Frozen shoulder? Let it go, Let it go….

I know what your thinking… frozen shoulders and Disney's animated film 'Frozen' is an obvious link, and yes it is. But it's not just the word frozen that links them, it's also the infamous song 'let it go' that also connects frozen shoulders and the physiotherapy treatment of them.

I see a lot of frozen shoulders, primary ones with no risk factors, secondary ones with ALL the risk factor, and I also see many who have been told they have frozen shoulder who clearly do not. So first what do I class a frozen shoulder, well that's simple, thats a stiff and very painful shoulder that has significant and EQUAL loss of both active AND passive movement in most directions, but has a normal x-ray. This loss of movement is classically into external rotation and elevation the most, but it tends to affect all movements, and the pain is severe, diffuse , all consuming and usually unrelenting. All 'true' frozen shoulders are extremely painful, extremely limiting, and extremely disabling. When I hear females telling me the pain in their shoulder is worse than child birth, I know I am dealing with a very, very painful condition.

What is a Frozen Shoulder?

Frozen shoulder is a pathology that is still not fully understood. It is an inflammatory condition that affects the capsular tissue of the shoulder, which causes significant neovascularisation, collagen proliferation, fibrosis, and eventual contracture of the capsular, reducing the volume of the shoulder joint significantly. (ref)

All frozen shoulders loose significant amounts of movement, as mentioned this is usually in many directions, and can be in differing amounts, but the fibrosis and contractures classically affect the anterior surperior capsule and rotator interval of the shoulder. This limits the big three of reaching over head, reaching out to the side, and reaching behind the back.

Diagnosis of a frozen shoulder, like most things, is usually done mainly with the subjective history. Patients age, medical history, onset, nature, aggs and eases all give clues of a frozen shoulder. Clinical examination to confirm a frozen shoulder is relativity simple, it involves looking for 3-4 movements that have EQUAL loss of both active and passive range of movement with significant pain at end of range, as well as doing resisted shoulder tests that usually produce no significant pain or weakness. This exam usually confirms a frozen shoulder. However many clinicians, myself included, will also ask for an x-ray to check it is normal before they fully confirm a diagnosis of a frozen shoulder.

Normal shoulder xray

The need for a normal x-ray to confirm a frozen shoulder has been debated and discussed a lot recently, especially on twitter in the last few weeks. The x-ray is first used to help exclude shoulder joint arthritis, however a frozen shoulder and an arthritic shoulder usually have a completely different onset and history. The x-ray has also been suggested to check for sinister pathology that can masquerade as a frozen shoulder (ref). However this practice has been questioned recently due to the very low incidence of sinister pathology presenting as shoulder pain, and if a shoulder x-ray is the right tool to check for suspected sinister pathology. I don't want to dwell on this topic too much, except to say that currently in my practice all frozen shoulders must have a normal x-ray before any treatment can begin.

How do you treat a Frozen Shoulder?

Treatment of a frozen shoulder is extremely varied from place to place, and from person to person (ref). There are many options and interventions available with little consensus or evidence on what is best. The options for frozen shoulders range from leave it alone to spontaneously resolve, and I am sure there are many frozen shoulders that do just this. Of course we don't know exactly how many, or what result they get as we don't get to see them for follow up.

Other more invasive treatments for frozen shoulder include intra-articular corticosteriod injections, or the increasingly popular, although highly dubious, high volume hydrodilatation injections. Then of course there are surgical options such as manipulation under anesthetic, which unfortunately are still being done despite the high risks of damage such as labral lesions, cuff tears, brachial plexus injury, and even fractures (ref). The gold standard surgical procedure for frozen shoulders now is arthroscopic release of contractures.

Physiotherapy is of course also a common treatment for frozen shoulders. This can include massage, joint mobilisations, manipulations, passive stretching, acupuncture, electrotherapy, and exercise (ref).

All these treatment options have there pro's and con's, and some have more evidence of effectiveness than others. I have my own biases and experiences against many of them. Again I don't want to dwell on these too much, just to say that a recent Cochrane review for frozen shoulder found that ALL manual therapy and exercise therapy was ineffective in the management of frozen shoulder (ref).

And I agree!

In my experience manual therapy and traditional physiotherapy methods for frozen shoulder do very, very little. I have tried them all, pulling and pressing people with painful frozen shoulders, here, there, and everywhere, all with little effect, and all too no avail. I know that some well known shoulder physios disagree with me and advocate deep tissue massage, joint mobilisations, and stretches for frozen shoulders (ref), but in my experience these are generally a waste of time, energy, and resources, and more importantly they only tend to cause patients unnecessary pain and distress for very little benefit.

