Complete Guide to Frozen Shoulder

No.53

Betteridge’s Law of Headlines strikes again!

I’ve left this “chapter” like this for a long time now, my snarky little joke: one blunt answer with a big footnote. But I knew eventually I’d have to get more specific and detailed to respond to reader objections, and now I have…

But what about kyphosis?!

A slightly slouched upper back is extremely unlikely to be a risk factor for frozen shoulder, or any other kind of shoulder pain. The position probably does limit shoulder ROM a little, but not enough to matter.

Kyphosis is the natural curve of the thoracic spine, from the mid to the upper back. If the curve is excessive, it’s hyperkyphosis, but people often leave off the “hyper” when talking about an excess. “You’re kyphotic” technically means “You’re fine, you have a normal spinal curvature,” but millions have been told that by their massage therapist or chiropractor who absolutely meant “your upper back is way too curved.”

And many people reckon that frozen shoulder is basically a case of getting “stuck” because of habitually poor posture. Here’s the most common form of this belief, as one of my readers put it to me: limited thoracic mobility “forces the shoulder to work in a compromised position and therefore contributes to shoulder pain.” And many people have extended that specifically to frozen shoulder.

So that’s the claim, a full-blown etiological hypothesis: hunching causes limited thoracic and shoulder mobility, which in turn causes frozen shoulder. It’s a reasonable thing to wonder about, but it’s also based on some unsafe assumptions and is unsupported or contradicted by the science. The evidence on this topic is, at best, discouragingly non-positive and inconclusive.54

Are people “stuck in flexion”?

The only people with pronounced hyperkyphosis are older women (”dowager’s hump”). So this idea isn’t just that hyperkyphosis is a risk factor for frozen shoulder, but that even subtle hyperkyphosis can put you in the danger zone.

Not only do I doubt that minor hyperkyphosis involves any significant movement limitation, but I’d also want to be careful about giving any patient that idea, because the fearful thought of a stuck spine might be more of a problem than any actual kyphosis. Pathologizing minor biomechanical factors is an excellent nocebo engine: making things worse with the power of suggestion, rather than better.

Does kyphosis affect shoulder range of motion in the first place?

Probably, yes. Barrett et al reported a “strong” evidence that you can lift your arms somewhat higher in an erect posture than in a slouched one. Which isn’t surprising, because the scapula slides around on the upper back and that mobile foundation is an important part of full shoulder function, so it makes sense in principle that hyperkyphosis could impact shoulder ROM.

Probably not much though.

I actually can’t reproduce this effect: when I go all hunchy, I cannot detect any difference in shoulder abduction or flexion. Maybe a wee bit, but for confirmation we’d have to get out the goniometer (tool that measures joint angles). I’m not flexible in general, a hardcore computer-posture guy, and not exactly young anymore. If I maintain what mobility I have for much longer, people are going to start accusing me of being “spry.” So if I have full (or nearly full) shoulder ROM while I’m hunching my back, presumably many other people do too.

And that’s with a hard, deliberate hunching of the back. In a more ordinary minor slouch — “poor posture” — my shoulder ROM seems completely normal. I’m not saying this to try to contradict the science, but to put it into perspective: it’s probably not a large effect, or any more surprising (or pathological) than having limited hip range of motion while seated. Just minor business-as-usual biomechanics.

The clinical significance of slightly limited ROM

Even if shoulder ROM is limited by minor thoracic flexion in some/many people… does it matter? As a risk factor for frozen shoulder specifically?

This is a data-free zone: there is exactly zero research on this specific question. All we can do is evaluate the plausibility, which I think is also exactly zero.

There would be a plague of frozen shoulder in elderly women with truly “hyper” kyphosis, and yet that’s not a thing. Frozen shoulder is well-known to affect people long before they have a dowager’s hump, and of course it also affects a great many people who have no hyperkyphosis at all.

It’s also logically important that people who recover from frozen shoulder typically get back to a full range of motion.

Most people don’t come anywhere close to using their full shoulder ROM in their normal activities. While it is broadly true that we “lose it” if we do not “use it,” the shoulder is an unusual loosey-goosey joint, and it doesn’t lose mobility quickly or from simple neglect. Despite not using the full range much, most people seem to hang onto their full shoulder ROM well past middle-age, as long as their shoulders are otherwise healthy.

Frozen shoulder is a pathological process that rapidly deprives the shoulder of a lot of ROM. I just do not believe that meltdown has anything to do with a slightly lower maximum range that people mostly don’t use or lose in the first place.

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Functional freezing, if it occurs, is probably a clinically quirky form of the common but obscure problem of sensitization. Sensitization is normally all about pain, but it can probably also suffocate movement, and the shoulder may be the perfect example.

So what is sensitization? It’s the tendency of the nervous system to get into a rut and start over-reacting to stimuli, like a smoke alarm that goes off when you boil a pot of water.55 This is a well-described property of chronic pain,56 the crown jewel of modern pain science,57 and evidence that either there is no God or only a cruel one. As a general rule, the longer any kind of pain lasts, the more likely sensitization is to become a factor, and even to take over and become the main problem.

Sensitization can complicate any chronic pain problem, and as my career lengthens I find myself writing about it more and more: all painful roads seem to lead to this topic. There is great variety in acute pain — there are many ways to start hurting — but chronic pain is often eventually dominated by sensitization, just one major mechanism, regardless of how it all started.

And yet pain can begin with sensitization, too. Certain kinds of pain — especially neck pain, back pain, and abdominal pain — can be the tip of a sensitization iceberg.

If functionally frozen shoulders are “sensitized,” how can they can be so painlessly stiff?

In the programming language I use to create PainScience.com (PHP), when two things are identical in every way, perfect clones, we would say it with three equal signs, like this:

A === B

So equal! If two things are equal-in-practice, but not necessarily of exactly the same type, we use two signs instead of three:

A == B

I am not saying that functional freezing === sensitization, but something more like freezing == sensitization or maybe just freezing ≈ sensitization (approximately equal). They are almost the same thing. Different forms of the same underlying phenomenon. (Did I just use a coding example to try to make my writing more “colourful”? Dork alert!)

Or maybe they just co-exist and overlap. I am making an educated guess that sensitization is present wherever functional freezing occurs (if it occurs). So I am going a little ways out on a hypothetical limb here, but there are some interesting reasons why stiffness might be more prominent than pain in this particular joint, especially in the later stages.

In the early stages, it’s likely that the inflammation of frozen shoulder would both be painful and sensitizing: “continuously increasing nociceptive impulse activity, as in early stages of adhesive capsulitis, could lead to peripheral and subsequently long-lasting central sensitization.”58

But later…

The shoulder is a super 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 — rather than issuing a warning in the form of pain.

By contrast, in many other joints, there’s much less range of motion, too little for there 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 a more “frozen” pattern, while joints with minimal range just hurt and don’t “freeze” nearly so much.

And that’s why I believe that sensitization and functional freezing may well be different faces of the same phenomenon.

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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 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 30s 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 age.

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. 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, it was extremely difficult to penetrate the joint capsule, due to all the scarring.

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 that was about as cryptic a case of frozen shoulder as there could possibly be: seemingly completely out of the blue. But would some kind of biological disposition to this condition eventually reveal itself? Indeed it would.…

So fast forward 10 more years. I had surgery this past June for Dupuytren’s contracture in my right hand. Again, no obvious risk factors: not old enough for that disease, not male, not diabetic, no Parkinson’s, etc. But 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 bad bike accident about 8 years ago which involved me landing on my palms and scraping deep wounds filled with pavement and glass. 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 overactive 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 diagnostics 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 understanding of her problem 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 can change lives even while remaining hard to diagnose, subtle and quirky. “An overactive immune system” is probably too general a way of saying it — if cops in one city become extremely overzealous with one type of crime, that’s not a national problem with “an overactive police force.” The immune system can and does go overboard in surprisingly specific ways — specific tissues in specific locations — without necessarily having any other major malfunctions. And so it’s possible to have subtle, quirky autoimmune disease, with consequences that fall well short of severe and easily explained, but which can still change lives.

So Tanya’s shoulder 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 — literally scarred into place by rampant inflammation caused entirely by a genetic glitch. And what a strong testimonial for surgery!

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These shoulder problems are presented roughly in order of how much they can imitate a case of frozen shoulder, 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 anatomically overlaps the joint capsule that gets inflamed in frozen shoulder. (And why a “rotator” cuff? Because the lion’s share of the muscle activity here is devoted to turning the ball of the humerus in its socket.) They are literally hard to separate: the muscles are effectively another layer of the joint capsule, their tendons merging with it. Which is why rotator cuff problems can be difficult to distinguish from frozen shoulder! You can almost make the case that the joint capsule is actually part of the rotator cuff, but that term does traditionally refer specifically to the muscles. But they are certainly intimately related.

Confusing things even more, rotator cuff issues 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.62 But the rotator cuff can hurt, and when it does, it mostly limits active movement, while frozen shoulders are frozen even when you are relaxed and someone else tries to move your shoulder for you (passive movement). Tears are violent and happen suddenly with intense exertion, a clear “oh shit” moment of injury. 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.

