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Frozen shoulder, also known as “adhesive capsulitis”, is a restrictive condition that can be painful and frequently affects abduction and external rotation of the shoulder joint. 
It affects more women than men, and usually occurs between the ages of 40 and 65.  In the past, it was thought to be a degenerative condition, but since it is rarely found in those over 70 years of age, this theory has been dismissed. 


Etiology

Theories include:

Intrinsic factors: such as musculoskeletal trauma, dislocations, rotator cuff tendinitis or im-pingement syndrome.
Extrinsic factors:  including myocardial infarctions, chronic bronchitis, breast surgery.
Postural dysfunction such as hyperkyphosis
Disuse following an injury which has lead to the shoulder being immobilized.
Systemic diseases - such as thyroid dysfunction and diabetes.


Signs and symptoms

There are three stages to the condition, acute, subacute and chronic, lasting up to a couple of years or more. 

Acute  is also referred to as the “first stage”, or “freezing phase” as well as the “painful stage”, it can last anywhere from two to nine months. 
The onset of pain is gradual, it might occur after an insidious occasion such as a minor pull of the shoulder, i.e. reaching for something in the back seat of a car. 
There might be muscle guarding with movement but resisted movements are usually pain free.
Stiffness is progressive, and muscle spasms may be present in the rotator cuff muscles. 
One of the more distinct features is the pain is more severe at night, the person cannot sleep on the affected side and pain is present around the outer regions of shoulder including the deltoid area.

Subacute or the “second stage”, “frozen phase”, or “stiffening phase” is a point at which the pain diminishes but patients increasingly complain about limited range of movement (ROM) i.e. the inability to comb ones hair, or fasten a bra. This stage can last from four to twelve months. 

Chronic the “third stage”, or the “thawing phase” or “resolution phase”, the patient has re-stricted range of movement but very little pain.
The whole process from stage one to three is said to take up to two years to resolve, or that the length of time for this final stage to resolve corresponds to the length of the two painful stages. 

Management

Treatment other than massage could entail physiotherapy, medication, surgery, acupuncture, osteopathy, joint mobilization and exercise. Remedial massage objectives can be divided into the three stages.  As a therapist, you may choose to use all of these techniques in one session or spread them across several  treatments.

Acute:

Reducing pain by applying relaxation massage using effleurage and pettrissage to decrease the sympathetic nervous system from firing continuously.  Trigger point therapy, NMT, is particularly effective at this stage. Sometimes the client can only tolerate the light touch of your hand resting on the affected, so do not rush. 
Maintaining ROM, mobilizing the hypomobile joints and addressing any compensating structures such as hyperkyphosis. Mild joint play applied in the early stages can effectively reduce spasms and pain, it can also have an effect on the outcome of the next two stages, whereby it can reduce the signs and symptoms significantly.  Oscillation techniques are effective but do not go to end of range.
Contraindications in the acute stage are do not do aggressive stretches and joint mobilization.


Subacute:

The work in the subacute stage incorporates the same techniques, with slight differences. Rather than just mobilizing a joint practitioners will need to address any adhesions and increase the ROM. If a client is on NSAID’s, friction is contraindicated. 
Reducing fascial restrictions using slow skin rolling is tolerated more readily at this time, but can be used in all stages. 


Chronic:

The main focus at this stage is to restore full range of motion, addressing scapular stability, end of range stretching, aggressive glenohumeral joint mobilization and movement re-education.  Muscle Energy Techniques are particularly effective, especially for the proprioceptive component within the technique. 

There is not necessarily a perfect ending to the resolution of a frozen shoulder, it does not tend to resolve quickly and can take up to a couple of years when treated, untreated a person can suffer with signs and symptoms for up to seven years.
Frequently full ROM is often not fully regained due to lesions, and some muscles such as the deltoid and rotator cuff muscles having atrophy from diminished use. Final results can be as low as a 30% improvement to 60%.
The happy ending part to this is the client is usually pain free and able to go about his normal everyday living in comfort.



By Susan Findlay BSc RGN, Dip SRMT
All rights reserved. Any reproducing of this article must have the author name and all the links intact.
Susan Findlay BSc RGN, Dip SRMT

Author: BSc RGN, Dip SRMT

Biography: Susan comes from a background in dance (22 years) and gymnastics in which she competed nationally in Canada. She originally trained as a Nurse in her home country and practiced for 7 years before coming over to England in 1993.

After a year in the NHS she retrained as a health and fitness instructor working with GPs and health centers. After years of teaching 20+ classes a week and running health programmes she wanted to integrate her medical, health and fitness background under one umbrella. Hence, she trained once more in Sport & Remedial Massage, incorportating her background into her treatments. She has a busy private practice in North London.

She has been teaching since 1998 at numerous colleges, as well as lecturing nationally and currently continues to do both.

As is expected from the evolutionary process, Susan founded the NLSSM from a desire to see other high quality centers offering a professional course in Sport & Remedial Massage. She is also on the council of GCMT (General Council for Massage Therapy) and is one of the co-founders of the ISRM (The Institute of Sport & Remedial Massage).

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