If you're facing persistent shoulder pain and limited movement, you might be dealing with Adhesive Capsulitis or a Frozen Shoulder. This condition often causes severe stiffness and intense pain, especially at nighttime, due to inflammation and scar tissue in the joint capsule. While it can be challenging, the good news is that we can significantly speed up the healing process in most cases. A combination of manual therapy, like Motion Specific Release (MSR), and a targeted exercise plan has been shown to effectively restore mobility and reduce pain, helping you get back to a more active, pain-free life sooner.
Our Success Rate is Over 90%
Our success rate in reducing pain and increasing function is over 90%. We have achieved this high effectiveness rate because of our multimodal, interdisciplinary approach.
Article Index:
Introduction
Diagnosis
Treatment
Exercises
Conclusion & References
Causes
The origins of Frozen Shoulder can be baffling, leaving many patients frustrated and confused. Researchers have identified two main types: primary and secondary.
Primary Frozen Shoulder: This type, also known as idiopathic, has no known cause and often appears out of nowhere.
Secondary Frozen Shoulder: This type develops due to a known cause or event, such as an injury or surgical procedure.
Risk Factors
Several factors can increase the likelihood of developing a Secondary Frozen Shoulder, including:
Smoking
Extended periods of immobilization
Trauma, injury, or previous shoulder surgery
Underlying health conditions such as diabetes, lung disease, heart disease, hyperthyroidism, and Parkinson's disease
Shoulder Joint Anatomy
The shoulder joint, known as the glenohumeral joint, is an impressive example of biomechanics at work. Here's how it functions:
Ball-and-Socket Design: The upper arm bone (humerus) fits into the socket (glenoid fossa) of the shoulder blade (scapula), allowing a wide range of motion.
Smooth Movement: The joint is surrounded by a ligamentous capsule filled with synovial fluid, which lubricates and ensures smooth, friction-free movement.
Stability and Support: Stability comes from the surrounding rotator cuff muscles and fascia, which support and guide shoulder movement.
Friction Reduction: The subscapularis muscle wraps around the coracoid process, reducing friction on the humeral head. Additionally, the subscapular fascia and subcoracoid bursae further minimize friction, protecting the joint during movement.
Together, these components ensure that the shoulder operates with both efficiency and stability, allowing for a wide range of motion while minimizing the risk of injury.
Physiological Changes During Frozen Shoulder
he development of Frozen Shoulder involves several key changes in the shoulder:
Inflammation and thickening of the joint capsule.
Extreme rigidity of the capsule, making movement difficult.
Reduced synovial fluid within the capsule, leading to less lubrication.
Contraction of the joint capsule, tightening the space for the humerus.
These changes result in a cramped environment for the upper arm bone, causing significant pain, stiffness, and limited movement, especially in shoulder abduction and external rotation. In short, Frozen Shoulder is marked by inflammation, thickening, and contraction of the joint capsule, leading to restricted movement and discomfort.
Three Phases of Frozen Shoulder
Frozen Shoulder typically progresses through three distinct phases, each lasting several months:
Painful or Freezing Phase (2-9 months): During this phase, any shoulder movement causes pain, and the range of motion begins to diminish.
Adhesion Phase (4-12 months): Pain levels may decrease, but the shoulder becomes significantly more restricted in movement. This is due to the thickening of the joint capsule with excessive collagen, making everyday tasks difficult.
Thawing or Resolution Phase (5-26 months): Pain subsides, and the shoulder's range of motion gradually improves.
Although these phases are common, the right mix of therapy, exercise, and possibly medication or injections can greatly shorten their duration and lessen their intensity.
Frozen Shoulder Examination
Effective evaluation of a patient presenting with Frozen Shoulder involves several key steps:
Assess Active and Passive Range of Motion: Examine the shoulder, cervical spine, and thoracic region to identify any limitations in movement, a hallmark symptom of Frozen Shoulder.
Check Rib Mobility: Pay special attention to the first rib. Restricted rib mobility can lead to shoulder and neck pain, potentially contributing to Frozen Shoulder symptoms.
Test External Rotation: Compare external rotation bilaterally. A positive test often shows a 50% or greater loss of rotation on the affected side compared to the unaffected side or less than 30 degrees of external rotation. This is a common indicator of Frozen Shoulder.
Verify Reduced Range of Motion in Other Planes: Ensure that at least two other planes of motion, such as abduction and flexion, are reduced by at least 25% compared to the unaffected side.
