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.

The Rotator Cuff + Biceps Brachii

The rotator cuff is a group of deep stabilizing muscles that all start on the scapula and stop on the head of the humerus.  As a whole they work together to hug the head of the humerus into the glenohumeral joint, but in addition to that the muscles all have their own unique actions based on where they originate and insert.  A review of the bony anatomy of the scapula and humerus may be helpful before reading this post.  

There are four muscles that make up the rotator cuff.  First, a brief overview of everything the shoulder can do at the glenohumeral joint.  Click here for a definition of these terms.

Adduction
Abduction
Horizontal adduction
Horizontal abduction
Lateral rotation
Medial rotation
Flexion
Extension

The muscles of the rotator cuff medially and laterally rotate as well as abduct the shoulder.  They also all work together to stabilize the head of the humerus in the glenoid fossa.

What does what?

Infraspinatus
The infraspinatus muscle is a lateral (external) rotator.  It originates on the posterior scapula in the infraspinous fossa.  Infraspinous means inferior to (below) the spine of the scapula.  That whole space is the origin of the infraspinatus.  From there it inserts on the posterior aspect of the greater tubercle of the humerus.  When the insertion comes toward the origin during contraction (the insertion always comes toward the origin as the origin is the fixed point), it creates lateral rotation of the shoulder.  If you’re reaching your arm overhead to brush the back of your hair, your shoulder is laterally rotated.  The top arm in gomukasana (cow’s face pose) is also in lateral rotation.  

Teres Minor
Teres minor goes with infraspinatus in the same way that teres major goes with the lats.  The two muscles share the same actions and therefore the teres minor acts as an assistant to its larger counterpart, the infraspinatus.  Teres minor originates on the upper two thirds of the lateral (outer) border of the scapula and also inserts on the posterior aspect of the greater tubercle of the humerus.  It shares the same jobs as the infraspinatus:  stabilize the head of the humerus in the glenohumeral socket and laterally rotate the shoulder.  

The term teres translates from Latin to mean rounded or tube shaped.  I love to learn little things like that because they help me remember either where a muscle or structure is, what is does, something about its shape or size, etc.  Learning the language is hugely helpful.  You can also remember which teres muscle assists which larger muscle like this:  The latissimus dorsi is a huge and superficial muscle, so it needs the major helper.  Infraspinatus is a smaller, deeper muscle and so it gets the minor helper.  

Subscapularis
The subscapularis is a mirror to the infraspinatus.  It originates on the anterior surface of the scapula in the subscapular fossa and inserts on the lesser tubercle of the humerus.  This is the only one of the four rotator cuff muscles that inserts on the lesser tubercle rather than the greater.  In addition to helping to stabilize the humeral head it also medially (or internally) rotates the shoulder.  If you take your right arm out to the side and use your left hand to grab the back flap of the armpit, and then press your right hand into your belly you will feel subscapularis engage.  During gomukasana pose with the arms, the shoulder of the bottom arm is medially rotated.  When the hands are clasped behind the back, the shoulders are medially rotated.  The deeper subscapularis medially rotates the shoulder with help from the more superficial teres major, latissimus dorsi and anterior fibers of the deltoid.  

Supraspinatus
The supraspinatus originates in the supraspinous fossa, which means superior to the spine of the scapula.  The fossa is deep, and this muscle sits underneath of the fibers of the upper trapezius and the deltoid.  The long head of the biceps brachii is right here too.  It inserts on the greater tubercle and abducts the shoulder.  When I first learned about this muscle, I learned that it was just an initiator of abduction (taking the arm away from the body), but after more reading I’ve learned it’s more than just an initiator.  It is involved in shoulder abduction up to about 90 degrees.  The supraspinatus, like all rotator cuff muscles, assists in stabilizing the head of the humerus as well as abducts the shoulder at the glenohumeral joint.  When you raise the arms for a sun salutation, the supraspinatus is working to lift the arms away from the body.  When the arms are outstretched in warrior two, the supraspinatus is working. 

Biceps Brachii
I wasn’t going to talk about this one yet since I haven’t made a post on the bony anatomy of the radius and ulna, but I can’t help myself.  I think it’s quite relevant here, so here is a brief introduction.  

Biceps means two heads, so to refer to the biceps brachii as simply the biceps, you could technically be talking about any two headed muscle on the body, particularly biceps femoris which is the two-headed outer hamstring muscle.  Brachii means arm (specifically the humerus), so biceps brachii means two-headed muscle on the upper arm.  

