Frozen Shoulder Guide

A readable self-help manual for one the strangest of all

common musculoskeletal problems, adhesive capsulitis
updated November 29 2016
by Paul Ingraham, Vancouver, Canada bio

Sometimes shoulders just seize up, painfully and mysteriously, for several months: frozen
shoulder.[Mayo] It comes with other diseases, usually diabetes, or it follows periods of
immobilisation — hold the shoulder in one position for long enough, and it actually may get
stuck there. The shoulder is the only joint that commonly “freezes” like this.1). Frozen
shoulder is a biological puzzle, and yet common. It’s hard to define precisely, diagnose
accurately, or treat effectively; it’s one the best examples of how musculoskeletal medicine is
surprisingly primitive still.

Good news, though: frozen shoulders almost always thaw!2 The condition usually retreats as
mysteriously as it attacks, within 10 months if you’re lucky, up to two years if you’re not. A
few people will continue to have trouble for much longer.3

Adhesive capsulitis [Wikipedia] is the more formal term for frozen shoulder: it describes the
characteristic stickyness that develops in the shoulder joint capsule. Sticky shoulder is
probably a better name.

Range of motion fails, usually just on one side.4 Most patients first notice that they are
having trouble reaching behind bra clasps, wallets, and back itches. About two thirds of
patients are women.
About footnotes. There are 43 footnotes in this document. Click to make them pop up without losing
your place. There are two types: more interesting extra content,1

and boring reference stuff.2

Try one!

Nature of the beast: frozen shoulder is a biological failure,

not a biomechanical one
Frozen shoulder is more like a disease than most common musculoskeletal problems. It is a
biological failure, not a biomechanical one. It is not a repetitive strain injury. In fact, if
anything, it’s the opposite of an overuse injury: it’s an under-use injury, frequently brought
on by a period of shoulder immobilization, stuck in a sling after a fracture or stroke.

It probably is a symptom of broader health problems. It mostly hits people over the age of
forty, much more so if you have diabetes and/or cardiovascular disease.5 Those problems are
commonly associated with obesity, and what they have in common is “metabolic syndrome”
[NIH] — trouble with managing fats and sugars in the blood, and chronic low-grade
inflammation everywhere.

Chronic low grade inflammation is increasingly seen as a part of other orthopaedic conditions
such as osteoarthritis — once considered a ‘cold’ wear and tear problem (as opposed to the
far more overt and ‘hot’ inflammation of rheumatoid arthritis).

Summer is coming — Frozen Shoulder, Cocks (Noijam.com)

No one knows why the shoulder joint capsule in particular would be the tip of this
dysfunctional iceberg. Why such a dramatic point of failure? Why that tissue in particular?
No one knows. But the relationship between frozen shoulder and metabolic syndrome is
clear, as well as other glitchy biology like hyperthyroidism.6 It is one of many conditions that
fall short of frank, diagnosable autoimmune disease like rheumatoid arthritis or lupus, but are
still obviously autoimmune in character and characterised by inflammatory over-reaction.

Revealingly, smoking is a major risk factor for shoulder problems,7 probably including
frozen shoulder. Smoking probably contributes to the poor health that frozen shoulder is an
expression of. Smoking is a well-known factor in many kinds of chronic pain.8

Someone in my personal life is a perfect example of the connection between metabolic

syndrome and frozen shoulder. She is catastrophically diabetic today, with failing kidneys,
but long ago, for about three years before her diabetes diagnosis, she suffered through a phase
of obviously inflammatory problems that prompted a tentative diagnosis of lupus. Lupus is
the autoimmune disease that usually gets diagnosed when no other autoimmune disease can
be identified. Unsurprisingly, she got frozen shoulder during this period, but it was only one
of several inflammatory over-reactions around her body — and diabetes itself may have been
one of the consequences of that inflammatory period of her life.

Shoulder neglect? An evolutionary perpsective on frozen shoulder

An interesting theory is frozen shoulder occurs because “the human shoulder evolved for
high speed projectile throwing” (Pietrzak 2016), and it suffers from neglect in modern living.
Sedentary tissues can cause trouble, and be more vulnerable to biological failure. In
particular, Pietrzak suggests, injury near the shoulder might trigger an inflammatory reaction
that’s just waiting to happen.