Facioscapulohumeral Muscular Dystrophy — This common form of muscular dystrophy affects mainly the face and/or shoulders and can lurk undiagnosed for decades, with only minor symptoms. For some patients the condition mainly manifests as shoulder weakness as the muscles in that area atrophy, and frozen shoulder is their first misdiagnosis. That was exactly what happened to my oldest friend, who wasn’t diagnosed correctly until his late 30s, years after being told he had frozen shoulder, even years after his trapezius muscle had already rather dramatically wasted away.

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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. Its sensitivity on a specific spot on the front of the shoulder, on the tip of a bone called the coracoid process.63 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 coracohumeral ligament can also usually be confirmed by diagnostic ultrasound.64 When it’s unhappy, it gets thicker.

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

An x-ray and/or an MRI scan 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 imaging isn’t exactly a foolproof method of detecting other causes anyway.

Other pros think imaging is a no-brainer and well worth the minor (radiation) risks of a single x-ray to check for surprises before proceeding with therapy.65 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 study showed that things turn out the same way whether ultrasound is used to help with diagnosis or not.66

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).67 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 coracohumeral ligament,68 which is strongly linked to shoulder capsule distress.

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I proposed above that functional freezing — a neurological stifling of movement, rather than a physical limitation imposed by a messed up joint capsule — could be the entire problem with many cases of frozen shoulder. Or at least a significant complication at certain stages. Since functional freezing might be much easier to treat, it would be great if there was a way to tell how much of a factor it is.

And there might be.

If functional freezing is a factor in your frozen shoulder, it’s probably because your brain is “worried” about the joint. That worry may be an excessive overreaction to dwindling inflammation (likely in the late stages), or it could be well justified by the state of the joint (likelier in the early stages). A contractured shoulder capsule will never allow extra movement, but inhibition can ease temporarily in some situations:

• during pain relief
• while deeply relaxed, or during gentle, relaxed movement
• while the shoulder is physically supported (by a helper, submerged in water)
• in the aftermath of safe-feeling but unusual stimulation, like vibration
• during and immediately after exercise

The clues might be subtle. For instance, you might get only a little extra range of motion, briefly and erratically, in specific contexts — but any clear increase in range when the shoulder is “happy” is all you need for confirmation. A contractured shoulder capsule will never allow extra movement, but inhibition can falter temporarily in the right circumstances.

Failure of ROM to ever improve in these circumstances does not prove that inhibition isn’t a factor. But even a single clear example of improved ROM would be impossible with a contractured shoulder.

Getting someone else to move your shoulder for you very very very gently

The best way to do this experiment is during a lovely massage, with a therapist who can be trusted to understand and implement the test respectfully. But anyone you trust could do it — no special expertise is needed, just the right gentle vibe.

Basically, you just let someone move your shoulder for you very slowly and gently while you focus on relaxing as deeply as possible. You’re doing your best to imitate being anaesthetized. 😜 If your helper can move your shoulder beyond its normal limits, then at least some of those limits must be imposed by the nervous system, not contracture.

A little enhancement: don’t just try to will yourself to relax, but actively focus on something pleasant. Visualize petting a beautiful, happy cat, for instance (assuming you like cats). Redirecting mental attention may be effective for short-circuiting inhibition.

The submersion “hack”: test your shoulder in the water

Brains aren’t dumb: they know that water is a much safer place to move a shoulder. While not every brain will be convinced, the comfort and support of submersion will probably be enough for many of them to allow some shoulder movement. A physical limitation will not yield in the pool (or anywhere) but a functional limitation might.

If your shoulder has the same limited range in and out of the water, it doesn’t prove anything. But if it obviously does move better in the water? Yahtzee! That would more or less confirm functional freezing… and provides great encouragement to do submerged rehab exercises as a treatment, too. This is one of the best possible examples of aquatic therapy.

Drugs that relax muscles might help to confirm the diagnosis

Muscle relaxants and other systemic sedatives and psychoactive drugs (benzos, opioids, pot, booze) are not as good at reducing muscle tone as you might think — but they do work to some degree, and your mileage may vary. And they might soften the intense inhibition of the rotator cuff muscles.

The most accessible way to test this is either with an over-the-counter muscle relaxant, or by having a couple beers — not both at the same time, please! They do not combine well! And then test your shoulder range of motion. If nothing changes, it doesn’t mean your shoulder isn’t functionally frozen — it just means that the drug isn’t working for you, and there are many possible reasons for that. But if you do get more range when you’re slightly sozzled… yahtzee! That’s a meaningful diagnostic checkmark in the functional freezing column.

There’s a full chapter below about muscle relaxants and related drugs.

Diagnosing sensitization, a “known associate” of functional freezing

Earlier I introduced the concept of sensitization: the over-reaction of the nervous system to stimuli that usually sets in and takes over and puts the “chronic” in chronic pain. In the context of frozen shoulder, there’s a lot of overlap between sensitization and functional freezing.

In my opinion, if you have one, you probably have the other, despite their differences, even though one involves pain and the other involves stiffness. I am hypothesizing that they are two sides of a coin: that your shoulder would hurt in a sensitized way … if your brain would allow movement. It’s not moving to avoid that pain.

The sensitized frozen shoulder patient often has more of a sensitization problem than a shoulder problem. But that begs the question:69 how can you tell the difference? It’s kind of like asking someone hard-of-hearing if their TV is turned up too loud: it sounds right to them. How are you supposed to know if your brain has turned its shoulder paranoia up too loud?

There truly is no way to be sure, but the more of these items you check off, the more likely you are to be sensitized. (These items are taken from many sources, but particularly Smart et al.70)

• Starting with the obvious: you have no obvious cause for your pain, no recent injury, no known source for the pain. You are medically unexplained.
• Your pain is chronic. Sensitization usually requires months to establish itself.
• Your pain is out of proportion to any known, recent injury.
• It’s hard to tell what’s going to make you feel better or worse. While some things may help or hurt consistently, others do not. You have good days and bad days and can’t figure out why.
• You are seriously pessimistic, and you have a lot of worries about it being a sign of something worse (e.g. catastrophizing).
• You have too much pain and tenderness elsewhere: sore anatomy that “shouldn’t” be sore because it’s unlikely to be related to your pain.
• A history of troubles in the areas that are strongly associated with sensitization: neck and shoulders, low back, abdomen, jaw.
• High overall stress load: exhaustion, poor sleep, chronic stress, anxiety, depression, and/or anything else that drains or menaces you (like another significant medical problem). Obviously almost any adult without a perfect life could check this one off, but it’s a matter of degree.
• You’re female. Unfortunately, this really is a risk factor!
• Overuse of stimulants like nicotine, caffeine, or more potent ones. Or withdrawal from sedatives like benzos (Valium), which can jangle your nerves for a surprisingly long time (months).
• Your pain is erratic and more likely to fade into the background when you’re happily preoccupied. This is a whole category of tricky, subtle possibilities.

That last one deserves some extra attention. Sensitization makes pain worse because the CNS is convinced that there’s more of a threat than there actually is. If pain backs off at times when the brain is “reassured” and/or distracted, that tends to indicate that sensitization is involved.

Failure to respond to “reassuring” situations doesn’t mean that there’s no sensitization — because it may just be too strong, which is absolutely possible. Likewise, a strong improvement doesn’t guarantee that there’s no pathology, or an injury still slowly healing — because the brain is capable of dampening any pain.

But a pattern of signs that your pain backs off when your brain is either reassured or preoccupied with higher priorities … that is a valuable clue, and well worth bearing in mind throughout any and all treatment experiments.

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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.

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Before I dive into the treatment options, I’d like to respond to a common reader concern that I do too much “debunking,” and not enough telling you what works and exactly how to do it. Although I get few refund requests — way below industry averages — most of the requests I do get are caused by this specific concern: Doesn’t $20 get me a road map to a cure? A step-by-step action plan? The savvy exercise regimen that will make the pain stop?

These things just don’t exist, as I warned in the introduction. I have not sold you a book without mentioning that.

Even if they did exist, prescribing a treatment “plan” is simply out of the question, because every case really is different — that’s not just a platitude. What works for one person really is not going to work for the next. I promise that I’m not holding out on you. I am not a cure salesman, and I will not tell you what you want to hear. There is no specific method or series of logical steps that will reliably cure any kind of chronic pain problem, least of all the tough kind I write books about.

No plan survives contact with the enemy.

Helmuth von Moltke the Elder

Many people reading this probably think plenty of debunking is quite reasonable, normal, and even ethical. But imagine some of the unreasonable expectations I hear from a few customers. For instance, one woman asked me for a refund because my book offered her “only suggestions”! What else is there? What did she expect? Binding arbitration? Click this link for a cure? Free magic wand with every purchase?

Historical perspective and the Age of Hype

The disappointing truth is that there is only a motley assortment of rather underwhelming options with complex pros and cons, but usually more “cons.” Some are better than others, but quite a few are dodgy, for obvious reasons: hope sells, and so there are many more poor options than there should be. Please blame reality for this … not me.

And blame the people who have given you false hope and raised your expectations of musculoskeletal medicine far beyond what it can possibly deliver.

We are living in the “Information Age,” but sometimes it seems more like it’s the Age of Marketing and Hype. An almost unbelievable amount of the information we consume is generated to promote products and services. The result has been an unprecedented flood of being told what we want to hear about absolutely anything.