However, there is a 'different' method for treating frozen shoulders that I have been using more and more over the years, which not only do I find far more effective, and far more tolerable for patients than 'traditional' physiotherapy, but more importantly it can be done independently, simply and easily by the patient with out a physio inflicting torture on them.

This is where my connection with the song 'let it go' comes in.

So what is this method of treating frozen shoulders? Well its using eccentric loading. Eccentric exercise has been shown to have many benefits in the management of many musculo-skeletal conditions, however they are not routinely used in the management of frozen shoulders, I think they should be.

One of the known benefits of eccentric exercise is improvements in joint flexibility via the processes of sarcomerogenesis. This is the physical addition of individual sarcomeres to musculotendinous junctions. This has been shown to produce a physical increase in the length of connective tissue, and so improves range of movement. Sarcomerogenesis has been shown to occur in the lower limb very quickly, very simply, and very easily. In fact eccentric loading has been shown to produce significant improvements in range of movement in far less time, and with far less energy than traditional stretching, and of course you also get stronger (ref)!

Effect of eccentric v's concentric exercises on increase in hamstring muscle length within two weeks (ref)

Warning: Anecdote alert ahead!

I have been using eccentric exercises with all my frozen shoulders after reading the effect they have on the lower limb a few years ago, and I have found patients find them not only more effective but simpler, easier and less painful to do than traditional stretching, and more importantly they seem to be more effective than ANY other kind of manual therapy I have used in the past.

There are a number of ways eccentric exercises can be done for frozen shoulders. The way I usually like to do them is to get the patient lying on their back. Then to hold a weight in their hand as they lower the weight slowly into external rotation towards a target that has been set just within their available tolerable range (a stack of books work well here).

They then return the arm to the start position, maybe using their other hand to assist on the concentric phase if needs be. They do a few reps and when the shoulder starts to feel 'looser' the target is adjusted and lowered by removing a few books to allow a little more movement to occur, a few more reps are completed, then the target re-adjusted again and so they continue as tolerated.

IMG_4879

I usually ask patients to do the reps slowly, the slower the better, and with a weight that is challenging to control down, but not too heavy as to feel 'out of control' or too painful. I usually dont give a fixed number of sets or reps, rather I ask them to do as many as they can. I like to ask most to try ans do 3 sets in a row with a few minutes rest inbetween, but this is adjustable depending on the individuals pain and tolerance.

Now I am not sure if the physiological effects of eccentric loading on the shoulder like this will be the same as seen in the lower limb as the loads used will be a lot lower, and so I am not convinced if the physiological stimulus will be enough to produce similar physiological adaption to occur such as sarcomerogenesis.

There is also very little research on eccentric loading and sarcomerogenesis in the upper limb. One paper did show some changes in the myofibril length when eccentric training was compared against concentric, but it was a small study on healthy individuals and not that conclusive (ref), but it's all I could find.

However, anecdotally when I use eccentric exercises like these on frozen shoulders I only see some really good results and marked improvements in range of movement and pain, very quickly, and I mean very, very quickly, usually within one or two sets, some times even within a few repetitions.

Now I am not for one minute suggesting that these immediate changes in range of shoulder movement are due to any mechanical or biological changes in the tissue, that just doesn't happen that quickly. However, what I do think is happening is a couple of things.

First is the well known hypo-analgesic effect of exercise allowing the patient to become more tolerant to the exercise (ref). I also think other psychological effects are at play when doing a resistance exercise with a painful body part. To begin with it can be a bit daunting and scary, but when done a few times and the patient realises and is reassured that they don't cause more pain, and in fact they reduce it, this allows the protective, reflexive muscle guarding and increased tension of the shoulder muscles to… 'let go'

Pain is a protective response. Pain causes muscles to guard. Frozen shoulders have a lot of pain. Frozen shoulders have a lot of muscles guarding. Eccentric exercises in my opinion helps these guarding muscles to 'let go'.

I often like to use analogy's to help patients understand the mechanisms of therapy effects where possible. One that works well for eccentric exercises is one I have 'borrowed' from Prof Peter O'Sullivan that he uses on his CFT workshops. This is by using a clenched fist as a metaphor for the shoulder muscles being tight and guarded. I demonstrate and explain with a clenched fist that this is what the pain causes the muscles around the shoulder joint to do, and these exercises start to 'let it go' so the movement can improve. See Pete's similar demo on a chap with low back pain here.

As far as I am aware there is no direct evidence for the use of eccentric loading exercises for frozen shoulders, but I do think this is something that needs to be looked into, and so I have started case study recording data of a group of frozen shoulders over 3 months.