I think it’s unlikely that the shoulder actually “evolved” for that purpose in the first place,9
and, even if it did, why would the shoulder be the only anatomy in the body with this
problem? Surely many body parts tend to stagnate in modern living, and yet — as already
noted — only shoulders “freeze” like this.

But there’s some strong support for Pietrzak’s idea. In 2013, Littlewood et al. made a detailed
argument that the symptoms of rotator cuff tendinopathy — and the shoulder joint capsule is
essentially just a bunch of rotator cuff tendons — can occur without any actual or impending
tissue damage.10 First they make the case that explanations for pain based on “peripherally
driven nociceptive mechanisms secondary to structural abnormality, or failed healing, appear
inadequate” — at least in the context of rotator cuff tendinopathy (and probably much else).
They’re on firm ground with that premise. So what is the problem? They propose that the
brain may react to relative overuse of de-conditioned tendon — tendon that’s just been lazing
around too much — with fearful avoidance of movement, a vicious cycle of painful inhibition
of function. This is completely consistent with Pietrzak’s idea. And “functional freezing” is
the next major topic…

Stiff but not frozen: the case for functional freezing

“Adhesive” capsulitis refers to a literal stuckness, and there’s no question that many or most
frozen shoulders are literally stuck in a limited range. But could some frozen shoulders be
less literally stuck? Could that stuckness sometimes be more of a functional limitation than a
physical one? Is it even possible that many cases are at least partially like this? What if, say,
60% of cases were 30% explained not by sticky joint capsule, but by an extreme reluctance
to move (neurological inhibition)?

And could functional limitation be more prevalant in cases that are dragging on and on? Do
some people slowly climb out of the frying pan of a sticky joint capsule and into the fire of a
shoulder that’s just too uncomfortable to move? What if the door of shoulder movement
stealthily transitioned from welded shut to just being rusted shut?

There’s hope in them thar hills, because a functional stiffness might be easier to loosen up
(with massage, say, or carefully planned exercise). And yet the opportunity might be
tragically missed! How would a patient even know that the situation had changed? There’s no
easy way to tell that something badly stuck is less badly stuck that it used to be.
I’ve used a lot of questions to introduce this topic because — surprise surprise — no one
actually knows. It’s a popular idea,11 but there is no compelling direct evidence of it. We
mostly just have an accumulation of evidence that the usual suspectsaren’t cutting it,
evidence that we’re missing something (which is what Littlewood  et  al is all about). And we
have clinical stories that seem to suggest it.12 If it’s true, it’s going to be hard to prove. And
it hasn’t been a focus of research because it’s so clear that most cases, and probably the worst
ones, really are dominated by adhesion — that’s the bigger problem. Worrying about a
functional limitation, especially in the earlier stages of freezing, may be like trying to sweep
up the ashes while the fire is still raging. But later on…

The possibility shouldn’t be completely ignored.

Over time, it’s possible that a functional limitation gradually becomes responsible for a larger
share of the immobility and pain of the condition. It probably wouldn’t sustain the full
ferocity of the condition, so I’ve depicted a slope downwards representing a general decline
in severity — but of course the mixture over time could vary a lot from patient to patient.

How would functional stiffness work?

There are two main ways that a functional limitation of shoulder ROM would probably work,
and we shouldn’t underestimate the power of either of them:

1. the brain can “shut down” a joint with neurological inhibition

2. the muscles can become unhealthy and rotten with “knots” (trigger points)

The brain is the boss of all function, and when it decides that a joint shouldn’t move, then it’s
not going to move — and because your conscious mind isn’t included in the decision, the
limitation can feel externally imposed. Your shoulder might as well be in vice. Inhibition
doesn’t feel “functional”: it just feels like you can’t move. Will power doesn’t come into this.
Your brain is protecting you from yourself. This is standard neurological procedure with
severe traumas.