The reality is that musculoskeletal medicine is surprisingly primitive. Medicine has always had bigger, scarier fish to fry than treating mere aches and pains and injuries, which were barely studied at all until the 1980s. Musculoskeletal medicine is still a cocky teenager, just starting to come of age and figure out that it doesn’t know everything. Even sports medicine specifically, with so much potential funding and relevance to occupational injuries, has been bizarrely slow to build its evidence base.

The trouble with pseudo-quackery: treatments that seem way more legit than they are

The most prominent problem in musculoskeletal medicine today is the prevalence of what I call “pseudo-quackery”: treatments that are about as sketchy as any old-timey snake oil, but seem modern and scientific and mainstream. A few classic examples: laser therapy, ultrasound, platelet-rich plasma, prolotherapy, nerve and muscle stimulation. But there are many more.

These disguised quackeries are actually based mainly on surprisingly stale tradition, speculation, and authority. They generate more false hopes and wasted time, energy, money, and harm than more traditional quackery because they are vastly more popular and very much part of mainstream medicine, or very friendly with it — even many hardened skeptics aren’t expecting snake oil when they go to see a physical therapist or an orthopaedic surgeon.

So musculoskeletal medicine is a minefield, and a lot of debunking just goes with the territory. But it doesn’t mean there’s no good news at all.

The good news

Despite all the debunking and disappointing evidence, I do indeed have positive things to say about several of the options. I have started this part of the book with a summary of all the options, and I will conclude it with another summary of my recommendations, focusing on the positive as much as possible, and what to actually do. Many things are worth trying, even if they aren’t sure things or sitting on any solid science:

We’re told to strengthen this muscle or stretch that one, or inject this substance into an injury, or zap it with heat or electricity or ultrasound … and sometimes it really works, even though placebo-controlled trials fail to validate the treatment. I’m a big advocate of better science to really understand what causes injuries and how to treat them — but in practice, I also believe that sometimes it’s worth trying something, anything, just in case it successfully ‘reboots’ your injury.

Alex Hutchinson, Sweat Science

An encouraging perspective, but of course it doesn’t mean you should try any old nonsense. And you may save some time and money avoiding several others (or at least re-prioritizing them). You may even avoid the heartbreak of those that can do some harm. Knowing what not to do is half the battle, if not more! Understanding the topic well enough to prioritize the imperfect options is actually a huge win, the best you can realistically hope for.

•

The “negativity” of ratiocination is a surprisingly big topic, often funny, and sometimes profound. I answer the accusation in more detail in a compilation of tales of outrageous hate mail, the ethics and tactics of debunking, what it’s like to (supposedly) be the #1 Public Enemy of Massage (a therapy everyone loves to love), and — my favourite — “advanced negativity,” a discussion of how cynicism is baked into science in the form of the null hypothesis.

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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.80

And if you are somewhere in 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 exercises 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.”

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!

Use it better: tips for better range of motion exercise

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. Or lie down on a bed and move your shoulder while the arm is fully supported. Or get a helper to provide partial support. Such tactics are a good way to take safe baby steps into the outer limits of your comfortable range.

Nothing is more supportive than water. Do range of motion exercises in the pool, with your shoulder and arm submerged. Highly recommended.

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.

How’s it hangin’? The pendulum exercise “dangles” the shoulder

One of the best and simplest light exercises for a frozen shoulder is the “pendulum” exercise, in which you just dangle the relaxed arm and swing it gently, letting the weight of the arm carry it back forth, or in small circles. You can do this from a standing or sitting position, leaning forward to give the arm a little room. You don’t even use the shoulder muscles: the movement is generated by tiny movements of the torso, and requires only the slightest muscular effort to sustain. Just tiny nudges will keep the arm swaying like a pendulum.

Done right — if you’re comfortable, if you keep it easy and relaxing — the pendulum exercise may even feel good. This gentle movement appears to be a minor but reliable pain-killer for many people.81 And when things are grim, even a little relief can be precious. Reader Hilary W.:

On my frozen shoulder journey, there were many nights when I was up at 2–4am sitting and crying. When nothing else would work, the pendulum exercise took just a tiny edge off the relentless aching pain.

And reader Russell W.:

Awake every hour or two overnight in excruciating pain, the pendulum swing gave a tiny amount of relief. I hope I never go back there again.

Serious analgesia? No. Sanity preserving edge-removal? Absolutely. And of course, regardless of any pain-killing effect, it’s just a good maximally gentle way to try to maintain shoulder mobility. Especially in the difficult early stages, the pendulum makes a good warm-up and warm-down from slightly more challenging mobilization exercises.

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Exercise is the closest thing there is to a general miracle drug,8283 and strength training is one of the best ways to exercise, practically like magic: healthier and more efficient than most people realize.84 This is why there’s a saying that you “can’t go wrong getting strong”… but with frozen shoulder you really 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, but there’s exactly zero direct scientific evidence about it. As far as I know, literally no one has ever tested this rigorously.

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 …

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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 to no avail. However, there is a “different” method for treating frozen shoulders that I have been using more and more over the years …

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

Physiotherapist Adam Meakins has a novel idea 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,85 especially that 2015 science experiment that showed that frozen shoulders unfroze substantially under anaesthesia.86 It involves progressively challenging range of motion, putting it firmly in the “use it or lose it” category of treatment approaches. Adam puts 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 … .

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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.87 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.88 They used a “static progressive stretch device,” in other words a gadget for applying a slowly-but-steadily increasing 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 recommend 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.

P.S. As with range of motion exercises, the pool is a particularly good place for stretching.

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The “window of opportunity” (WOO) is a period of pain relief and/or confidence that makes it easier to do normal activities and rehab exercises. This is a popular notion in physical therapy.

And the WOO might be an especially important idea in frozen shoulder rehab, because so many of the more promising treatment methods are either about creating or using these windows. While that is broadly true of rehab for many other conditions, it’s especially relevant to frozen shoulder because of the possible role of functional freezing. A WOO is mainly useful to the extent that freezing is caused by excessive neurological inhibition. A brain that is incorrectly convinced that it has to limit shoulder movement might be more easily persuaded to lift the ban if you do rehab exercise while the pain is blunted.

And a WOO might even be useful for frozen shoulder involving contracture. These patients also need to do whatever they can to maintain shoulder range, and there are surely better and worse times to do that. Reduced pain is a good example of a better time!

WOO woo?

Maybe the WOO is bullshit. While there’s probably some legitimacy in the idea of a window of opportunity, the notoriously skeptical physical therapist blogger Adam Meakins argues that the idea of a window of opportunity is often just a thin, self-serving justification for using ineffective methods, “more for the therapists’ benefit rather than the patients’.”89 I completely agree. I see it all the time.

Ineffective therapies can still often produce transient, trivial pain relief because almost anything can.90 In some cases, such minor benefits might be encouraging and motivating enough to constitute a meaningful opportunity to advance recovery. For instance, someone might be more willing to do some exercise, or get an extra boost fighting their nicotine addiction.

But in many cases it’s probably just not enough — too brief, too minor — and the WOO is just a weak excuse for a treatment that has little else to recommend it.

What makes a better WOO?

A somewhat more reliable pain-relief effect… and a target like functional freezing, that has a better chance of actually benefitting from a WOO.

And so windows of opportunity will come up again several times in the rest of the tutorial. So far, I’ve only discussed treatment options that would be facilitated by a WOO, like range of motion exercises, strengthening, and stretching. Other treatments, like pain medications, steroid injections, massage, vibration, or icing/heating are mainly about creating WOOs.

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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,91 which are:

• aspirin (Bayer, Bufferin)
• ibuprofen (Advil, Motrin)
• naproxen (Aleve, Naprosyn)

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.

There is also some potential to use pain-killers to create windows of opportunity for better rehab — a period of pain relief where other treatments may be easier and more effective. But there’s not a lot of opportunity, because for most people the pain relief just won’t be very great. If you find a drug and (safe) dose that seems to work better, it’s worth making a point of taking them half an hour before, say, doing your strengthening exercises.

Safety first!

At any dose, these drugs can cause heart attacks and strokes92 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.

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Photo by Jose Luis Sanchez Pereyra on Unsplash

Perhaps the most interesting & controversial plant in the world.

Cannabis is a plant, most notably marijuana (bred for its narcotic effects) and the major strain of hemp (bred for other purposes). It’s one of the most interesting plants in the world because it produces chemicals with interesting effects, the cannabinoids. The most interesting and famous of those are THC (tetrahydrocannabinol) and CBD (cannabidiol). All cannabis contains THC, CBD, and hundreds of other related compounds, but there’s a lot more THC in marijuana plants, and a lot more CBD in hemp.

THC gets you high (psychoactive effects), and CBD does not. Both are alleged to be pain killers: it’s their most popular medicinal use (either that or as a sleep aid), but CBD is much less studied.

The evidence for pain-killing

So, are cannabinoids effective pain killers? “It’s complicated”!

As a science journalist, I am honour bound to emphasize that cannabinoids are not proven pain-killers. “Proof” is a high bar that has not yet been cleared. A huge 2017 review of the scientific literature on cannabis concluded that there is “substantial evidence that cannabis is an effective treatment for chronic pain in adults.”93 But the review also explains that the evidence shows only modest benefits so far, there is uncertainty about every detail, and significant practical problems abound for both researchers and consumers.

