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.