Trigger points are a tough topic, because no one really knows exactly what they are, but
there’s no question that people often develop sensitive spots in soft tissue. Although their
nature is unexplained and controversial,13 the usual way of explaining them seems like a
great fit for frozen shoulder: “tiny cramps” in the muscle would make it uncomfortable,
weak, and less stretchy, like a knotted bungie cord. If the rotator cuff and other shoulder
muscles were full of trigger points, perhaps the net effect would feel an awful lot like literal
“freezing.”

Further on in the tutorial, I’ll discuss disinhibition strategies, and the (hopelessly imperfect)
options for trying to treat trigger points.

“Adhesive” may be the wrong word: shrunk, not stuck

There is no detail of this condition that isn’t controversial and mysterious, and what shows it
better than a challenge to its name? Nagy et al (among others) argue that “adhesive” is
inaccurate:14 it’s not an adhered joint capsule, but rather a contractured one. Contracture
[Wikipedia] is the shortening or hardening of tissue. In more familiar words, they’re saying the
joint has been “shrink wrapped” by a joint capsule that has tightened, rather than surrounded
by loose layers of joint capsule that are have gotten stuck together.

What’s in a name? Maybe a lot in this case: this difference could be extremely important to
treatment. Sticky layers can be pulled apart; contracture is an issue that’s probably a lot
harder to force.

So, what’s really going on? It’s probably impossible to call this one. We can infer from the
partial successes of some surgical procedures that contracture probably isn’t the whole story,
so that’s one decent clue. But the main problem with the theory is that there’s not much
information about this adhesion versus contracture business. It seems to have originated with
a couple papers way back in 1989 and 1995,1516 with virtually no confirmation, elaboration,
or even contradiction from researchers since then. (I’ll continue looking.) Having watched
similar scientific controveries about other problems go back and forth for many years, with
new studies over-turning old ones as often as I change my socks, I’m not comfortable taking
a position on this one: for now I’ll just point out that there’s an interesting question mark
here.

Confirming the diagnosis: classic frozen shoulder

symptoms
Frozen shoulder isn’t hard to diagnose — or rather, it shouldn’t be. Physical therapist and
shoulder guy Adam Meakins sees “a lot of frozen shoulders,” but also “many who have been
told they have frozen shoulder who clearly do not.”17 There can be confusion with other
conditions (reviewed below). The defining symptoms of frozen shoulder are:
  Reduced mobility of a shoulder joint in three long stages:
1. Freezing: Increasingly painful restricted movement for 6 weeks to 9 months.
Pain is usually “severe, diffuse, all consuming, and usually unrelenting,”18 in
the shoulder, sometimes the upper arm as well.
2. Frozen: Restricted but relatively painless for 4 to 6 months.19
3. Thawing: The gradual return of movement over 6 to 24 months.
 The first movements to go are usually reaching straight up and behind the back.
 Night pain, especially when lying on the affected side.
 A sensitive coracoid process (see next section).

The dead giveaway symptom: a specific painful spot, on the coracoid process

ZOOM

Other than the slow-but-steady loss of mobility, there’s one particularly strong defining
symptom (“pathognomonic”) that’s good to know about, but you might never notice if you
don’t go looking for it. It occurs in more than 95% of cases, but only in 10-15% of other
kinds of shoulder pain. It’s sensitivity on a specific spot on the front of the shoulder, on the
tip of a bone called the coracoid process.20 This odd little bone points forward like a finger,
just below the end of the collar bone. If you feel around in the tissue there, it’s hard to miss
— and if it hurts quite a bit (more than 3 on a scale of 10, say), that’s the sign you’re looking
for.

Other shoulder problems that could be confused with adhesive capsulitis

These are presented roughly in order of how much they can seem like frozen shoulder, briefly
explaining them and highlighting the major differences:

Rotator cuff tendinopathy or tear. The rotator cuff is a group of four muscles that surrounds
the shoulder joint like a “cuff,” and that cuff is anatomically overlapping the joint capsule
that gets inflamed in frozen shoulder — which is why rotator cuff problems can be difficult to
distinguish from frozen shoulder. Confusing things even more, rotator cuff trouble might
make movement uncomfortable, as with frozen shoulder, but not necessarily. Rotator cuff
abnormalities and lesions increase steadily later in life, like arthritis, but are also amazingly
common in pain-free younger people — in other words, even there’s an “obvious” problem
on an X-ray or MRI, it ain’t necessarily the problem.21 But the rotator cuff can hurt, and
when it does, it mostly limit active movement, whereas frozen shoulders are frozen even
when you are relaxed and someone else tries to moves your shoulder for you (passive
movement). And tears tend to happen suddenly with exertion, a clear “oh shit” moment of
injury. And with tears or tendonitis, the pain is usually limited to more specific spots and
movements than with frozen shoulder.

