Adhesive Capsulitis

Adhesive capsulitis, also known as frozen shoulder, is a musculoskeletal condition in which the connective tissues surrounding the glenohumeral joint become inflamed and thickened, causing pain and a significantly reduced range of motion. The etiology of this disease is unclear, with some experts suggesting it begins with an adhesion between the anterior aspect of the glenohumeral capsule to the head of the humerus, and others suggesting it begins outside of the capsule in tissues such as ligaments, the rotator cuff and biceps brachii muscles and the subacromial bursae.  Adhesive capsulitis is classified as either primary or secondary, primary meaning no event or factor leading up to the disorder can be identified and the etiology is idiopathic, and secondary meaning it is preceded by trauma or the subsequent splinting and immobilization that follows an injury.

Adhesive capsulitis is most common in women between the ages of 50 and 70. Once it occurs in one shoulder, there is about a 50% chance it will occur in the other at some point, though a simultaneous bilateral occurrence is rare. Diabetes mellitus is the most common comorbid condition, others include hyperthyroidism, hypothyroidism, Parkinson’s disease, cardiac disease, pulmonary disease, stroke and some surgeries such as cardiac catheterization, neurosurgery and radical neck dissection. A person with one or more of these conditions is at higher risk for developing adhesive capsulitis. Western medical treatments for frozen shoulder include analgesics ranging from aspirin to narcotics for pain management, corticosteroid injections to manage inflammation, arthroscopic surgery to loosen the joint capsule, joint manipulation under anesthesia and simply waiting it out. Many patients are unwilling to wait it out, as the process can be quite disabling and take years to run its course. The three stages of the disease are described below as they would occur in a patient choosing not to receive surgical intervention.

During the first stage, or “freezing” stage, the shoulder gradually loses up to 85% of its range of motion, both active and passive. The pain often presents at night, while the patient is sleeping and immobile. Over the course of 3-9 months, the shoulder becomes increasingly more painful and stiff. Clients in this phase do not always seek treatment immediately because they think the issue will resolve on its own. If a gradual decrease in range of motion and pain are observed in a client, it is necessary to locally contraindicate the area and refer them to their primary care physician for an examination and diagnosis, as direct bodywork over the shoulder could worsen symptoms. Once diagnosed, patients may be taking prescribed pain medications which can mask pain/symptoms and thereby systemically contraindicate massage until the drug is out of the body. If the client has not taken a recent dose, massage to the rest of the body can be helpful by increasing parasympathetic tone and decreasing stress. Extra care must be taken to ensure the client is positioned comfortably on the table. They may need extra pillows or rolled up towels to support the affected joint as to not exacerbate symptoms, which could set the client back. Even with a diagnosis, massage, movement therapy and hot hydrotherapy are locally contraindicated throughout the duration of the freezing phase due to acute pain and active inflammation. 

Once the progression stabilizes, the shoulder enters what is called the “frozen” stage, which lasts between 4 and 12 months. It is characterized by extreme pain at the end of a very limited range of motion, causing the musculature around the glenohumeral joint to be unused and thereby affected as well. It is important that massage therapists be mindful not exacerbate inflammation or pain by over treating or doing intense bodywork on the shoulder, but generally gentle massage and hot hydrotherapy (to the client’s tolerance) are indicated during this phase and can provide the client with short term relief. Massage is systemically contraindicated if the client has taken a recent dose of pain medication.

Eventually, the pain at the end of ROM dissipates and the third and final phase, the “thawing” stage, begins. This stage can last anywhere from 1-4 years and is defined by a gradual and unexplained return of range of motion. Some people with adhesive capsulitis will see their range of motion return to normal, however up to 50% of people suffer a long term deficiency that can last up to 10 years. Massage, movement therapy and warm/hot hydrotherapy are indicated during this phase to restore normal function to the glenohumeral joint and the surrounding tissues and musculature. As with the other phases, extra pillows or rolled up towels may be used to provide the client with the comfort and support they need in order to be able to relax and receive the full benefits of massage. Beneficial homework to give clients may include stretching, strengthening and range of motion exercises for the shoulder. Clients in this phase may benefit greatly from receiving weekly massage, as well as working with another alternative care practitioner such as a yoga therapist or acupuncturist. Movement therapy techniques during a massage session would all be to the client’s tolerance and include pinning and stretching the rotator cuff and biceps brachii muscles, taking the client through passive range of motion, exercising weakened affected muscles and post isometric relaxation to create a new resting length for shortened muscles. It is important to let the client know that movement therapy may cause discomfort in this phase, but that it is necessary for restoring proper function. Verbal and nonverbal communication between therapist and client is essential. 

Overall, massage therapy is beneficial and indicated for normalizing muscle tone, reducing pain and restoring range of motion in clients recovering from adhesive capsulitis, particularly those in the thawing phase. 

Bibliography

Werner, Ruth. A Massage Therapist’s Guide to Pathology. Wolters Kluwer, 2016.

Manske, Robert C., and Daniel Prohaska. “Diagnosis and management of adhesive capsulitis.” Current Reviews in Musculoskeletal Medicine, Humana Press Inc, Dec 2008, www.ncbi.nlm.nih.gov/pmc/articles/PMC2682415/.

“Frozen shoulder.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 10 Mar. 2015, www.mayoclinic.org/diseases-conditions/frozen-shoulder/symptoms-causes/syc-20372684.

“Adhesive Capsulitis (Frozen Shoulder).” Practice Essentials, Problem, Epidemiology, 21 Sept. 2017, www.emedicine.medscape.com/article/1261598-overview.