Now, you may also be thinking why am I using a strengthening exercise for a frozen shoulder, which is not a contractile dysfunction but rather a capsular issue.

Well that's because the capsule of the shoulder and the rotator cuff are one and the same structure. Anyone who has seen shoulder anatomy with there own eyes will tell you the rotator cuff and the capsule are blended structures with no clear differentiation, and although they have different roles in the shoulder, they are essentially the same structure.

Shoulder anatomy

It must be remembered that the rotator cuff acts directly on a shoulder capsule by pulling on it to move, rotate, and stabilise the humeral head. So any contraction of the rotator cuff will place tension on the shoulder capsule, and so repeated tension and exercising of the cuff will have a repeated tension affects on the capsule tissue as well.

So The next time you have a patient with a frozen shoulder try using some eccentric loading exercises, and see for yourself how simple, easy and effective they can be. Of course you can supplement these with other modalities if you want. I don't. I like my patients to do these, and then do some more of these, and then do some more of these, for the whole session, in various positions and angles.

Also try explaining to your patient's with frozen shoulders to 'let it go, let it go…' and try using the clenched fist analogy. However, breaking into song as you do this is entirely optional, but occasionally I do find that it helps with some of my patients, they are either to stunned or shocked at my singing to realise that they have just let their shoulder… 'go'

I don't mind the cold anyway…

As always thanks for reading

Adam

 

36 thoughts on “Frozen shoulder? Let it go, Let it go….

  1. This is timely I’ve been re-reading a lot of your old posts and wondered how you use eccentrics. I have a couple of questions:

    1. Do you use the same procedure on lat pulldowns?
    2. Do you eccentrics to improve internal rotation?
    3. I personally have stiff but completely painfree shoulders. Would this work well for increasing rom in pain free shoulders generally?
    4. Do you recommend 3x per week or so?

    Thank you!

    • Hi Jack

      1) yes lat pull down eccentrics are great for helping over head flexibility
      2) yep porn-stars are awesome for this
      3) yep
      4) yep thats a good starting place and build from there

      Cheers

      Adam

      • Thank you very much. Any chance you will put together a shoulder/RC strength training guide for sale that would incorporate these concepts altogether? I’m talking about for the gym rat population. Its seems to me that shoulder injury prevention is fraught with gruism and over-complicated concepts here in the US.

      • One more followup. Would you limit the total number of eccentric exercises? I plan to tack this on to the end of training sessions. Would you just work one at a time or could you do, for example, overhead and internal rom at the same time? Thanks again!

  2. Interesting! New ideas are fun to investigate however raises many questions!

    1) Anecdotaly what outcomes do you see? i.e post exercise is there a objective or subjective improvement in movement at all and is this maintained? or is it just an analgesia producing exercise with the – ‘you have to wait 18months malarky’?
    2) How many sessions would you typically invest in a client with a ‘frozen shoulder.’
    3) As per Jeremy Lewis article on aetiology of frozen shoulder there are many definitions of ‘frozen shoulder’- primary/secondary/intrinsic/iatrogenic etc etc do you work with these definitions and does this influence treatment. i.e. if ‘primaryfrozen shoulder’ with 0deg ext rot and blocked end feel you would still do eccentrics?
    4) you quote the current definition of frozen shoulder (capsular tissue) however then go on to say the rotator cuff is intrinsically linked with the capsule involved with FS- do you feel the definition needs re-classification? if so what to?
    5) I may have misinterpreted but the premise of the eccentrics ‘working’ is that it targets the rotator cuff via sarcomerogenesis? If the cuff is the limiting factor is it really a true frozen shoulder or is it just fear/avoidance in which case would any other guided exercise with reasssurance and encouragement work?
    6) Have you found any catagories of FS patients this just doesn’t work with at all?

    Tack.

    Sven
    x

    • Hi Sven

      1) I see improvements in both ROM and pain after eccentrics, it varies from person to person, but typically pain is reduced 3-4 points on VAS after 5-10 mins of them, ROM changes again is variable but on average in ER and FLEX it can be a good 10-20 degrees
      2) Thats down to the patient to decide, I dont use hands on Rx so once the patient feels they are fully informed and educated re the condition and can self Mx thats fine by me, usually its about 4-6 session over a couple of months at a push.
      3) yes there are many sub groups of frozen shoulder and yes some resolve quicker and are not as restricted as other, eg post surgical FS, this doesnt change my approach, I just advised the patient to grade the exposure to the exercises as tolerated, some can do more than others, I keep it that simple
      4) Good question, no I dont think it needs re-classification that jut confuses things. We just need to be aware that the cuff and capsule are blended and the cuff acts on the capsule
      5) As I state I dont know if the eccentrics will cause any significant sarcomerogenesis due to the different loads and the pathology limiting, as I state I think this COULD be an explanation but as I also state I also think the ‘let it go’ factor is more to play here in that the exercises just causes a reduction in the cuff guarding and tension from the pain increased tone.
      6) No, not yet…