Subacromial and subdeltoid bursitis are closely related to rotator cuff tendonitis, but instead
of tendons they affect bursae (the anatomical padding between tendons and other structures).

Arthritis of the big shoulder joint mostly occurs beyond middle age, and usually develops
more slowly-but-steadily, and isn’t as severe. An X-ray will show clear signs of joint
degeneration that won’t be seen with adhesive capsulitis. Shoulder arthritis often involves a
history of injury.

Acromioclavicular arthropathy is degeneration of the joint at the outside end of the collar
bone. It does not really affect shoulder range of motion, the pain is more specific to that
superficial joint, and it’s usually associated with a history of overuse and injury, usually
athletic.

Tendonitis of the biceps tendon. Tenderness sticks to the front of the shoulder with this
condition. Biceps contraction is painful, but other movements are normal.

Cervical disk degeneration, basically arthritis of the spine, can cause pain, weakness, and
numbness that spreads out into the shoulder and can make it seem “frozen,” but this problem
usually also spreads further: symptoms in the hand and wrist will usually be more prominent
with this problem.

Autoimmune diseases like lupus or rheumatoid arthritis can affect many joints in the body,
including the shoulder — but they usually do affect multiple joints, and cause several other
health problems that obviously set them apart.

Cancer is one of the least likely causes of frozen-shoulder-ish pain, but a tumour in or near
the joint is a possibility. Watch out for other signs of failing health, especially night sweats
and weight loss and shortness of breath.

Do you need a shoulder x-ray?

It’s not a bad idea, but the “need” part can be debated. An x-ray is potentially helpful for
excluding shoulder joint arthritis or scary causes of pain like a tumour, but some
professionals will sensibly advise against it because frozen shoulder is quite distinctive
clinically, because it’s rare for a sinister condition to masquerade as frozen shoulder, and
because x-ray isn’t exactly a foolproof method of detecting other causes anyway. Other pros
think an x-ray is a no-brainer and well worth the minor (radiation) risks of a single x-ray to
check for surprises before proceeding with therapy.22 There is no evidence-based right
answer to this.

Frozen shoulder treatment: it can’t be “cured,” but it

probably can be managed and minimized
Every professional seems to have their own take on frozen shoulder treatment, even doing
nothing at all: some believe it should just be left alone to run its course, and it’s an
understandable position. In a 2004 test with 77 patients, “supervised neglect” actually worked
(slightly) better than “intensive physical therapy”!23 Why even go on? It sounds like nothing
works. But that was a study of the tip of the iceberg,24 hardly the last work — it’s just a great
way to caution patients against spending a bunch of time and money on basic physiotherapy.

At one of the scale, there’s the “do nothing” crowd. At the other, there there are many
different kinds of more dramatic cure claims, as there is for any difficult condition. Despite
too-good-to-be-true promises, there really is no known effective treatment for frozen shoulder
[NHS] — nothing that actually prevents the capsule from adhering, nothing that can free it up
without doing more harm than good, nothing that clearly, reliably makes the ordeal shorter or
easier for most patients.

However, range of motion can probably be preserved to some degree by early use-it-or-lose-it
interventions. And the pain can be helped (which in turns helps with the “using”). Pain can
almost always be helped.

“Despite over a hundred years of treating this condition the definition, diagnosis, pathology
& most efficacious treatments are still largely unclear.”