Check for Muscle Guarding with the Coracoid Pain Test: Apply digital pressure to the coracoid process area to detect localized pain, a frequent symptom of Frozen Shoulder.
For a comprehensive assessment, the following videos demonstrate the orthopedic, neurological, and vascular tests that should be performed during the examination of Frozen Shoulder:
Frozen Shoulder Testing
This video demonstrates some of the typical orthopedic examination procedures used to evaluate a patient with Frozen Shoulder.
Shoulder Examination - Orthopaedic Testing
This video utilizes orthopedic examination procedures to diagnose common causes of shoulder pain, including Frozen Shoulder, and explains the evaluation process.
Upper Limb Neuro Exam
The upper limb neurological examination is a critical component of the overall neurological evaluation that assesses the motor and sensory neurons that supply the upper limbs. This examination is crucial in detecting any nervous system impairment.
Peripheral Vascular Examination - Key Points
Performing a peripheral vascular examination is crucial to rule out signs of vascular-related pathology. It can help to mitigate potential cardiovascular and cerebrovascular complications through early detection and treatment. This video highlights some commonly performed procedures in daily clinical practice for assessing peripheral vascular health.
Assessing All Shoulder Joints
To fully evaluate shoulder mobility, it's essential to assess all four shoulder joints, along with standard orthopedic and neurological tests. Here’s a quick guide:
Sternoclavicular (SC) Joint: Check for 45° elevation, 5° depression, 15° protraction, 15° retraction, and axial rotation. A fused SC joint can severely limit shoulder movement.
Scapulothoracic (ST) Joint: Ensure the scapula moves freely with the rib cage, allowing elevation, depression, protraction, retraction, and rotation of the glenoid fossa.
Acromioclavicular (AC) Joint: Evaluate for axial rotation and anteroposterior movement, with a total glide and rotation of 20-30°, coordinated with shoulder movements.
Glenohumeral (GH) Joint: In Frozen Shoulder, focus on the anterior and inferior capsular regions, ensuring the GH joint can move freely in all three planes.
A thorough assessment of these joints helps identify shoulder limitations and guides effective treatment.
Diagnostic Imaging
Your healthcare provider may order X-rays to rule out other causes of your shoulder pain. For Frozen Shoulder, plain X-rays are typically recommended to check for infections, cancer spread, large calcium deposits, bone blood supply loss, or severe joint damage.
If you have a smoking history, a chest X-ray with a special view may be needed to check for a Pancoast tumour, which can press on nerves near the shoulder and mimic Frozen Shoulder symptoms.
Differential Diagnosis of Frozen Shoulder
When diagnosing Frozen Shoulder, it's crucial to consider other conditions with similar symptoms:
Bursitis: Shows greater passive range of motion (PROM) than Frozen Shoulder, though both are painful in the early stages.
Osteoarthritis (OA): Limits active range of motion (AROM) in abduction and external rotation, but PROM remains unaffected.
Rotator Cuff Syndrome: Symptoms closely resemble Frozen Shoulder; MRI or ultrasound may be required for differentiation.
Shoulder Impingement Syndrome: Involves tendon irritation, leading to pain and limited motion, especially in overhead activities.
Labral Tears: Can cause pain, clicking, and instability, often mimicking Frozen Shoulder symptoms.
Shoulder Instability: Results from trauma or overuse, presenting with pain and a "giving way" sensation during movement.
Calcific Tendinitis: Calcium deposits in tendons lead to intense pain and restricted movement, similar to Frozen Shoulder.
Thoracic Outlet Syndrome: Compression of nerves or blood vessels causes pain, numbness, and tingling, overlapping with Frozen Shoulder.
Rheumatoid Arthritis: An autoimmune condition that causes pain, swelling, and stiffness in the shoulder.
Shoulder Fractures: Fractures, especially of the humeral head or clavicle, can cause pain and restriction that may be confused with Frozen Shoulder.
Peripheral Nerve Injuries: Nerve damage in the shoulder area can result in pain and weakness, potentially mimicking Frozen Shoulder.
Accurately distinguishing between these conditions is essential to ensure effective treatment and optimal patient outcomes.
Frozen Shoulder Treatment
Manual therapy is essential for treating all phases of Frozen Shoulder, backed by extensive research. These therapies aim to reduce pain, enhance mobility, and improve daily activities.
Manual Therapy Techniques:
Shoulder Joint Mobilization: Passive motion within the joint's natural range helps reduce pain and improve mobility by stretching muscles, ligaments, and tendons.