And that was hardly the last or only word. Other reviews of largely the same evidence have been much less optimistic. In 2017, Nugent et al looked at 27 scientific trials of cannabis for chronic pain trials, and it was disappointing: weakly positive for neuropathic pain, and just inconclusive otherwise.94 In 2019, Häuser et al wrote “Cannabis medicines can be regarded to be third-line therapy for chronic neuropathic pain. There are signals of a lack of efficacy for all other chronic pain syndromes.”95

So that’s not great.

Can getting high help? The role of psychotropic effects in treating frozen shoulder

THC might have some bonus effects for some patients because it can cause euphoria, reduce anxiety, improve sleep, and indirectly function as a muscle relaxant. It’s probably not a potent muscle relaxant, but nothing else is either (nothing you want to take regularly anyway). More about that in the muscle relaxant chapter.

None of this is “pain-killing,” per se, but these effects may have some potential to help you cope with pain. Better yet, maybe they can even dial back the movement inhibition that probably accounts for some percentage of the problem. Testing your ROM while high is probably a good idea. The results may surprise you.

It could also backfire. Please do be aware that THC can cause anxiety just as easily as it can reduce it. Your mileage will vary. And there’s nothing relaxing or disinhibiting about anxiety!

Usage guidelines for beginners

If you’re new to marijuana, there’s a bit of a learning curve. Here are some tips:

• Pure topical CBD creams and oils are overall the safest and most convenient, so they should probably be your first priority to try. THC may be where it’s at, but it’s harder to use…
• Use caution with THC edibles! Dosing and duration of effect are huge wildcards. You can get way, way too high for comfort — not very dangerous, but scary.
• Avoid vaporizers that use oil infused with cannabinoids, due to scandalous, tragic safety issues because asshole manufacturers have added other dangerous, un-tested substances96. Dozens of people died in 2019. Died!
• Infused oils aside, vaping raw cannabis in moderation is quite safe.97 Just take it easy for at least your first three times — just one or two modest inhalations of vapour is just fine to start.

For more detailed information, see Marijuana for Pain.

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photo by Paul Ingraham

Ripening seed head of an opium poppy.

The notorious opioids, derived from the milk of the poppy flower,98 are mainstream drugs like codeine, and the infamous heroin derivatives and imitators like Oxycontin, Percocet, and Vicodin. Most patients assume that opioids are “powerful” pain killers, and we joke about “the good stuff” like it’s a given that it will do the job if anything will, despite the well-known horrors of addiction and overdose. But opioids are curiously impotent for many kinds of pain and people.

(Opioids do not include the infamous benzodiazepines, like Valium, discussed in the muscle relaxants section.)

Opioids mostly induce deep relaxation and euphoria that may make you not care about pain, as opposed to “killing” pain. But not caring is not a cure, and their efficacy is surprisingly poor for musculoskeletal pain, especially chronic pain (non-cancer).99 Some people are even genetically immune to them.100 They can also backfire and cause pain.101 And, of course, life-altering opioid addictions and life-ending overdoses are shockingly common. The CDC declared in early 2016 that opioids should not be an option for chronic musculoskeletal pain: there’s just too much danger, and too little evidence of benefit.102

Demonizing an entire class of drugs is usually a bad idea. Not everyone gets addicted and some people get real relief, so there’s plenty of grey area here despite the risks. With proper medical supervision, opioids might provide some much needed relief from a particularly debilitating and extreme chronic pain problem like frozen shoulder.

There is no direct scientific evidence about the efficacy of oral opioids for frozen shoulder one way or another.

Weak versus strong opioids

The weak opioids are drugs like codeine, dihydrocodeine, and tramadol. The strong opioids are either morphine itself (the gold standard, the canonical opioid drug) or its derivatives and synthetic imitators like fentanyl, hydromorphone, methadone and oxycodone.

It seems like it would make sense to experiment with weak opioids before strong, but the weak ones are notoriously ineffective at lower doses, and when you increase the dose the efficacy doesn’t go up very much but you do get a lot more side effects! Bad deal. If you need any opioids, you probably need strong ones. If you don’t need strong opioids, weak ones aren’t worth it either. But that’s just an opinion, a starting place for a chat with your doctor.

The case for opioids for frozen shoulder

Many doctors will tell any frozen shoulder patient who asks for opioids that “the condition is self-limiting,” and therefore the risks just aren’t worth it — even if they think it will help. While it’s probably not actually true that frozen shoulder is self-limiting (a likely myth debunked way back in the introduction), it is true of the painful, “freezing” phase of the condition. That agonizing phase is definitely going to end.

So what’s the rationalization for using opioids despite the expiry date on frozen shoulder pain? If opioids are useful for anything outside of palliative care, it’s exactly this: temporary prescriptions to help people get through rough patches of severe, debilitating pain. Short-term emergency use is one of the best ways to use opioids (and other dangerous drugs, like tranquilizers).

It’s debatable whether the painful phase of frozen shoulder is actually an “emergency,” but it sure looks like it to me in some cases. Losing the use of an arm and suffering through many weeks of severe pain is rough for anyone, but it’s particularly bad for some people. For people who really badly need to use what little shoulder ROM they have left, without excruciating pain, a short-term supply of strong opioids could be a life saver.

So should you ask for opioids? And how?

Overall, I don’t think it’s a great idea for most frozen shoulder patients — just a few people experiencing the worst consequences of the condition.

Most doctors will be hard to convince. Prescribing opioids has become a nightmarish minefield for physicians, and many refuse to prescribe them at all, or only where the need is the most extreme (and most will not think that includes frozen shoulder). And yet, paradoxically, you can also still find plenty of evidence that the opioid epidemic is raging on, driven by continued excessive prescription of opioids!

So it’s a little hard to know what you’ll encounter if you ask a physician about this. If you do, here are some critical talking points:

• Acknowledge that it’s a bit radical, and show a clear awareness of the danger of addiction.
• Request supervision, low doses, and a limited supply.
• Emphasize that you’re only seeking partial relief to keep you functional during the worst of the freezing (painful, inflamed) stage of the condition.

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Corticosteroids are potent anti-inflammatory agents (and not the same thing as the anabolic steroids taken by bodybuilders.103). They are an exotic kind of pain-killer. Think of them as ibuprofen on, er, steroids.

Oral corticosteroids can be invaluable for management of severe widespread inflammatory conditions — like rheumatoid arthritis, say — but they are overkill for almost any painful “hot spot,” like trying to put out a frying-pan fire by turning on the sprinkler system. If you can avoid exposing other tissues to corticosteroids, you should, because they are a bit of a bull in a biological china shop.104 Injection is preferred for its precision.

But oral corticosteroids certainly kill pain! No doubt about that. From a 2006 Cochrane review: “Oral steroids provide significant short-term benefits in pain, range of movement of the shoulder and function in adhesive capsulitis.”105

The concern is about the side effects, which can be so dire that they should only be tolerated if they are the lesser evil, and only the most desperate patients should consider risking those side effects for frozen shoulder relief. Few doctors would sign off on it, not with injection as a perfectly good alternative. Injections are popular because oral steroids are a terrible idea for most musculoskeletal conditions.

The rest of this chapter will consider injections only — which have their own problems, but they are at least much more local problems. Injections also have some significant potential with frozen shoulder specifically — more than any other musculoskeletal condition I can think of.

Injecting corticosteroids

Wherever pain is caused by inflammation, corticosteroid injections are also likely to produce substantial temporary pain relief — at the cost of a (minimally) invasive procedure with some risks. They can be injected with a needle, or blasted through the skin with an electrical charge (iontophoresis).

In the case of frozen shoulder, it’s clear that these injections function as a kind of super pain-killer — they can reduce pain.106

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.107 The difference is probably attributable to different pathology. Tendinitis is often incorrectly regarded as inflammatory, when in fact it is probably more degenerative in character, so it’s not much of a surprise that a powerful anti-inflammatory medication has less impact. But the painful freezing stage of frozen shoulder 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.

For frozen shoulder, it’s clear that there are benefits … and equally clear that they don’t last, and that the freezing of the joint proceeds relentlessly despite the pain relief.

Just how temporary are we talking about? Several weeks of relief, maybe four months at the very best… and that’s with repeated injections.

A 2007 review concluded that “up to three injections were beneficial, with limited evidence that four to six injections were beneficial.”108 And beyond six? Uncharted waters! But it’s extremely 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.

Bottom line: powerful short-term medicine. That has value, but there might be a way that we can exploit that short-term benefit for even greater value…

When life hands you short-term benefits…

I find it easier to push the limits of range of motion in a joint that isn’t screaming at me. I bet you feel the same way. I bet even American Republicans and Democrats could agree on that.

With potent short-term benefits, the main use of corticosteroid injections for frozen shoulder should probably be to facilitate ROM-maintaining exercise, simply because it’s quite a bit easier to do those rehab exercises when your pain is dampened.

This might be the ultimate example of a treatment that creates a “window of opportunity” (WOO) for better rehab. Perhaps it creates a bigger window than any other therapy — because the window is basically opened by pain relief, and steroids provide quite a lot of that, for a while.