Only a few scientific reviews of frozen shoulder treatments have been published, but they
suffer badly from the “garbage in, garbage out” problem: there’s not enough good quality
research to review. And so there’s a strong theme in their conclusions: no one really knows
what works yet, and most of the better evidence we do have is either unimpressive or outright
disappointing. “Despite over a hundred years of treating this condition the definition,
diagnosis, pathology and most efficacious treatments are still largely unclear.”25

In a typical example, Maund  et  al reviewed 31 studies in 2012, “many” of which were “at
high risk of bias,” concluding after great effort that were is “limited clinical evidence on the
effectiveness of treatments for primary frozen shoulder.”26 The authors of a big 2014 review
sounded particularly underwhelmed: they concluded that that hardly anything seems to work,
and nothing works for long.27 Out of 32 trials, not one “compared a combination of manual
therapy and exercise versus placebo or no intervention” — in other words, a total lack of
evidence on what is probably the most important treatment topic.

Favejee et al is one the more optimistic reviews, somehow finding — in the same literature
Maund et al and Page et al looked at! — some moderate to strong evidence for the short term
benefits of some treatments.28 But emphasis on the short term: “most of the included studies
reported short-term results” only.

This unhelpful mess of mediocre evidence and “more study needed” conclusions is a good
demonstration how musculoskeletal medicine is still surprisingly primitive.29 Frozen
shoulder seems worthy of considerably more and better research attention than it has gotten!

Use it or lose it: movement therapy to prevent the capsule from adhering too
much too soon

If you believe you are in the early stages of frozen shoulder, immediately begin a campaign
of mobilizations: gently, thoroughly use as much of your range of motion as you can without
excessive discomfort.30 This a nice collection of exercises for the shoulder, with good
illustrations: “7 stretching & strengthening exercises for a frozen shoulder.” [Harvard Health]
Give your range of motion a little helping hand, too. For instance, use a wall to support the
weight of your arm while “walking” up the wall with your fingers. Such tactics are a good
way to take safe baby steps into the outer limits of your comfortable range.

Emphasize any activity you enjoy that requires extensive shoulder range of motion. If you
have none, consider taking one up: tennis, for instance. You may find it difficult, but making
movement challenges fun is a really valuable rehab principle.

What if you can’t move it? Then imagine moving it. Seriously! A very large component of
movement is neurological. When we lose range of motion, it’s both a physical and a
neurological loss. If you can’t preserve the physical, keep working on the neurological!

The Meakins method: eccentric loading + “let it go”

In my experience manual therapy and traditional physiotherapy methods for frozen shoulder
do very, very little. I have tried them all, pulling and pressing people with painful frozen
shoulders, here, there, and everywhere, all with little effect, and all too no avail. However,
there is a “different” method for treating frozen shoulders that I have been using more and
more over the years…

Frozen shoulder? Let it go, Let it go…., Meakins (TheSportsPhysio.wordpress.com)

Physiotherapist Adam Meakins has a novel idea idea about how to treat frozen shoulder.
Although it’s not clearly evidence based, it is an educated guess from a particularly good
guesser about shoulders, with some strong theoretical foundations.31 It involves
progressively challenging range of motion, putting it firmly in the “use it or lose it” category
of treatment approaches. Adam put’s another spin on that, teaching his patients to use it
specifically with eccentric contractions: that is, contracting muscles while they lengthen.

An eccentric or braking contraction is an interesting but routine type of muscular contraction

that seems like a paradox: the muscle is contracting even as it is lengthening! Eccentric
contraction is a bit physiologically mysterious, and is known to be harder on muscle, causing
more soreness (quadriceps after hiking down a mountain is the classic example) — a good
stimulus to adaptation, in tendon as well as muscle. See Eccentric Contraction: A weird bit of
muscle physiology.

Why use “contraction” here at all, if frozen shoulder isn’t a muscle problem? The complex
rotator cuff muscle group is seamlessly blended with the joint capsule, and to stimulate one is
to stimulate the other… and eccentric contraction is an interesting stimulus, well known to
have unusual and potentially rehabilitative effects on connective tissue. It is often used as a
tendonitis treatment.

Another consideration is the on-going debate about how much of a role muscle tension may
play in frozen shoulder, either greatly complicating or actually mimicking an adhered
capsule: functional freezing. To the extent that the freezing is functional, then it does make a
lot of sense to work with the shoulder muscles.