      Cheers

      Adam

  3. Really interesting stuff Adam, and a great read as always. I have to say that in my mind it makes sense……. keeping things simple- if a joint has become contracted and stiff then physically trying to ‘force’ it to relax with manual therapy, acupuncture, deep tissue massage etc seems destined to fail. We know the body cannot be cajoled out of a tissue reaction or process by manual therapy.

    However giving it something active to do i.e getting the contractile tissue to work in a controlled way rather than trying to get it to ‘relax’ would appear a more sensible route i.e working with it rather than against it.

    But again it will probably challenge patients beliefs as much as the therapists as they tend to come expecting to receive manual therapy and to a lay person if a joint is stiff, tight and painful then massage et al would seem sensible. It requires a strong (mentally) therapist who can explain clearly their reasoning in a clear fashion to deliver exercises for Frozen shoulder rather give in an go along the mobs and manual therapy route. The clenched fist metaphor seems useful in that regards.

    Chris
    @HealthPhysio

  4. Hi Adam,

    First of all great blog….I am seeing a couple of patients with frozen shoulder at present so will definitely give these eccentrics ago. I usually use heat with some MET techniques which I personally find useful.

    With regards to the graph am I correct in thinking that there was only increase in fascicle length in those “trained” individuals doing eccentrics? And not “untrained”?

    Many thanks

  5. Afternoon,

    This is a very interesting piece and overall I tend to agree with you. I think they are far more complex than we often think, with a wide range of variables.
    I do not believe I have ever had much success with them when the pain and loss of movement is starting to increase.
    I can remember two cases in the past, both middle aged women, who developed frozen shoulders with no identifiable cause.
    One had referral into the arm. Both had severely restricted ROM in capsular pattern. Both wanted to go nowhere near a surgeon. I gave them advice and education and some basic exercises to progress as able. One took around 15 months to get better and one just over two years; the one with the referred symptoms.
    Both ended up symptom free with a slight reduction in all ranges. Say about 95% ROM roughly. I do know one of them has never had another.
    It makes me wonder if the value of physiotherapy is good education and advice initially, along with being at the end of a telephone for them. Then at end stage, making sure full ROM and muscle power is achieved.

    On a slight tangent, if you ever get time have a look at a Wills cigarette card collection called Physical Culture. I would be interested to know your thoughts on the exercises and if they had it right almost a hundred years ago.

    Kind regards

    • Thanks, I will check those cards out… But I’m sure they had the right idea, nothings changed that much in 100 years except our ability to confuse and clutter things up too much.

      And you make excellent points, management of frozen shoulder for a lot of people is reassurance its nothing serious and that it will resolve and how to manage it. This is a common strategy I use for many

    • Hi Pierre

      I could tell you but then I’d have to kill you, or you could come on my weekend course and I could show you in person… :0)

      Only joking, I ‘hit’ the stiff shoulder with eccentrics in all directions, all positions as tolerated by each individual, but usually I find the direction or two most restricted and start there, usually this is ER and Flex

      Cheers

      Adam

  6. I was surprised, and a bit horrified, to see you mention acupuncture with a straight face. It’s not as though it was one of the many things where there’s no reason to think it works. There’s evidence that it doesn’t work. See http://www.dcscience.net/2013/06/10/connect-physical-health-sells-quackery-to-nhs/

    It should really not be hard to randomise patients to treatment and no treatment. Only when that’s done will we able to eliminate regression to the mean as the explanation for what’s observed. It beats me why nobody has bothered to do this.

    • I really don’t know how you can ‘see my face’ from reading a blog David? There is no ‘straight’ in it all

      I mentioned acupuncture in one sentence, describing how they are often used together with ALL the other ineffective treatments such as ALL manual therapy and ALL exercise therapy, and include a Cochrane review highlighting their ineffectiveness.

      I also said in the blog I have no wish to dwell on these as this is not the purpose of this blog.

      I am well aware of the evidence on acupuncture’s ineffectiveness and am dismayed as you at its continued use in healthcare, and have been, and continue to be a ardent critic of it.

      But this blog is NOT about blasted, bleeding, bloody acupuncture!

