What is Frozen Shoulder? (Adhesive Capsulitis)

Frozen Shoulder Syndrome (FSS) is a common and debilitating condition. It is a clinical diagnosis and is only very rarely the result of an underlying illness or pathology. FSS is common, affecting 2-5% of the population. One of the many enigmas is that once cured it (almost) never comes back again.

The condition is often misdiagnosed so we like to keep things simple and define it as  "a stiff shoulder with less than 50% of normal range of active and passive motion in any direction".

The important point here is that you can’t lift the shoulder and neither can anyone else lift it for you – it is completely stiff and locked. Other conditions can cause the shoulder to stiffen but, typically, only in certain directions of movement.

Inflammation

In a Frozen Shoulder Syndrome the lax capsular sack becomes sticky and can sometimes (though not always) form adhesions; hence the name of the condition. The stickiness is brought on through inflammation; research has pinpointed the source of this is in the rotator interval. This inflammation often starts in the groove behind the biceps tendon. (This can occur after a small injury, like reaching for the back seat of the car but often you may not remember anything). Once established this inflammation spreads into other shoulder soft tissues and can cause swelling in other shoulder sacks (bursae). This is because the muscles, ligaments, and bursae within the shoulder are very much interconnected.

Stiffness

The stiffness is due to an 'over-reaction' of the body to the inflammation (within the rotator interval/biceps groove). The body then seems to 'switch off' muscles in a coordinated sequence; this sequence is the same for everyone and we call it the 'capsular pattern'. In less than a week the arm movements start to diminish, and within a few weeks the arm literally becomes frozen and for many, can not be raised more than 40° in any direction. The muscles of the rotator cuff become weak and start slowly to waste away, leaving the arm to hang stiff and immobile.

Causes of Frozen Shoulder

Despite the fact that Dr. Duplay first described the syndrome in the late 19th Century, the causes of frozen shoulder (or Adhesive Capsulitis) are poorly understood.

It often appears for no apparent reason (primary) but can stem from an injury to the shoulder (secondary). In our experience, it tends to start with a 'tweak' in the shoulder that doesn't seem to resolve. Often after reaching behind - for example onto the back seat of the car! This 'tweak' seems to occur in the region of the long head of the biceps; it is the cause of that horrible sharp catching pain.

Frozen Shoulder can last up to 30 months if left untreated, but there is a proven technique that can relieve the symptoms and speed up recovery. Once cured, Frozen Shoulder almost never re-occurs (in the same shoulder).

Risk Factors for Frozen Shoulder

• Aging - In Japan frozen shoulder syndrome is called "Fifties Shoulder".
• Posture - especially round-shouldered
• Shoulder-intensive sports
• Shoulder intensive or repetitive manual occupation
• Diabetes - Types I and II
• Trauma
• Immobilisation / splinting
• Fracture of the collar bone or humerus (arm bone)
• Surgery (especially after shoulder surgery, or mastectomy with breast reconstruction)

How Long does Frozen Shoulder Last?

We generally observe four distinct phases which - without treatment -endure over an average period of 30 months. (Note: the treatment I have developed generally speeds things up by about 10 times!).

Without Treatment	Niel-Asher Technique™
Pre-Freezing (0-4 weeks)	1-5 Sessions
Freezing (1-8 months)	7-13 Sessions
Frozen (9-16 months)	5-8 Sessions
Thawing (12-40 months)	4-7 Sessions

*This is an average and may vary if there is another underlying shoulder pathology like a rotator cuff tendon problem or if there is diabetes (which usually slows the healing process by 50%).

Traditional Treatments
Shoulder pain is traditionally treated by injections, tablets and or surgery. The following is a list of the treatments for the frozen shoulder BUT most of the treatments apply to many other shoulder complaints.

Until now these have been either palliative or invasive. An article published by UK 'Which magazines' examined every single published research trial for the treatment of frozen shoulder syndrome. The 'Drugs and therapeutic Bulletin' (Nov 2000) makes the statement that until now 'no treatment has been demonstrated to either reduce the duration or severity of frozen shoulder syndrome'. The most common treatments are listed below. Click on the treatment if you want to find out more about the evidence behind them:

Cortisone injections
Cortisone injections are often administered during the freezing and frozen phases. It is not uncommon to have up to 4 injections. Rarely, cortisone injections seem to cure the problem, sometimes they may give a few months of pain relief, but for the majority of patients, they seem to give only a week or two of symptomatic relief. The steroid is a crystalline substance which is injected into the joint capsule.

Evidence base (EBM) for current treatment regimens:
Corticosteroid injections: These are either injected into the space between the acromion and the humeral head (subacromial bursa) or into the shoulder joint itself. Three randomized placebo-controlled trials (RCTS) have been fully published; the results were mixed. On average 3 injections were given 1 week apart. Pain relief did seem to improve briefly, but there were unwanted side effects such as facial flushing and irregular menstrual bleeding; also, in diabetics, injections have a detrimental effect on insulin metabolism, de-stabilizing the blood sugar levels for 36-48 hours.

Oral corticosteroids: In one open trial, 40 patients with a stiff shoulder for at least 1 month were randomized to receive either enteric coated prednisolone 10mg every morning for 4 weeks, reducing to 5mg daily for a further 2 weeks, or no specific treatment. All were given light pendular swinging exercises and paracetamol or a weak opioid and diazepam at night. The prednisolone group demonstrated reduced night pain for the first few weeks but by 5 months there was no difference between the two groups. The side effects of oral steroids are well documented.

NSAID therapy : Results of 5 randomized placebo-controlled clinical trials seem to suggest that NSAIDs used for a few weeks are probably more effective than placebo in the short term for relieving shoulder pain and thus improving function. NSAIDs can have side effects, especially when taken with GIT problems.

Manipulation under anesthetic (MUA)
Manipulation under anesthetic (MUA) again this is performed in the freezing phase (at least after 6 months) it is performed under general anesthetic and followed up by several months of physiotherapy. Complications arising from this include fractures and dislocations of the Humerus, rotator cuff tears, increased inflammation and scarring and nerve palsy (especially radial Nerve.)

The Niel-Asher Technique™
A frozen shoulder seems to result from the way the brain responds to inflammation around the long head of the biceps, in the rotator interval (see anatomy). In some people, and we still don't know why the brain overreacts to this inflammation by switching off groups of muscles and changing their dynamics.

Traditionally, muscles are thought to operate around joints in triangles; one muscle group holds the joint still (fixators), one muscle tenses up and pulls the joint one way (agonist) whilst another opposite muscle (antagonist) relaxes.

In shoulder problems, these smooth and seamless operations no longer operate properly and agonists, antagonists, and fixators become confused. The brain responds to this by recruiting alternative muscles to do jobs they are not designed for (synergists).

The Niel-Asher Technique™ stimulates groups of receptors embedded in the muscles to fire their messages to the brain. This creates a new and specific neurological profile within the part of the brain called the somatosensory cortex. By stimulating these reflexes in a specific sequence, it is possible to change the way the brain fires muscles (the motor output).

This situation occurs in most shoulder problems and Niel-Asher has invented specific treatment sequences for a range of conditions such as Rotator cuff problems, biceps tendonitis, bursitis, arthritis, and tendinopathy. These techniques are approved and used worldwide by Doctors, Physical Therapists, Osteopaths, and Chiropractors.

Dr. Keezer is a licensed provider of the Niel-Asher Technique™