Soft Tissue Mobilization: Manual pressure on soft tissues releases adhesions and trigger points, reducing pain and improving mobility.
Trigger Point Release: Applying pressure to areas of muscle spasm or tension reduces pain and increases joint mobility.
Myofascial Release: Sustained pressure on myofascial tissues reduces pain, improves mobility, and increases flexibility.
MSR Fascial Expansion: This technique merges insights in fascia, kinetic chain relationships, and acupuncture principles.
For further guidance, the following videos demonstrate orthopedic, neurological, and vascular testing, as well as manual therapy techniques for Frozen Shoulder:
Demonstration Videos
MSR Fascial Expansion:
Shoulder Pain - Utilizing fascial expansions in shoulder pain management presents an effective strategy that merges contemporary insights in fascia, kinetic chain relationships, and core principles of acupuncture or traditional Chinese medicine.
5 Point Shoulder Joint Mobilization - Part 1:
This video demonstrates the Motion Specific Release "5 Point Shoulder Joint Mobilization" protocol. The shoulder comprises five distinct joints, and understanding their interrelationships is key to effective treatment. This protocol mobilizes each joint to reduce pain and improve mobility. Only a qualified practitioner should perform this procedure.
6 ‐ Point MSR Rotator Cuff Protocol:
In this video, Dr. Abelson demonstrates the 6-Point MSR Rotator Cuff Protocol. The rotator cuff includes four key muscles: supraspinatus, infraspinatus, teres minor, and subscapularis (SITS muscles). These muscles are vital for shoulder movement. Ensuring they are strong, flexible, and balanced is essential for optimal shoulder function.
Concurrent Treatments
Effective treatment of Frozen Shoulder often requires a combined approach. Manual therapy, exercise, anti-inflammatory drugs, and joint injections can accelerate pain relief and improve mobility. While injections alone may offer temporary relief, research shows better results when combined with therapy and exercise.
Anti-inflammatory drugs are particularly useful in Phase 1 to enhance tolerance to therapy, but they may not be enough on their own for long-term symptom relief. For the best results, an integrated approach involving manual therapy, exercise, and medications or injections is recommended.
Treatment During Painful or Freezing Phase
During the Painful or Freezing Phase of Frozen Shoulder, the focus should be on reducing pain and inflammation, improving blood circulation, and gradually increasing the range of motion. Recommended strategies include:
Avoiding painful activities.
Heat therapy should be applied with a heating pad or warm towel to increase blood flow and reduce muscle viscosity.
Performing exercises within a pain-free Active Range of Motion (AROM).
Doing short-duration stretching exercises (2 to 5 seconds) 4 to 6 times daily.
Using pulley or pole exercises as tolerated.
Performing pendulum exercises multiple times per day.
Applying gentle manual therapy techniques to enhance range of motion, reduce muscle viscosity, increase blood flow, displace waste products, and speed up healing.
Mobilizing/manipulating restrictions in the thoracic and cervical regions if needed.
Avoid increasing the range of motion during this phase to prevent further injury.
Treatment During The Adhesion Phase
In the Adhesion Phase of Frozen Shoulder, the following strategies are recommended:
Heat Therapy: Use heat to increase blood flow, improve range of motion, and reduce muscle stiffness.
Stretching Exercises: Perform stretching exercises within patient tolerance, gradually becoming more aggressive and prolonged to achieve plastic elongation and increase active range of motion.
Joint Mobilization: Mobilize the shoulder joint to its end range to improve motion and stretch contracted peri-articular structures such as muscles, ligaments, and tendons. Shoulder joint distraction can also be used.
Manual Therapy: Continue Phase 1 manual therapy procedures, considering a larger kinetic chain and slightly increasing intensity within patient tolerance.
Treatment During The Thawing or Resolution Phase
Recommended treatments for this phase include:
Heat Therapy: Use heat to increase range of motion and reduce muscle viscosity.
Stretching: Increase the frequency and duration of stretching exercises to patient tolerance.
Pulley or Pole Exercises: Perform these exercises twice daily as tolerated.
Manual Therapy: Apply manual therapy procedures considering local areas and a larger kinetic chain within patient tolerance.
Importance of Early Intervention
Research shows that manual therapy improves function at any stage of Frozen Shoulder, with the greatest benefits seen when treatment starts early. Therefore, early intervention is crucial for optimal results.
Recommended Treatment Frequency
Recommended Treatment Frequency for Frozen Shoulder:
Painful/Freezing Phase: 1-2 times weekly, with a clinical review every 2 weeks, then monthly.