So what exactly do you do? You slowly lower a small weight into a manageable stretch into
your most limited movements. You make it as easy as possible at first, and you up the ante
every few days. You tolerate a little discomfort, but not too much. You don’t want to push
hard through pain, but you do want to strive to ease through any muscle tension holding you
back: “let it go,” as Adam puts it…referencing the song, of course. 😃 And you do all of this
with the confidence that your shoulder tissues are probably not as raunchy as they feel.

See his article for full details with pictures: Frozen shoulder? Let it go, Let it go….

Over-the-counter pain killers for frozen shoulder

Some pain relief may be possible with the use of a topical analgesic like Voltaren®. The
medication may not soak in deeply enough for a significant effect, but it’s worth trying —
and topical delivery is much better than dosing your entire system with edible pain-killers,
which have a dizzying array of side effects, some of them serious.32

Corticosteroids for frozen shoulder

Corticosteroids are potent anti-inflammatory agents. Wherever pain is caused by

inflammation, corticosteroid injections are likely to produce substantial temporary pain relief
— at the cost of an invasive procedures with some risks. In the case of frozen shoulder, it’s
very clear that these injections function as a kind of super pain-killer — they definitely
reduce pain.33 However, it’s equally clear that the benefits don’t last, and the freezing of the
joint proceeds. The main use of corticosteroid injections for frozen shoulder is probably to
facilitate ROM-maintaining exercise.

Treating frozen shoulder with diet

An anti-inflammatory diet — also known as a healthy diet, with a few specific features —
might reduce the severity and duration of frozen shoulder.

As explained above, frozen shoulder is strongly associated with metabolic syndrome, which
in turn is strongly associated with poor fitness, obesity, aging, a typical modern junky diet,
genetics (of course), and maybe chronic stress, anxiety, and fatigue as well.34 One of the
main biological consequences of metabolic syndrome is a lot of subtle inflammation, which
can to all kinds of trouble in time, especially cardiovascular disease … and even frozen
shoulders. An “anti-inflammatory” diet is not magic: it’s just eating to minimize metabolic
syndrome and its consequences, the kind of diet that practically everyone everywhere should
be eating anyway.

There is no evidence at all — zip, zero, zilch — that eating this way will specifically help a
condition like frozen shoulder. By the time your shoulder is freezing, it could be way too late
for your diet to make any difference. Or maybe it’s not! Maybe this is one of the reasons why
some people take much longer to recover than others. No one knows, but all of this is very
reasonable speculation, and it’s well worth trying, for obvious reasons: it’s good for you
otherwise, even if it has no effect on frozen shoulder.

There’s a more extreme dietary option to consider…

Treating frozen shoulder with a ketogenic diet (a longshot that might be worthwhile)
Diets that force you to mainly burn fat for energy, instead of carbohydrates — a ketogenic
diet [AuthorityNutrition.com], like the infamous Atkins diet — have some well-established
benefitsmay be anti-inflammatory and de-sensitizing.35

This is a completely experimental treatment. However, like an anti-inflammatory diet (AKA

“healthy”), it has a non-crazy rationale, and it’s safe and inexpensive to dabble in. As long as
you don’t get extreme, the worst case scenario is putting up with a fussy and unpleasant
change in eating habits. Nevertheless, I am obliged to suggest that you run this by your
physician and/or a nutritionist.

Fasting is another option, but it might work (and perhaps simply because it includes a
ketogensis), but it’s harder and less safe — so I’m less inclined to actually recommend it. But
if you are keen on the idea fasting for whatever reason, it’s another possibility to consider.

I have a separate article devoted to this topic which suggests some other possible strategies
for reducing systemic inflammation. To the extent that any of them work at all (quite
unknown), they would likely support recovery from frozen shoulder.

Chronic, Subtle, Systemic Inflammation A possible insidious cause of mysterious chronic

pain ~ 3,750 words

Massage therapy for frozen shoulders: symptom relief at least, possibly more

Although the adhesions in the shoulder joint capsule cannot be broken by massage — not
safely at any rate — it undoubtedly is possible for massage to relieve some of the discomfort
that usually develops in the area. Many patients crave massage therapy for this condition. In
the best case scenario, a surprising amount of the discomfort of frozen shoulder is just a
symptom that can be treated by massage. At least a little, at least temporarily. And we should
never knock a little symptom relief.