The long head originates at the supraglenoid tubercle (the bony prominence above the glenoid fossa), while the short head starts on the coracoid process (beak-shaped bony prominence on the anterior scapula).  Before becoming the meaty belly of muscle on the anterior surface of the upper arm that probably nearly everyone could point out, the tendon of the long head of the biceps brachii passes through the glenoid fossa as well as the intertubercular groove.  The intertubercular groove is the space between the insertion points of the rotator cuff muscles.  The glenoid fossa is, of course, the shoulder socket.  Looking at the photo below you can see how interrelated the rotator cuff and the tendon of the long head of biceps brachii really are.  

It plays a role in shoulder flexion but an even bigger role in supinating the forearm.  It also flexes the elbow.  More to come on the biceps brachii as well as bony anatomy of the radius and ulna in a later post. 

Side view of the right shoulder without the humeral head. Clemente Anatomy.

The Lats + Teres Major

In part two of my fascial layers blog, I wrote about aponeuroses being thick sheets of connective tissue that serve as attachment sites for some muscles.  One of those muscles that has a point of origin on the thoracolumbar aponeurosis is the very large, thin and superficial back and arm muscle known as the latissimus dorsi, or the lats.  This muscle is particularly interesting for a few reasons.  One, while most of its fibers are found covering the majority of the lower and middle back, it’s actually an arm mover.  The lats connect the pelvis to the upper arm bone to create medial rotation, adduction and extension at the glenohumeral joint, which is the ball and socket joint more commonly known as the shoulder joint.  The actions of the latissimus dorsi are easy to remember if you can remember that it’s the handcuff muscle.  If you were being arrested and handcuffed (and I hope you never are), your arms would be medially rotated, a little bit extended and also adducting across the midline behind you.  

The main actions of the lats are medial rotation, adduction and extension of the shoulder.  If you stand or sit upright with your arms relaxed heavily by your sides and turn the palm back behind you or spin your thumbs back behind you, that’s medial rotation of the shoulder.  If you reach both arms back behind you, that’s extension of the shoulder and if you then clasp your hands, bringing the arms together behind the back, that’s adduction.  (Side note: ABduction is when you take away from the midline. To abduct is to take away so it you take the arm or leg out to the side away from the body, that is abduction of the shoulder or hip.  ADduction is the opposite, it’s adding to the midline.  When the arms are out to the side and you bring them back down, that’s called adduction because you’re adding the arms back to the midline).  In addition to being able to move the arm, the lats also assist in lateral flexion of the trunk and can help extend the spine as well as tilt the pelvis anteriorly and laterally.  

HOW DOES A BACK MUSCLE MOVE THE ARM?

The lats have points of origin on the posterior iliac crest (top of the back of your hip bones), the thoracolumbar aponeurosis, the last few ribs (varies in cadavers), the spinous processes of last six thoracic vertebrae and in some people they cross the inferior angle of the scapula as well.  That is a huge origin and a lot of words.  All you really need to know is that it’s a large and superficial back muscle that originates on the pelvis, ribs, spine, fascia and sometimes the scapula so it can affect all of those things.  

The second interesting thing about the latissimus dorsi is that from its origin, it thickens around the armpit and wraps underneath to insert on the front of the upper arm bone in the space between the greater and lesser tubercles of the humerus called the intertubercular groove.  The lats form the posterior wall of the axilla, which is the fancy word for armpit.  You can feel for these more lateral fibers by taking your right hand to find the back flap of your left armpit and gently pressing your elbow in to your side to engage the fibers.  

A third interesting thing is that the lats have a helper, a smaller muscle that does exactly the same thing to help get the job done.  This muscle is called teres major, not to be confused with teres minor which is just above it and rotates the shoulder in the opposite direction.  Teres major originates on the inferior angle of the scapula (as the lats sometimes do too) and the lower third of the lateral border of the scapula.  Just like the lats, teres major wraps under the armpit to also insert on the front of the arm just distal to the intertubercular groove at the crest of the greater tubercle.  It doesn’t affect the trunk or the pelvis because it doesn’t cross them, but it does medially rotate, extend and adduct the shoulder.  Both the latissimus dorsi and the teres major are handcuff muscles.  

WHEN ARE THE LATS + TERES MAJOR CONTRACTING?

When you grab onto a pull up bar and pull yourself up, the lats and teres major are contracting (or shortening) which means the origin is working to bring the insertion toward it to complete one, some or all of the actions.  When the hands are clasped behind the back, the lats and teres major are also contracting as the shoulder is medially rotates, extended and adducted.  People with really developed lats may have a hard time clasping their hands behind their backs because of high motor tone and lots of dense muscle fibers.  

WHEN ARE THE LATS + TERES MAJOR LENGTHENING? 

Child’s pose with the arms stretched out in front is a nice stretch for the lats and teres major.  You can walk the arms and upper body off to one side to deepen the stretch on the other and vice versa.  Any time you are reaching the arms overhead, the lats are stretching.