There’s no direct evidence to support the claim that steroid injections will not only provide short-term relief, but also create a useful WOO that actually improves long-term results when properly exploited. It’s a hard thing to study, because it’s hard to define “properly exploited.” What exactly should you do with the WOO? A small WOO with a minor effort at doing better rehab while you have the chance might have no real impact at all. Maybe the exact type of exercise you do while the WOO is open is important. To the best of my knowledge, this has not been studied — probably because it would be quite tricky to study.

But it is plausible. If the WOO concept has any validity at all — always open to debate — this seems like it’s one of the best possible candidates.

Happily, there is actually some indirect evidence. A 2017 meta-analysis didn’t just confirm the typical short-term pain relief benefits of corticosteroid injection, but also this:109

Intra-articular corticosteroid injection resulted in greater improvement in passive ROM both in the short and the long terms.

Long-term benefits of any kind are noteworthy, and this just happens to be exactly the benefit I would hope to see if short-term pain relief can actually facilitate frozen shoulder rehab. And yet that conclusion was based on studies that were not specifically studying how to make the best of the window-of-opportunity provided by the pain relief. Maybe people with frozen shoulder who get steroid injections just naturally use their shoulders more, because they can — less pain, more movement.

If a detectable long-term benefit in ROM can occur without any particular attempt to exploit the WOO… well, then, I am optimistic that actually trying to exploit the WOO is a promising strategy.

Injection advice summarized

Anyone with a really debilitating case of frozen shoulder should consider getting one or two intra-articular injections during the painful (freezing) stage. I think three is pushing it: the risks start to outweight the benefits at that point. They should be spaced about 4-6 weeks apart, and the second one should only be done if the pain has gotten quite bad again.

There are two specific reasons for this advice:

1. Pain relief is inherently valuable. Frozen shoulder can be an extremely disabling condition, and short-term pain relief alone has significant value, regardless of anything else.
2. It’s just a hypothesis that pain-relief will facilitate better rehab… but it has some good plausibility, a bit of indirect evidence, and “costs” nothing extra — the intervention is already justified by the first reason.

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“Muscle relaxant” is an odd category of drug. There are several drugs that are relaxing, but are not exactly “muscle relaxants” because they are not specifically interfering with the biology of muscle contraction. A true muscle relaxant is essentially a poison that messes directly with muscle physiology.

You really don’t want too much of a true muscle relaxant. It can cross into paralysis. Amazonians used a muscle relaxant … on their poison arrows. Curare poison relaxes you to death. European explorers encountered the stuff early in their visits to North America, and it led to some of the earliest scientific studies in pharmacology.

And yet, on the other hand, it’s not clear that the muscle relaxant drugs are actually interfering with muscle contraction! So it’s a tricky topic.

As with many other treatment options discussed in this book, this one is mostly only relevant to functional frozen shoulder. If your shoulder joint is inflamed and contractured, even an extremely potent muscle relaxant is not going to make any difference. You could paralyze those muscles, and your shoulder would still be frozen.

For functional frozen shoulder, however, a muscle relaxant is an intriguing idea with real potential. In principle, it could even be used to diagnose functional freezing: to the extent that a muscle relaxant improves your range, it isolates muscular inhibition as a cause.

Muscle relaxant primer

Muscle relaxants come in many related varieties,110 but only one that is widely available without a prescription: methocarbamol, as found in Robaxin, Robaxacet, and similar brand names.

There are also several prescription muscle relaxants, obscure to most patients, but most notably carisoprodol (Soma), cyclobenzaprine (Flexeril), metaxalone (Skelaxin).

All muscle relaxants are tame cousins of the truly potent sedatives (also discussed below), and can cause significant drowsiness, dizziness, and a laundry list of other common side effects, but there’s also a surprisingly wide range of safe dosage (hard to overdose).

Methocarbamol and friends are not widely used because they are not super effective. It’s probably because they’ve been around forever, because the drowsiness they cause makes them feel more potent than they actually are, and because relaxing muscles just seems like such a good idea to literally everyone, both patients and pros. I think perhaps muscle relaxants have been grandfathered into modern, scientific medicine. Tradition-based medicine, rather than evidence-based medicine.

Muscle relaxants are surprisingly unstudied, like many other popular drugs.111 In particular, good luck finding any study of the effect of these drugs on muscle function. It’s not clear if muscle relaxants actually relax muscles, or if they just make us feel more relaxed.

What evidence we do have is not exactly high quality.112113114

An expert of my acquaintance thinks they are useless specifically at low dosages.115

Acute back pain is the only condition for which there is adequate data. Some muscle relaxants (including methocarbamol) do appear to be roughly as effective for acute back pain as common over-the-counter pain killers116117 — so they can help, but not all that much, and with great potential for side effects. It’s also damning that there doesn’t seem to be much difference between muscle relaxants: “Comparison studies have not shown one skeletal muscle relaxant to be superior to another.”118 So we have a class of drugs that shows little sign of effect, no matter which flavour you use. Whoop-de-do!

Even a prescription muscle relaxant like carisoprodol (Soma) is so impotent that patients will (this is bizarre) actually tense up if they are lied to and told that the drug is a stimulant.119 (The study was quite interesting — if you only read one footnote about a study in this book, this would be a good one to choose.) Clearly the brain is the boss of your muscle tone, and the drugs only nudge us towards relaxation. Bear this fun fact in mind for the discussion of alcohol and other psychoactive drugs coming up — it’s a ray of hope.

And here’s another fun fact: even anasthesia doesn’t truly “relax” muscle.120 It stops voluntary contraction, but it doesn’t eliminate muscle tone. Only death does that, and even in that extreme case the tenacity of the contractile proteins is demonstrated in the phenomenon of rigor mortis.121

Muscle relaxants clearly work at least a little for some people, some of the time, probably usually at higher doses. And they are relatively safe to experiment with, even at higher dosages. In fact, it’s so hard to overdose on them that I even feel comfortable endorsing cautious testing of a larger dosage than what’s recommended on the box. Just don’t go driving, don’t combine with alcohol, and be alert for significant side effects — they aren’t effective enough to bother with if they harass you with side effects.

Narcotic “muscle relaxants” (sedatives like Valium)

If our goal is to loosen up the muscular control of the shoulder joint, is there any drug at all that will definitely do the job? Any drug that’s reasonably accessible?

Narcotic sedatives, mainly the benzodiazepenes, relax everything. Like the opioids, the benzos are another “nuclear option” — they do interfere with muscle contraction, while also interfering with everything else: like consciousness! Many drugs have highly unpredictable effects, but the benzos are as potent and predictable as cobra venom.

The most famous of all the sedatives is diazepam, AKA Valium, a benzodiazepene. But it is only the most infamous member of a family of rogues, like Klonopin, Ativan, and Xanax.

Just because they are potent — and they certainly are that — does not mean they actually work, or that they work by relaxing muscles. A 2017 study showed that “Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain” (they put the result right into the title).122 However, I suspect that the your-mileage-may-vary factor is huge with these drugs.

As with the milder muscle relaxants, it’s surprisingly unclear whether or not these drugs actually reduce muscle tone, or whether they achieve relaxation indirectly via their potent sedative and psychoactive effects. Those psychoactive effects are a huge wildcard that could account for a wide range of responses. They are primarily used to relieve anxiety and improve sleep, both of which could easily relieve pain on their own.

I don’t think there’s any question that benzos might be a useful tool for loosening up a functionally frozen shoulder. And frozen shoulder can be so debilitating that it seems worth at least considering this treatment option, despite the hazards… which are a big deal.

Benzos really do involve dire risks of physical dependence and addiction, and withdrawal can be nightmarish, dangerous, and even lethal at the extremes. Although it is possible to take and stop taking benzos safely, many people do not get the information and help they need for that. Sadly, I have extensive personal experience with benzo withdrawal, and I’ve written about that in detail.123

However, benzos can be safe if used in moderation for short periods only. They are a dangerous tool, like a gun, which must be respected and used with great caution. If you’re interested in dancing with this devil, don’t just ask your doctor for a prescription: make a point of showing your prudence by asking for only a 2-week supply of a small dosage only (the exact amount varies with the specific drug).124

The curious case of alcohol as a pseudo-muscle-relaxant

Alcohol is hard on your system in many ways. It’s a myth that a drink every night is a tonic, and there really is no safe intake level125 — it is a poison, and it can make people more vulnerable to chronic pain. And yet…

There’s plenty to be said for a glass of wine or beer as a kind of medicine.126 Anecdotally, moderate usage seems useful for taking the edge off nearly any kind of pain. This may be because it’s functioning as a kind of muscle relaxant, or at least as a general sedative.

Let me be clear: alcohol is not a muscle relaxant per se,127 not in a biochemical sense (and warning: it also combines dangerously with actual muscle relaxants and sedatives). In a world full of alcoholism and drug addiction, obviously a “prescription” of alcohol has to be offered and taken rather cautiously. But it is highly accessible, cheap, relatively harmless in moderation, and it’s a psychoactive drug — and anything that bends your mind has the potential to be a mild, obliquely effective muscle relaxant.

All psychoactive drugs — anti-depressants, alcohol, marijuana, amphetamines, opioids, benzodiazepines — often seem to help almost any problem, but the emphasis is on seem, because they mainly affect mood: “It is my impression that ‘pain-killing’ drugs improve the patient’s mood rather than take away the pain.” (Sarno)

Mood isn’t nothing. If you are genuinely happy and relaxed… if that’s something alcohol can do for you…

Given the potential importance of reducing inhibition of shoulder function in frozen shoulder, I don’t think there’s any question that I would try to get a little tipsy before doing my mobilization exercises.

