  22. 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
  23. 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
  24. [Internet]. Zhang S. Why Are Cases of Shoulder Injuries From Vaccines Increasing?; 2019 May 21 [cited 19 May 24]. BACK TO TEXT
  25. 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
  26. Pietrzak 2016, op. cit. BACK TO TEXT
  27. 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
  28. 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
  29. 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
  30. 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
  31. 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
  32. 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
  33. 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.

  34. 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
  35. 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. 3788 words. BACK TO TEXT
  36. 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
  37. Codman, E. The shoulder. Boston: Todd. 1934. BACK TO TEXT
  38. 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
  39. 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
  40. 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
  41. 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
  42. Bunker 2009, op. cit. BACK TO TEXT
  43. 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
  44. [Internet]. Meakins A. Frozen shoulder? Let it go, Let it go … .; 2016 July 27 [cited 17 Oct 26]. BACK TO TEXT
  45. [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
  46. 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
  47. 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
  48. 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
  49. Lee JC, Sykes C, Saifuddin A, Connell D. Adhesive capsulitis: sonographic changes in the rotator cuff interval with arthroscopic correlation. Skeletal Radiol. 2005 Sep;34(9):522–7. PubMed #15999280.  BACK TO TEXT
  50. Homsi C, Bordalo-Rodrigues M, da Silva JJ, Stump XM. Ultrasound in adhesive capsulitis of the shoulder: is assessment of the coracohumeral ligament a valuable diagnostic tool? Skeletal Radiol. 2006 Sep;35(9):673–8. PubMed #16724200.  BACK TO TEXT
  51. 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
  52. Homsi 2006, op. cit. BACK TO TEXT
  53. 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
  54. Wong 2017, op. cit. BACK TO TEXT
  55. Clement 2013, op. cit. BACK TO TEXT
  56. 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.

  57. 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
  58. 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
  59. 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
  60. 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
  61. 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
  62. 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
  63. PS Ingraham. A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta. 2841 words. BACK TO TEXT
  64. 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
  65. 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
  66. Hollmann 2015, op. cit. BACK TO TEXT
  67. Harvey LA, Katalinic OM, Herbert RD, et al. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev. 2017 Jan;1:CD007455. PubMed #28146605.  PainSci #52742. 

    This is a Cochrane review of static stretch for the treatment and prevention of contractures. The verdict? A clear thumbs down. Based on “high-quality evidence” they concluded that “stretch is not effective for the treatment and prevention of contractures.”

  68. Ibrahim M, Donatelli R, Hellman M, Echternach J. Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study. Physiotherapy. 2014 Sep;100(3):228–34. PubMed #24211154.  BACK TO TEXT
  69. 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
  70. 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 killers 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.

  71. 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
  72. Shah N, Lewis M. Shoulder adhesive capsulitis: systematic review of randomised trials using multiple corticosteroid injections. Br J Gen Pract. 2007 Aug;57(541):662–7. PubMed #17688763.  BACK TO TEXT
  73. 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.

  74. 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
  75. 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).

  76. 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.

  77. 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
  78. van der Windt DA, van der Heijden GJ, van den Berg SG, et al. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain. 1999 Jun;81(3):257–71. PubMed #10431713.  BACK TO TEXT
  79. Dogru H, Basaran S, Sarpel T. Effectiveness of therapeutic ultrasound in adhesive capsulitis. Joint Bone Spine. 2008 Jul;75(4):445–50. PubMed #18455944.  BACK TO TEXT
  80. Page MJ, Green S, Kramer S, et al. Electrotherapy modalities for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014 Oct;(10):CD011324. PubMed #25271097.  This 2014 review of electrotherapies, including ultrasound, was technically inconclusive but mostly just discouraging. They might not have found enough evidence for a firm neagtive conclusion, but they sure didn’t find any clear positive evidence either. BACK TO TEXT
  81. Schandelmaier S, Kaushal A, Lytvyn L, et al. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. BMJ. 2017 Feb;356:j656. PubMed #28348110.  PainSci #52780.  From the abstract: “trials at low risk of bias failed to show a benefit with LIPUS, while trials at high risk of bias suggested a benefit” and “LIPUS does not improve outcomes important to patients and probably has no effect on radiographic bone healing.” BACK TO TEXT
  82. Hussein AZ, Donatelli RA. The efficacy of radial extracorporeal shockwave therapy in shoulder adhesive capsulitis: a prospective, randomised, double-blind, placebo-controlled, clinical study. European Journal of Physiotherapy. 2016 Mar;18(1):63–76. BACK TO TEXT
  83. Hussein et al hit all the highlights of well-designed experiment. The researchers gave real shockwave therapy to one group of 52 patients weekly for a month, and sham shockwave therapy to the other group, and measured pain and function. The real shockwave group did “significantly” better, with the researchers notably claiming both statistical and clinical significance of the results … but not reporting the actual effect sizes in the abstract, which is always suspicious (if they are impressive, they get featured).