Adhesion Phase: Once weekly, with monthly clinical reviews.
Thawing/Resolution Phase: Bi-weekly to monthly, with reviews every 2-3 months (if needed).
Logic of Treatment Recommendations
Manual therapy is crucial for Frozen Shoulder for several reasons:
Pain Relief: It directly addresses one of the most debilitating symptoms—pain. By manipulating and mobilizing the affected tissues, manual therapy can alleviate pain and improve quality of life, facilitating better sleep.
Phase Duration: It can potentially shorten the duration of each phase by minimizing thickening and adhesions that restrict movement, accelerating the transition between phases.
Range of Motion: Improved range of motion through manual therapy helps maintain functionality, allowing patients to perform daily activities with less hindrance.
Treatment Frequency Overview
Painful or Freezing Phase (2-9 months)
Frequency: Manual therapy 1-2 times weekly to alleviate pain.
Clinical Review: Every 2 weeks initially, then monthly based on improvement.
Adhesion Phase (4-12 months)
Frequency: Manual therapy once weekly to prevent further loss of range of motion and begin restoring mobility.
Clinical Review: Monthly reviews to monitor stiffness, joint capsule thickening, and daily activity capability.
Thawing or Resolution Phase (5-26 months)
Frequency: Manual therapy bi-weekly to monthly, focusing on enhancing range of motion.
Clinical Review: Bi-monthly to quarterly, depending on pain and mobility improvement.
Note: Treatment frequency and review times should be adjusted based on individual patient needs and response to therapy.
Frozen Shoulder Exercises
Frozen Shoulder Routine
We prescribe a home exercise regimen for Frozen Shoulder, including pendulum exercises, 5-part proprioceptive neuromuscular facilitation (PNF), and partner stretches. These exercises aim to improve range of motion, reduce stiffness, and promote healing. Here’s a sample of the recommended exercises.
5 Daily Shoulder Mobilization Exercise Routine
This video is particularly helpful for those in the later stages of Frozen Shoulder. These targeted exercises enhance posture, mobility, and range of motion. Incorporating them into your daily routine can significantly improve shoulder health.
Strengthening Internal & External Shoulder Rotation
As your range of motion improves, adding rotator cuff strengthening exercises to your Frozen Shoulder routine is crucial. Start with a thorough warm-up and stretching, then focus on strengthening internal and external shoulder rotations to boost stability and function.
When Conservative Care Is Not Enough
If conservative treatments for Frozen Shoulder aren’t bringing relief, surgery may become an option. Procedures like selective arthroscopic capsular release or an inferior capsulotomy have delivered positive results for some patients.
Surgery is usually considered only after six months of unsuccessful conservative treatment. Before deciding on this next step, it’s important to thoroughly discuss the potential benefits and risks with your healthcare provider.
Why Choose Our Approach for Frozen Shoulder Treatment
Our comprehensive approach to treating Frozen Shoulder consistently delivers a success rate of over 90% in reducing pain and improving function. Here’s why our method stands out:
Established Expertise: Developed by Dr. Brian Abelson, the MSR methodology is backed by over 30 years of clinical experience and the successful treatment of more than 25,000 patients, ensuring you receive the highest standard of care.
Thorough Assessments: We start with a detailed evaluation to identify all contributing factors, laying the groundwork for a precise and effective treatment plan.
Advanced MSR Procedures: Our specialized Motion-Specific Release (MSR) techniques target joint stiffness and fascial restrictions, promoting faster recovery.
Customized Exercise Programs: We design personalized exercise regimens to improve shoulder mobility, strength, and overall function, ensuring a faster recovery.
Logical, Evidence-Based Approach: Our structured treatment plans integrate manual therapy, exercises, and supportive measures.
With a success rate of over 90%, choose our proven, patient-centered approach for effective, long-term relief from Frozen Shoulder. Begin your journey to recovery with confidence.
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DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical practice and experience in treating over 25,000 patients, Dr. Abelson created the powerful and effective Motion Specific Release (MSR) Treatment Systems.
As an internationally best-selling author, he aims to educate and share techniques to benefit the broader healthcare community.
A perpetual student himself, Dr. Abelson continually integrates leading-edge techniques into the MSR programs, with a strong emphasis on multidisciplinary care. His work constantly emphasizes patient-centred care and advancing treatment methods. His practice, Kinetic Health, is located in Calgary, Alberta, Canada.
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