THC as a pseudo-muscle-relaxant

Tetrahydrocannabinol (THC) is the most famous cannabinoid produced by cannabis (marijuana). It is another relatively safe and accessible psychoactive drug, probably the only other one that seems tame enough to take seriously for this purpose. (Sure, you could blow your mind with acid or ecstasy and hope for a muscle relaxant effect, but that seems like overkill.) Obviously its accessibility varies widely from place to place as the entire world grapples slowly and awkwardly with legalization.

Like alcohol, THC doesn’t zap muscle tone directly, but it probably can do it indirectly and erratically.

If you are happy and relaxed while stoned, it’s certainly possible that inhibited shoulder movement will be less inhibited. Whether or not that would meaningfully affect the kind of particularly fierce functional inhibition that might be a factor in frozen shoulder is anybody’s guess, but it seems worth trying.

For this purpose, virtually any strain of marijuana will do, but ideally a THC-rich one (not CBD) because you want the psychoactive effects. You want to get high before working on your shoulder range of motion. Whee!

With pot, there is also the added potential for direct pain relief (discussed above, along with usage guidelines).

And so I do tentatively recommend THC as another “muscle relaxant” worth experimenting with.

Botox?

Botox is the infamous face-paralyzing drug of the stars! It’s a special case, quite different from the other muscle relaxants. Like curare on poison arrows, Botox is outrageously toxic and doesn’t “relax” muscles but just outright paralyzes them, even in small doses.

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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 only. 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”!128 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 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. That window of 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.

Creating windows of opportunity might be the secret to the power of massage in general. Although the value of such opportunities is often exaggerated, massage may be particularly good at it.129

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 noticeable 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

Massage is the most obvious and natural way to attempt to treat “trigger points,” but only one of several options, which I will bundle together in the next chapter.

Other benefits of massage

Proven benefits of massage are much less common than you might think. While many papers claim to show a wide variety of benefits, most of them are poor quality experiments that couldn’t actually prove anything. However, there are a few more credible sources, and the best — maybe the only — established benefit of massage is that it’s helpful for anxiety and depression.130

Both anxiety and depression are a lot more likely in people suffering from a serious chronic condition like a bad case of frozen shoulder. And reducing anxiety in particular could certainly be a useful part of a desensitization strategy.

A benefit like that may not have much to do with frozen shoulder specifically, but it is highly relevant: it’s so worthwhile that it essentially guarantees that your money won’t be wasted. Whether massage therapy does anything for your frozen shoulder or not, it is at least good for your “soul.”

Perhaps one of the reasons massage reduces depression and anxiety: it’s relaxing. While not proven as well as you might think, it is a pretty safe bet,131 and the idea is further supported by evidence that massage therapy may reduce blood pressure132133 and helps people to sleep, even when they are under the unusual stresses of hospital care.134

And there are likely other general health benefits as well, even if they haven’t been proven.

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Trigger points (TrPs) are sore spots associated with aching and stiffness, as common as pimples, which may be a cause and/or complication of nearly almost anything else that hurts. Their nature is poorly understood and controversial,135 but the main theory is that they are a “micro cramp,” just one member of a big family of unwanted muscle contractions.

Trigger points might be a major mechanism for “functional freezing” in cases of frozen shoulder.

Rubbing trigger points seems to ease them. No one knows how well it actually works, or even if it works at all.136 But it certainly does seem to, and often surprisingly easily.137 All advice about trigger points on PainScience.com is based on “seeming” and scientific plausibility, which is weak sauce.138

However, given the potential importance in frozen shoulder, presumptive treatment — treating as if trigger points matter — is worth a try if you focus on the safer and cheaper options: mainly self-massage, possibly supplemented with some professional massage help as long as it isn’t overly aggressive.

Dry needling is popular too, and I will discuss it below mainly to discourage you from using it: it’s more expensive and risky, without being more likely to help. And then there a few other possibilities, like getting professional help, addressing medical factors, medications, injections, exercise therapies (especially stretch), ergonomics, and much more.

How to treat trigger points with self-massage

Grope around your shoulder with fingers and thumbs and find acutely sensitive, aching spots in muscle tissue. You may or may not feel a slight bump or twitch, but those are inconsistent and unreliable signs. Finding trigger points is the exact opposite of an exact science,139 but don’t sweat it: just cast a wide and pleasant net, it doesn’t matter if some effort is “wasted” on some wrong spots.

The soreness of a trigger point should feel “relevant” — that is, the soreness of the spot should feel like it is related to your shoulder pain, rather than some other kind of discomfort that just happens to be in the same area. See below for several more specific places to look for relevant TrPs.

Massage tools are essential for exploring the back of the shoulder in search of TrPs beyond the reach of your hands. It’s important to be able to explore the back of the shoulder, because there could be trigger points all over and around the shoulder blade that are relevant. (More about locations to explore below.) What tools? Mostly balls.140

When you find a sore spot, either simply press and hold for a while (10–100 seconds), or apply small kneading strokes, either circular or back and forth. You’re hoping for the sensitivity to ease, which is what we traditionally call a “release” in trigger point therapy.

Rub very gently at first, just tugging the skin to and fro over the surface of the sore spot — some initial gentleness has a specific purpose, don’t skip it — and then ramp up to rubbing firmly but not viciously. You’re not trying to “kill” it, you’re trying to soothe and “scratch” it. Too much intensity can backfire, and a just-right intensity may actually be a key to success: vivid and clear “good pain” is an ideal level, intense but somehow satisfying. Don’t grimace through it as if a brutal massage therapist was inflicting it on you.

A good first self-massage experiment should take several days, two or three sessions per day, with a few minutes of exploration each time. If you are finding points that feel relevant but they aren’t easing, you could up the ante and try a few basic upgrades: treat right before bedtime, get better tools (a firmer, smaller ball like a lacross ball can be a game-changer), avoid chills or actually have a hot bath/shower with treatment, or follow treatment with light exercise.

If a couple weeks of this yields little or nothing, it’s time to give up, or get some professional help to explore other possibilities.

Where to search for trigger points relevant to frozen shoulder

• The deltoid muscle is the most obvious of the shoulder muscles, but also the least likely to harbour trigger points relevant to frozen shoulder. You should check it anyway, but the deltoid is not an especially “triggery” muscle in my experience.
• It’s the muscles of the infamous, “rotator cuff” muscle group — prone to tears — that are much more likely to matter. These muscles all have tendons that surround the shoulder joint, like a “cuff.” They are all attached to some part of the shoulder blade at the other end.
• One of the rotator cuff, the subscapularis, is between the back and the shoulder blade, and virtually untouchable except a little bit in the armpit. Although subscapularis trigger points may be relevant to frozen shoulder, this is a very difficult area for amateurs, and trying to describe it is beyond the scope of this tutorial, and a reason to consider professional help.
• The infraspinatus is much more accessible — though still awkwardly out of reach on the back of the shoulder — and is worth some special consideration: Perfect Spot No. 14, The Most Predictable Unsuspected Cause of Shoulder Pain. Despite the fact that it seems to be far from the problem, way over on the back of the shoulder, infraspinatus TrPs routinely “shoot” pain through and around the shoulder (referred pain). You may be amazed at how relevant infraspinatus trigger points feel. See that article for much more detail — it’s an important supplement to this chapter. If you’re going to try to treat frozen shoulder with trigger point therapy, you’re going to have to get to know your infraspinatus.

The approximate location of Spot 14 & friends in the infraspinatus triangle. The pale blue band across the top indicates the most worthwhile area. Notice how remote spot 14 is from the shoulder joint. Click to embiggen.

Professional trigger point therapy (mostly massage)

Some important things to bear in mind if you seek trigger point therapy for frozen shoulder:

• We’re mostly talking about massage therapists — they are the most likely kind of professional to be competent to help — but you can also get help with trigger points from other kinds of healthcare professionals. There are other kinds of trigger point therapy, but none are great options.
• It’s a crapshoot. The quality of trigger point therapy is all over the map and low on average. So you have to be prepared to shop around for someone who seems humble, sensible, and experienced. See How Do Your Find Good Quality Massage Therapy?.
• When in doubt, it is much better to just have a great shoulder massage than bad trigger point therapy. There is plenty of overlap between decent trigger point therapy and an ordinary pleasant massage.
• Please, never tolerate extremes of massage pressure.

Warning! Although it’s not “massage” per se, many massage therapists will nevertheless be tempted to manually force your shoulder range as part of the treatment. Do not allow this! It’s especially likely because of the obsession with fascial release in that profession.141 Remember, you could easily be dealing with someone who knows less than 5% of what is contained in this document, and they could be overconfident and reckless with your vulnerable shoulder joint.

It’s not all gloomy. For what it’s worth, many massage therapists do claim to have cured cases of frozen shoulder,142 and it’s not hard to see why, and I suspect some of them are even true. I actually 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.

Other kinds of trigger point therapy

There are several other major types of trigger point therapy. Not one is promising for the average headache patient, but all are worth considering when you get more desperate. If I was in my third year of frozen shoulder, I might start considering these options. Here are the other approaches, quickly summarized. (Again, every topic here is explored in much greater detail in my book).