But massage might have more profound relevance to frozen shoulder. As discussed earlier in
the tutorial, some shoulders may be more functionally than literally frozen, and this is more
likely in chronic cases. If true, then massage may could theoretically treat the root of the
problem. If it works, here’s how it might work…

Reducing neurological inhibition with massage

The stimulation of massage, probably combined with slow passive movements, might
encourage and reassure the nervous system that it’s okay to move the shoulder again, such
that it can reconsider the shoulder “lockdown” policy it may be entrenched in. Any reduction
of neurological inhibition would create an opportunity for more movement, but that window
opportunity might be narrow, especially at first. If there’s any increase in range of motion
following massage, that’s a great sign that should be exploited by gently exploring the
improved ROM as much as possible for as long as it lasts.

The massage treatment itself should be low key as well: this is all about convincing the
nervous system that there’s no danger. Excessively intense massage could actually backfire.

A major disadvantage of this approach is that it could be slow and therefore expensive. How
good is massage at facilitating the resolution of neurological inhibition? Can it do it at all? No
one knows. It’s probably not worth pursuing if there’s no noticable improvement within
roughly 6 half-hour massages of the shoulder and area (and even that’s getting to be quite a
costly experiment). However, note that there are also other, less expensive ways to “reassure”
nervous systems about shoulders.

Treating trigger points with massage

If a frozen shoulder is functionally frozen, muscle “knots” or trigger points may be one of the
causes of the tightness. Rubbing trigger points seems to ease them! No one knows how well
this works, or even if it works at all, but it is a safe treatment to experiment with, often
pleasant if done well, even cheap if you learn to do some yourself, and it’s not hard to dabble
in. Trigger point treatment is covered in great detail elsewhere on this site. I have a basic
trigger point self-treatment guide, and a huge trigger point tutorial for the toughest cases, for
both patients and professionals.

But basically… just rub the sore spots. Somehow I’ve written about a quarter million words
about “just rub the sore spots.” 😮

Although massaging nearly any muscle tissue in the area may be useful, there is one that’s
worth some special consideration: Perfect Spot No. 14, The Most Predictable Unsuspected
Cause of Shoulder Pain.

For what it’s worth, many massage therapists do claim to have cured cases of frozen
shoulder.36 It’s not hard to see why. I have my own highly relevant treatment story — the
one about my uncle-in-law, near the beginning of that page — worth a detour if the massage
angle interests you.

Forcing the issue: ripping the adhesions to increase range of motion

Warning! Please do not allow a health care professional to attempt to forcefully increase your
range of motion! This can cause extreme pain from the rupture of adhesions, which quickly
get sticky again. Also, resistance from muscles protecting the joint can be so substantial that
it is impossible to apply force effectively to the actual joint capsule, and muscles may tear
instead of adhesions. There is no proven benefit to this therapeutic approach, and substantial
risk.

Doing the same thing under anaesthesia, although hardly safe, is much more promising…

Manipulation Under Anesthesia (MUA) and related methods (surgery and pseudo-
surgeries)
The shoulder can be paralyzed by injecting anaesthetic into a thick web of nerves emerging
from neck (brachial plexus), which greatly reduces muscular tone (but probably doesn’t
actually eliminate it.37) A doctor can then apply force much more directly and precisely to
the adhesions in the joint capsule, without fighting through much muscular resistance.

Does it work? If only we knew! This is a pseudo-surgery, and like many surgeries, it is
understudied.

Unfortunately, this is only an option for desperate patients, because there are substantial risks
to this procedure.38 Some people go straight from the freezer to the frying pan of a serious
manipulation injury or — ironically — permanent hypermobility with recurrent disclocations.
There’s also a substantial rehab process after the surgery — things are a bit wonky
afterwards, even if it goes well, and it takes time. (And it’s not an option at all for patients
with past dislocations, fractures, or bone loss.)