Axial vs. Appendicular

In order to have a good understanding of anatomical directional and positional terms, it is first helpful to know the difference between the axial skeleton and the appendicular skeleton. I’m thinking in particular of the terms proximal and distal, I’ll explain those more in a moment.

The axial skeleton includes the skull and all the cranial bones, the spine, the ribs and the hyoid bone. The hyoid bone is just inferior to the mandible (jaw bone) and it sits anterior to (in front of) the third cervical vertebrae. A little side note- the hyoid is the only bone in the body that doesn’t articulate with another bone. It serves as an attachment site for the suprahyoid and infrahyoid muscles. The small but strong suprahyoids elevate the tongue and open the mouth while the thin and more dainty infrahyoids act as an antagonist (do the opposite). 

The appendicular skeleton is everything else. It’s everything that attaches on to the axial skeleton. Think “appendages”. The pelvis, femur, fibula, tibia and all of the foot bones as well as the scapula, clavicle, humerus, radius, ulna and all of the hand bones are classified as appendicular.  All of those bones are essentially stuck on to the axial skeleton, which is the centermost part of your skeletonWe use the terms proximal and distal to describe the position of one thing to another in relation to the appendicular skeleton. If it’s closer to the appendicular skeleton it’s called proximal. Proximity means “close to” or nearness so you can remember it that way. Distal means distant or away from, so it’s farther away from the appendicular skeleton. 

Here are some examples:
The calcaneus is distal to the patella. The patella is proximal to the calcaneus.
The wrist is distal to the elbow. The elbow is proximal to the wrist.
The phalanges are distal to the metacarpals. The metacarpals are proximal to the phalanges.
The distal end of the femur articulates with the proximal end of the tibia. 

When we lengthen the spine, we are creating axial extension- creating more space between each of the vertebrae in the vertebral column. From either a seated or standing position, imagine your feet or your pelvis getting heavier on the floor while you actively reach the crown of the head toward the ceiling, like you’re balancing a heavy book. You should feel your spine grow a little longer- this is axial extension.

Erector Spinae Group

The erectors are a powerful group of muscles on the back that start on the sacrum and climb the spine and ribs all the way up to the occiput.  Like a lot of muscles, the ESG has the potential to get complicated/confusing really quickly, but I’m here to break it down in a way that hopefully makes a lot of sense to you. 

Firstly, we’re looking at three muscles here: spinalis, longissumus and iliocostalis. Spinalis is closest to the spine, or the most medial of the three. It climbs the spinous processes. Just lateral to the spinalis is the longissumus, the middle of the three erectors. It climbs the transverse processes. The most lateral of the three is the iliocostalis. If you really think about the name of that muscle it will tell you exactly where it is- on the ilium and the ribs (costal means rib). The iliocostalis climbs the ribs. 

Let’s talk about the commonalities. 

Spinalis, longissimus and iliocostalis all work together to produce the same movements. When the fibers on the right contract, the spine laterally flexes to the right. When the fibers on the left contract, the spine laterally flexes to the left. Lateral flexion is a side bend. When all of the fibers work together and contract at the same time, the spine extends. The upper fibers of these three muscles also assist in laterally flexing and rotating the head and neck to the same side, as well as extending the head and neck. 

In addition to sharing the same actions, they also share a point of origin on the thoracolumbar aponeurosis, also known as the common tendon. The thoracolumbar aponeurosis is a broad, thick, diamond-shaped tendon that goes from the sacrum over to the ilium and then up the spinous processes of the lumbar vertebrae to the lower thoracic vertebrae.  

Let’s look at them individually, starting with the medial spinalis. The spinalis muscle originates on the common tendon (spinous processes of the upper lumbar and lower thoracic vertebrae) and the ligamentum nuchae as well as on the spinous process of C-7. The ligamentum nuchae is the big, thick neck ligament. 

Doesn’t that seem weird that it starts in one spot, skips over a spot in the middle and then starts again somewhere higher up? 

Yes!

This works because the muscle inserts on the spaces in between. In this case the insertion is on the spinous processes of the upper thoracic vertebrae (this is between the two points of origin) and then also on all of the spinous processes of all of the cervical vertebrae (except for C-7, because the muscle originates there). To me, it feels less important that you remember exactly where the origin/insertion is and more important that you remember the muscle climbs the spinous processes and pulls the spine backward into extension. 

The middle muscle is called longissimus. It’s the thickest and, hence its name, the longest of the three. It originates on the common tendon as well as the transverse processes of the first five thoracic vertebrae (T-1 through T-5). The spinalis climbs the spinous processes while the longissimus climbs the transverse processes. Like the spinalis, the longissimus also does that thing where it starts, skips some space and then starts again. It inserts itself between the two points of origin on the lower 9 ribs (ribs 4-12), the transverse processes of all of the cervical vertebrae (C-1 through C-7) and the mastoid process of the temporal bone, which is behind the ear. You can easily feel this one on yourself or someone else, it’s about two inches wide and its cable-y fibers are on either side of the spine. 

If you don’t remember anything else about the longissimus, remember that its the middle erector as well as the longest, thickest and most easily palpable.

Iliocostalis is the rib climber. It originates on the common tendon and the posterior surfaces of all the ribs (1-12). To get over to the ribs, it inserts on the transverse processes of the first three lumbar vertebrae, then climbs the posterior surfaces of all the ribs to get the the transverse processes of the lower cervical vertebrae. 

Bhujangasana (cobra pose) is a great way to strengthen these commonly tight but overstretched muscles. I like to practice and teach this one with strong legs and little to no weight in the hands to really get these muscles firing.