Stretching seems like a good idea for “knots” that may be micro-cramps by nature. It might work about the same way that stretching out a calf cramp works: you win the tug-of-war with contracting muscle, just on a tiny scale. As with massage, people believe it helps, including some experts. Unfortunately, there are major problems in both theory and practice. Even if it’s possible in principle to win a tug-of-war with some trigger points, it’s unlikely to work with all of them, and especially not the worst ones. How can we pull apart a powerful contraction knot — a tiny segment of muscle fibres in full spasm — with anything less than pliers, a vice, and a glass of bourbon? That trigger point is like a knot in a bungie cord: all we’re going to do is stretch the bungie cord on either side of the knot.

Stretch with … spraying? A coolant spray, that is. This is one of the “original” types of trigger point therapy, used by Dr. Janet Travell (famous for her study and promotion of trigger point therapy in the 1970s and 80s). It’s just stretching enhanced by a chill on the skin, which might have some interesting reflex effects. It is obscure, rarely practiced today, and unvalidated scientifically — but probably worth a shot if you can find someone who does it.

Maybe stabbing will help! “Dry needling” is a popular but sketchy method of treating trigger points with acupuncture needles (but it’s not acupuncture143). It is “dry” needling to distinguish it from “wet” injections of medications. It involves some risks, from wasted money to worsened pain to infection and (seriously) lung puncture.

Lung puncture might seem unlikely during dry needling therapy for frozen shoulder, but there are a number of muscles on the chest wall that might be targeted to try to help the shoulder, as well as the lateral neck, where the tippy top of the lungs are surprisingly exposed (they are higher than people realize, and lurk just under the skin at the base of the side of the neck).

Needling is provided mostly by physical therapists. Every practitioner will claim they know what it’s doing, but none of them can actually explain it in any detail: ideas about it are imprecise and contradictory speculation. It feels potent and patients have a love/hate relationship with it. Other than a handful of positive studies,144 the science is discouraging.145 I do not think it’s a good option for most people: it is plausible and interesting theoretically, but also has risks, costs a lot, and can hurt like hell. Few patients should be willing to accept those downsides without much better evidence that it works.

Shiatsu is another Asian therapy that might include some “accidental” trigger point therapy. It’s needle-less Japanese acupuncture, using lots of pressure to stimulate acupuncture points, so it definitely includes a bunch of vitalistic nonsense (“energy medicine”). Nevertheless, it has far more in common with massage therapy than acupuncture does. Remove the Japanese elements and it’s just “acupressure,” which can be almost indistinguishable from trigger point therapy. Typical shiatsu/acupressure is 30-60% in tune with what I consider to be good trigger point therapy… which is probably better than some bad trigger point therapy.

Injection. Trigger points may be treatable by injecting them with a saline solution (to dilute the tissue fluids), with an anaesthetic or anti-inflammatory medication, or even with Botox to paralyze and “deactivate” them. Evidence of efficacy is incomplete and unimpressive so far. A 2001 review concluded that “Any effect of these therapies is likely because of the needle or placebo rather than the injection of either saline or active drug.”146

Addressing other medical factors

There is one more major approach to trigger point therapy that is much more important: attempting to reduce the biological vulnerabilities that may cause trigger points (and/or other kinds of chronic pain). This can be a huge project and a bit of a wild goose chase, but it’s a near certainty that there are at least some treatable medical factors, such as disturbed sleep, nutrient deficiencies, or hormonal imbalances, that make trigger points worse.

See Vulnerability to Chronic Pain.

Recap of key trigger point points

• Trigger points may actually be a major mechanism for “functional freezing” in cases of chronic shoulder pain.
• Trigger point therapy is experimental but can be very safe, cheap, and easy.
• Self-treatment is mostly about finding sore spots in the shoulder and rubbing and squeezing them with fingers or balls, at moderate intensity, a couple times a day for a week or two.
• There is a particularly good spot to look for trigger points relevant to frozen shoulder: the infraspinatus muscle, on the back of the shoulder blade. (The subscapularis is probably equally relevant, but much harder to access.)
• Good professional help with trigger point therapy is hard to find, but any good quality shoulder massage is probably better than bad trigger point therapy. So mainly just try to find a massage therapist whose style you love.
• There are several other kinds of trigger point therapy — most notably the needles, both dry and wet — but none of them are promising options for frozen shoulder patients.

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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.”147 There’s also good evidence of an absence of benefit for shoulder pain more specifically — in a fairly big 2009 study, ultrasound couldn’t beat a placebo.148

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.149 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.150

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.151 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.

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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 meaningless, 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 …

• Only one of the studies is worth even one damn: a 2016 trial certainly seems to be a home run, with 53 patients who got real shockwaves doing much better than 53 who got fake shockwaves.152 But there are some serious concerns about that study,153 and it’s one damn only has value if combined with studies that are worth a damn or two of their own. Unfortunately, there are none.
• Another was similar in overall design — including the same key flaws — but smaller and with results that were even less convincing.154
• The third study is still less impressive, worth mentioning only because there are so few to mention. It’s just a lame little study that tries to sound optimistic but actually isn’t.155 Worthless.

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.

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When the primary complaint is pain, the treatment of pain should be primary.

Barrett Dorko, Physical Therapist, online discussion, 2010

The specific cause of chronic pain may often be less important than general sensitivity and biological vulnerability to any pain. The biggest risk factors for pain chronicity are things like poor health, fitness, and socioeconomic status, inequality… and they overshadow common scapegoats like poor posture, spinal degeneration, or even repetitive strain injury.

For instance, just for the sake of argument, what if you knew that contractured shoulders hurt in some people and not in others? Or it hurts much more in some people than others? What if only some contractured shoulders hurt because only some people have a neurological vulnerability? Is that really a “shoulder” problem?

Seems more like a sensitivity problem.

How can nothing in particular make us hurt? Because pain is weird, a generally oversensitive alarm system (sensitization again) that can produce false alarms even at the best of times, and more of them when your system is under strain.

Frozen shoulder is an especially good example of this, as a condition that occurs much more often in people with metabolic syndrome.

There are several common modifiable risk factors for any kind of chronic pain that are typically neglected:

• smoking, excessive drinking
• lack of exercise, a terrible diet, obesity, metabolic syndrome (all of which is virtually synonymous with chronic inflammation)
• stress, anxiety, depression, social isolation, discrimination, perceived poverty
• insomnia, which is probably king of all underestimated drivers of pain
• some common-ish nutrient deficiencies, most notably vitamin D and magnesium
• some drug side effects and complications that increase systemic sensitivity

These are all things you can change, in theory.

As tempting as it is to focus on the shoulder, it may make much more sense to work on these bigger picture issues. It’s difficult, of course. The big factors are often thoroughly entangled, all making each other worse. An impoverished single mom with a nasty ex-husband, a nicotine addiction, and looming diabetes is going to have a tough time digging her way out of that mess. And yet it could be her only real hope, too.

Metabolic syndrome and frozen shoulder

Many common stubborn painful problems are particularly associated with one of the vulnerabilities above. For instance, headaches are strongly linked to sleep and mood disorders.

And frozen shoulder is linked to metabolic syndrome. It’s a perfect example of the importance of general risk factors, because it is so clearly a disease, not an injury. Better still, it’s a disease that is actually clearly linked to metabolic syndrome. Frozen shoulder is a specific physical problem that can emerge from a general biological vulnerability — along with many others, but only in frozen shoulder do we have this particularly fascinating combination of a seemingly physical/mechanical problem with very biological roots.

If metabolic syndrome is indeed the real reason that a glenohumeral joint seizes up in the first place, then obviously, please, do everything you can to combat metabolic syndrome! Which is basically — you’re going to love this — get in shape. All the things we associate with fitness. Not easy, but simple!

It may be too late to prevent frozen shoulder, but it’s certainly not too late to improve your odds of fighting clear of it. Remember, this is a condition that can go on for years in some people — it is not clearly “self-limiting” as so many professionals believe. It is a Very Good Idea to do everything you can to improve the odds of recovering sooner rather than later. Although no one actually knows this, it’s highly plausible that the severity of metabolic syndrome could be the difference between cases that resolve relatively quickly and those that drag on and on.

How to reduce general vulnerability to pain

And what can you do about this? “Easy”: get healthier! With a variety of vulnerability reduction projects, AKA “lifestyle medicine.” So not actually easy at all, but simple in principle.

Many of the options follow obviously from the list of vulnerabilities above, but for the sake of thoroughness I summarize them here. This advice will seem general to the point of being trite and useless, but that’s actually the point: we want specific treatments, but general ones actually do matter a lot.

• Get more exercise. It’s the closest thing there is to a miracle drug. Building strength is really valuable and surprisingly efficient.
• Get more sleep. Protecting your sleep is probably almost as good an investment as exercise.
• Eat an “anti-inflammatory diet” — which is just healthy! It’s more about avoiding dietary causes of inflammation (junk food and excess, basically) rather than consuming anything “medicinal.” (The omega-3 fatty acids — fish, nuts — are by far the best example of nutrition that verges on medicinal. Everyone should probably eat more mackerel.) Intermittent fasting (skipping some meals) is an approach, overhyped but probably based on a seed of truth.
• Inhale less smoke. If you smoke, you already know you should quit, of course. And now that COVID-19 is rampaging around the world, you have the best reason yet.
• Drink less alcohol. Alcohol is a poison, and the more you drink, the harder it is on your system. (Moderate drinking is pretty harmless, but the popular idea that it’s actually “healthy” is nonsense.)
• De-stress. The ultimate easier-said-than-done challenge! If you are a candidate for an anxiety disorder diagnosis, exploring and treating that should probably be your top priority.
• Make more friends. “Loneliness” is an incredibly common and underestimated stressor.