Does it work? If only we knew! This is a pseudo-surgery, and like many surgeries,39 it is
understudied and based more on seeming to make sense than any hard evidence. There are a
few mediocre scientific tests, but there’s just not enough good quality data yet. It’s important
to bear in mind that many orthopedic surgeries have been proven ineffective, even though
they too seemed liked good ideas.40 This one might actually work, or it might not. It’s just a
gamble.

Arthroscopic capsular release

Another way to force the issue, and likely safer that MUA, is arthroscopic or “keyhole”
surgery. The goal is exactly the same, but the method is much less brutish: instead of tactical
wrenching of the joint until the adhesions tear, a surgeon goes in with a tiny camera through a
tiny incision and cuts things free.

Although we don’t have good data on whether manipulation or cutting actually work, we do
know that each one is roughly as good as the other.41 All other things being equal, I’d prefer
not to get wrenched around.

Joint capsule inflation (arthrographic distension, hydrodilatation injections)

When you blow up a balloon, it is often stuck to itself, and slightly adhered layers of rubber
peel away from each other as you force them apart with air pressure. The same principle is
used in hydrodilation injections, only the ballon is the shoulder joint capsule, and it’s inflated
with saline solution (maybe with some steroids as well, to help with the inevitable spike in
inflammation). Like blowing up a ballon, the pressure is supposed to inflate the capsule.

In no other way is the shoulder joint capsule like a balloon, and simplistic analogies like this
are often misleading in medicine. Adam Meakins calls distension “highly dubious.” It has
barely been tested, but the conclusion of a 2008 scientific review of just five studies makes it
sound almost promising:42

There is "silver" level evidence that arthrographic distension with saline and steroid provides
short-term benefits in pain, range of movement and function in adhesive capsulitis. It is
uncertain whether this is better than alternative interventions.
Still, “uncertain” is an understatement there!

Fortunately, there is some more encouraging evidence from 2013 trial, only the second one
ever to produce long term results (and it also included diabetic patients).43 It’s far from
proof, but it’s better than nothing.

Despite that evidence, this procedure is based mostly on “common sense” of the doctorly
sort: it seems like a good idea. Maybe it helps and maybe it doesn’t. As with arthroscopic
release, I’d certainly try this before manipulation under anaesthesia, for the safety. But I
certainly wouldn’t bet on the outcome. Remember that there’s no way this treatment method
can work (in principle) if the joint is actually contractured rather than adhered (see above,
“Adhesive” may be the wrong word: shrunk, not stuck).

My (wife’s) frozen shoulder story

On this website, I often write about conditions I have some personal experience with. In this
case, it’s not my own experience, but my wife’s: a rip-roaring case in the aftermath of a very
serious car accident, adding injury to injury.

Have you got a frozen shoulder story you’d like me to share here? Contact me.

She says the shoulder was the worst pain she had in the entire recovery experience (and she
broke several bones, including her skull, spine and pelvis). We have a rather vivid memory of
walking down the street together one day, near the peak of the problem, and she tripped a
little and reflexively tried to stabilize herself with the bad shoulder. WOW. Never seen her
react like that to anything, before or since!

But there’s a peculiar wrinkle in her story: she actually already had a full-blown case of
frozen shoulder when the accident happened. It cleared up completely for several months
during the the initial stages of rehab. And then it returned! It’s like the accident hit the
“pause” button. What can we make of this? It’s hard to interpret for sure, but I think one
possibility is that it means that the first phase of her frozen shoulder was functional: not an
adhesive capsulitis, but a neurological ban on movement which was lifted when the accident
changed her “priorities,” and then re-imposed when her body started to recover from the
severe injuries.

About Paul Ingraham

I am a science writer, former massage therapist, and I was the assistant editor at
ScienceBasedMedicine.org for several years. I have had my share of injuries and pain
challenges as a runner and ultimate player. My wife and I live in downtown Vancouver,
Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on
Facebook or Twitter.

Related Reading
Why Does Pain Hurt? — The inflammation of frozen shoulder is exasperatingly mysterious.
This article explains how inflammation can be “glitchy” — an interesting perpsective that
might help make sense of frozen shoulder.

Into the Fire — The story of a difficult shoulder rehab. Although not a case of adhesive
capsulitis, there’s lots of relevant detail about how any shoulder pain can get stubborn.