    Despite the good design, a major concern here is that sham treatment. Shockwave therapy is high energy, and uncomfortable at best, painful at worst. In the sham group, the shockwaves were simply “blocked.” It seems like many or most patients would certainly know that they weren’t getting the real shockwave therapy … which would spoil the data for sure.

    The results are very promising, but it’s a mystery why shockwave therapy would work, the effect they observed was probably not very large, and there’s probably one huge flaw that would be a deal-breaker.

  84. Vahdatpour B, Taheri P, Zade AZ, Moradian S. Efficacy of extracorporeal shockwave therapy in frozen shoulder. Int J Prev Med. 2014 Jul;5(7):875–81. PubMed #25104999.  PainSci #53178.  In this case, the sham was simply this: “the device was turned off and placed on the patient's shoulder for the same period of time.” How that fools anyone who has the slightest clue of the nature of the treatment is beyond me. They overconfidently concluded that ESWT “seems to have positive effects … based on completely unconvincing data. “A difference,” not large, and barely statistically significant, by some measures … but no difference in internal rotation (the most important). Meh. BACK TO TEXT
  85. Chen CY, Hu CC, Weng PW, et al. Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis. J Shoulder Elbow Surg. 2014 Dec;23(12):1843–1851. PubMed #25441567.  They compared shockwave therapy to oral steroids and “both groups showed significant improvement”… meaning they both did equally poorly. Neither works well, if at all. BACK TO TEXT
  86. Tweet, Sep 24, 2014, Greg Lehman (@GregLehman), physical therapist and chiropractor. BACK TO TEXT
  87. It is a myth that muscles are paralyzed by anaesthesia and that surgeons have to be extremely careful not to dislocate joints. There is still normal muscle tone with standard anasthesia, and in fact, “There is a constant battle to relax the muscles during some procedures,” explains Dr. Steven Levin [in private correspondence]. “Maybe the newer anesthetics have more curare-like effects, but if they do, they would have to intubate every patient. If the patient is breathing on their own, they have muscle tone! Sometimes, when fixing a fracture or repairing a ligament, the patient must be curarized.”

    The curare poison is the only way to truly paralyze muscle for surgery, but it’s used sparingly and specifically: it’s not part of normal anaesthesia, which only stops protective reflexes. “You have to be awfully insensitive not to know when you are exceeding tissue limits,” Dr. Levin says.

    Even a supposedly relaxed muscle shrinks about 20% when cut. The tone is mediated by the brain and spinal cord, which is not affected by anaesthesia. 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.

  88. 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
  89. Harris I. Surgery: The ultimate placebo. NewSouth Publishing; 2016. BACK TO TEXT
  90. 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
  91. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2017 Nov. PubMed #29169668.  PainSci #52836.  A common shoulder problem involves pain when lifting the arm past 90˚, which supposedly involves pinching of sensitive structures under the ledge of bone that overhangs the shoulder, the acromium. It seems like a simple mechanical problem with an obvious surgical fix: make some more room! But this test cast serious doubt on the efficacy of that approach … like so many other “common sense” orthopedic surgeries. BACK TO TEXT
  92. In case it’s not obvious, chiropractors have a long history of silence critics by suing them, most infamously the case of Simon Singh. Although there are many “good” chiropractors today, the profession has always been mired in many serious controversies. BACK TO TEXT
  93. Bakhtadze M, Oolo AO. The Trigenics® OAT Research Study. Russian Journal of Manual Therapy. 2012 Dec. BACK TO TEXT
  94. Was it actually published in a peer-reviewed journal? I can find no record of the existence of the Russian Journal of Manual Therapy. Google has not indexed any page on the Internet that cites any paper published in it other than this one. It’s not indexed by PubMed either. If the journal ever existed, it does not exist in any form online today, which is basically inconceivable for a journal that was allegedly publishing in 2012. It’s either hopelessly obscure or fake, and I suspect the latter. BACK TO TEXT
  95. 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
  96. 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
  97. 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
  98. 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