      Regards

      Adam

  7. Hi Adam,

    I’m Ainhoa, a phisical therapist of Spain.

    I am currently treating a patient with frozen shoulder. I found small benefeits with proprioception and isometric exercises, I try to use eccentric exercises .

    Thank you!

  8. Hi Adam, love your stuff! im actually going to Your workshop in Sandnes Norway next year.

    I was just wondering could you apply some of Your ideas to other injuries in the shoulder that causes reduced ROM and pain?

  9. HI Adam
    I just tried the Eccentric work on one of my Frozen Shoulder patient. I found 10 deg increase in ROM in all direction Post ER eccentrics.I have asked him to repeat it at home,will be seeing him in 2 weeks.Will feedback on my findings.
    I will try this for few patients and if i feel good about it ,i dont mind collaborating for a larger study.

    • Hi Mohammed

      Thats great to hear the case series I have started at the moment is also finding some great results. However this does need to be compared against either a control group or other stretching protocol or both to see if its any more effective, that will be the next step once I have written this case series up

      Cheers

      Adam

  10. Hello Adam,

    Seems like a interesting concept for a bachelor thesis. Could you please give us an update on your 3-month study ? How are the relapse rates for the patients solely doing eccentrics ?

    Best regards from Budapest,
    Daniel

  11. Hi Adam,

    Thank you for introducing new concepts (for free!). Definitely a tempting topic for my bahcelor thesis. How is the 3 month case study going ? Would be very interesting to see the preliminary results 🙂

    Kind regards from Budapest,
    Daniel

  12. Hi Adam, you may be interested to hear that I had the ‘dubious’ hydrodilation precedure done on my frozen shoulder in the UK. Within 24 hours I had regained a tremendous amount of mobility and lost most of the pain. I am now at the point where I am trying (and failing) to regain that last bit of range of movement through stretching so will now try your eccentric exercises. Thanks.

  13. Hi Adam

    I have had 2 episodes of frozen shoulder. My left one was remedied by manipulation under anaesthetic and that worked well. I have had my current right frozen shoulder for almost a year and the pain was off the threshold – so much so that I am on morphine patches and awaiting (another) steroid injection. I frantically searched the web for how to beat frozen shoulder pain and came across your blog. Hallellujah!!! On Friday I sat on the side of my bed crying and unable to think past the dreadful pain, a searing ache all the way down the centre of my arm, muscle spasms and incredible pain that stopped me in my tracks if I moved my shoulder even the slightest in the wrong way. I did 5 sets of your exercises on Friday afternoon and another few on Friday night. That was the first night in a year that I had any decent sleep. It is still painful but the deep, continuous arm pain has gone and I have about 30% more movement in my shoulder now. I cannot thank you enough and with your permission I will link this to my blog? I cannot believe that none of the health professionals I have seen have advised this type of exercise – so simple yet so effective – it is like a miracle!! I am continuing the exercise and hope to report a full recovery in due course.

    • Susan , How as it all worked out for you . I’d be interested to hear your progress. I’m about to start these exercises and hope I get some improvement

  14. I currently have bilateral frozen shoulder , (yes lucky me) my dominate arm being the worse affected. I have little to no internal rotation on my dominate arm (right) meaning I can even reach over and touch my left side (front) and back, well thats just not happening .

    Right arm started in Sept 2016 with the Dr doing an ultra sound and saying it was bicep tendonitis, I had one cortisone shot into bursa but that did nothing. My arm became so painful over the next month it was stupid and slight movement would drop me to my knees .. then i felt the left arm going so i quickly began moving that all the time so as to preserve as much movement as i could.

    Now Im at mild pain in right side and same in left. Cant sleep most nights for more that an hour at a time, however the last few days have been ok with 3-4 hour sleeps.. yay

    Ive been going back to the gym ( i noticed the muscle wastage around my triceps) as i figured I can only do as much as my shoulders will allow which is not much.. a few bicep curls and reverse tricep curls etc.

    I’ve noticed that my Teres major? (son says its my lats i don’t think he’s right though) is so tight and if I put external pressure on it , OMG It brings tears to my eyes, My whole back feels like a spring that’s about to uncoil?

    Im going to go home after work and give your exercises at try. I’m open to anything besides amputation , though that thought did cross my mind a while back.

    • How’s it going Lisa, I work for a physio and over the past 2/3 months it appears that I am getting a frozen shoulder which I am just dreading as there seem to be no quick solutions? He has suggested that I visit a doctor and get a cortisone treatment but I am not sure about that. Please let me know how you are doing?
      Kind Regards
      Linda

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