Tackling all of this vulnerability-reducing stuff could turn into a complete personal makeover, a huge project that might never end (and probably shouldn’t). Like any difficult, complex problem, you break it up into pieces and start with the easiest bits. It’s a long-term “pick your battles” challenge.

More exercise and sleep deprivation are usually the lowest hanging fruit. Quitting bad habits like smoking, drinking, and junk food are harder but simple and very effective. In some cases, loneliness can be almost easy to fix (join a club).

Where’s the science? Does this work? No one knows. It’s plausible and likely. But you really cannot waste your time trying to be a healthier, fitter person!

I discuss all of these options and more in much greater detail elsewhere. See Vulnerability to Chronic Pain: Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems.

And there’s more about the tricky diet thing in the next section, because anti-inflammatory dieting may be particularly relevant to frozen shoulder.

The best evidence for treating persistent pain points towards improving general health, as opposed to fixing specific “issues in the tissues.”

Playing With Movement, by Todd Hargrove, p. 217

Combatting sensitization specifically

One of the ways that all of these non-specific approaches do their job is by taming “sensitization,” the tendency of chronic pain to get exaggerated and a bit weird. This goes on with almost all chronic pain to some degree, but probably frozen shoulder more than most, because of the way shoulder “lockdown” seems to characterize many cases.

In addition to general ways of fighting sensitization summarized here, there are also some more specific ways to do it, mainly avoidance and exposure. See a little below: “Hacking the neurology of pain: desensitization and disinhibition.”

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An anti-inflammatory diet is also known as just a healthy diet. It’s not so much that it’s "anti-inflammatory" to eat good/specific foods as it’s inflammatory to eat crap. An improvement in your diet could conceivably reduce the severity and duration of frozen shoulder. And the worst-case scenario is that you’re eating better for general health. You can’t really go too far wrong with this.

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.156 One of the main biological consequences of metabolic syndrome is a lot of subtle inflammation, which can lead 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 might be much 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 (low carb and/or fasting)

Diets that force you to mainly burn fat for energy, instead of carbohydrates — a ketogenic diet , like the infamous Atkins diet — have some well-established benefits and might be anti-inflammatory and de-sensitizing.157

The most popular way to induce some ketogenesis is with some intermittent fasting — also known as “skipping some meals.” This practice has achieved Hype Factor 10 as of early 2020 and with the publication of a widely cited New England Journal of Medicine paper that’s quite enthusiastic about it.158 The “growing body of evidence” has been exaggerated by everyone (surprise surprise), and fasting has not yet been shown to be “anti-inflammatory” per se. There is quite literally only one good modern study showing clear evidence of an anti-inflammatory effect in humans.159 That’s the bad news.

Nevertheless, an anti-inflammatory effect of fasting is plausible, based on lots of indirect evidence (e.g. animal and cellular research and some evidence that fasting improves autoimmune diseases). It’s also just a reasonable diet. As long as you don’t get too extreme, the worst-case scenario is getting pretty hangry (angry from hunger). And it’s probably perfectly good as a weight-loss diet if nothing else. You’ll even save time and money, making it a great rarity in rehab — even the most harmless treatment experiments usually take some money/time.

I can’t truly recommend something so obviously unproven… but I’d do it myself. Please run it by your physician and/or a nutritionist. And let’s just be super clear that it’s a completely experimental treatment and its benefits are being widely overhyped right now.

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I have a separate article that explores 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.

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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, it implies that treatment should try to desensitize and disinhibit. How exactly is that done?

There’s a Nobel prize for anyone with a good 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. The chapter about reducing general vulnerabity to pain chronicity was essentially all about taming sensitization, although we’re going to get more specific here.

Most of the other treatment options covered so far involve building up confidence that you can, in fact, still use your shoulder, which I sometimes optimistically call the “confidence cure” in conditions where it’s even more important (back pain is a big one). 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.

Avoidance and exposure

The basic template for all rehab is to “calm shit down” and then “build shit up,”160 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 it really is okay to use your shoulder. Ideally, you do this when it is as safe and comfortable as possible, during therapeutic windows of opportunity (created mainly by pain relief).

This recalibration process is complex, slow, and uncertain — there are lots of ways it can get derailed — but the principle is sound. It should always be in your mind in any kind of rehab.

For more detailed discussions of sensitization and what to do about it, see:

• Sensitization in Chronic Pain — Pain itself can change how pain works, resulting in more pain with less provocation
• Pain is Weird — Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues
• Vulnerability to Chronic Pain — Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems

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Warning! Please do not allow a health care professional to attempt to forcefully increase your range of motion! This could cause extreme pain from the rupture of adhesions (which would probably quickly get sticky again anyway). If contracture is more prominent than adhesions (likely), then some other structure will tear before the capsule is affected. It’s also possible that muscle guarding of the joint could be impossible to overcome, and again the result could be traumatic failure rather than “release.”

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 …

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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 it161). Other nerve blocks are also a possibility, but the brachial plexus is the most common target. A doctor can then apply force much more directly and precisely to the adhesions in the joint capsule, without fighting through as much muscular resistance.

Unfortunately, this is only an option for desperate patients, because there are substantial risks to this procedure.162 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,163 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.164 This includes other shoulder surgeries that seem like no-brainers, like decompression for impingement — more or less completely shot down by a 2017 trial.165

So any untested surgery for frozen shoulder might actually work … or it might not. It’s just a gamble.

Colin’s cautionary tale: MUA that backfired

In the late 2000s, Colin injured his shoulder while weightlifting, a small labrum tear. The labrum is a kind of “gasket,” a rubbery ring of cartilage around the rim of the socket of the shoulder joint.

The tear was surgically repaired by a famous surgeon (not the MUA yet, just repairing the tear). This surgeon was a pioneer in his field, a high status doctor who worked for a major sports team and patched up celebrity athletes. He was easy to trust.

After the first couple weeks of post-surgical physical therapy, Colin’s shoulder started aching more than expected. It may have been an inflammatory response to the specific physical therapy exercises or the trauma of the surgery, or maybe just a little bacterial contamination of the joint (see “Surgery and vaccination as causes of shoulder joint infection”). Nobody was sure.

While collectively brainstorming, Colin mentioned that he had a minor bleeding disorder. The surgeon took that as a signal, and called a halt to the rehab effort, even though it had only just started. Colin asked about the possibility of his shoulder freezing due to incomplete physical therapy, having only regained a small portion of his range of motion. The surgeon thought it was unlikely. But then, over the next few weeks, Colin’s shoulder definitely froze.

After a second attempt at physical therapy for frozen shoulder, the surgeon recommended a second surgery, a manipulation under anaesthesia, to “release” the frozen shoulder. There were some reasons to doubt the wisdom of this, but famous surgeons are persuasive, and Colin was desperate and he agreed to it.

The point of manipulation under anaesthesia is to forcefully break the allegedly sticky layers of joint capsule. If that’s not actually the problem — for instance, if the joint capsule is “shrunk, not stuck,” contractured and not adhered — then something else is going to tear. The weakest link in the chain.

Which, in Colin’s case, was probably his injured labrum.

He woke up much worse off. Of course you expect to be worse at first after MUA, but this was a major, lasting exacerbation. His shoulder was more frozen than ever: what little ROM he’d had was gone, and his pain was way up. Months later, an MRI revealed that his labrum tear, originally just 20˚, had expanded to a 340˚ — that is, almost the entire ring of cartilage around the socket had come free from the joint.

In the aftermath of the surgery, genetic testing suggested Ehlers–Danlos syndrome, a disease of fragile connective tissue and hypermobility. EDS is strongly linked to chronic pain, and not just because it makes patients prone to tears and dislocation injuries — even patients without a frank injury often suffer from chronic widespread pain.

Forceful manipulation of an EDS patient’s joints is a Very Bad Idea. Nobody knew about the EDS at the time, but the hypermobility disorders aren’t rare and there were clues that any competent surgeon should have been watching for. Famous surgeons are easy to trust, but the other edge on that sword is that they are often also old-school and set in their ways. Incompetence probably was a factor, but impossible to prove.

Rehab was extremely slow and complicated for Colin. His surgical misdaventure became the seed of a larger struggle with chronic pain. There was no happy ending. A decade later, he has finally improved some — but, he says, the health and fitness he enjoyed before that original shoulder injury is probably gone forever.

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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,166 I will offer no direct opinion on the value of the technique; I will highlight some features of the treatment method, as presented on FrozenShoulderClinic.com, 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 2018,167 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.”168 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.

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Another way to force the issue, and likely safer than manipulation under anaesthesia, 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.169 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 hydrodilatation 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:170

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 a 2013 trial, only the second one ever to produce long term results (and it also included diabetic patients).171 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).172

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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