Frozen Shoulder And How You Can Survive It
Don’t let frozen shoulder pain beat you An electronic book by Doctor Gordon Cameron
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Frozen Shoulder and How to Survive It
Legal Stuff
Doctor Cameron has made every effort to provide authoritative information on the subject of Shoulder Pain and Frozen Shoulder No promises are made about the results you will obtain using this material. This book is offered with the understanding that it is not intended to substitute for face to face advice on medical issues. If you feel that such assistance is needed, then please seek early assessment from a local doctor. You are solely responsible for any consequences arising from your use of this information. It is unsafe to attempt to diagnose your own o wn medical symptoms and Doctor Cameron strongly recommends that you do not attempt to do so.
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Frozen Shoulder and How to Survive It A message from Doctor Cameron
“If you are reading this then I guess that either you or someone close to you is suffering from the pain of a frozen shoulder. Life is tough if you have h ave a frozen shoulder and there’s no getting away from the fact that day to day existence can be a bit of a struggle.
We rarely realise how much we depend on our shoulder functioning normally until something goes wrong with it – a loss in the normal range of shoulder movements is at best an indignity and at worst a disaster when it comes to dealing with the normal day to day chores of life. The pain can be bad enough to bring normal life temporarily to a halt. I’ve written this book to give you the power to beat your shoulder symptoms – let’s let’ s get your life back to normal and let’s get started NOW !” About Me
I live and work in Edinburgh, Scotland and specialise in treating pain from the spine, joints and muscles. I am fascinated by the condition that has come to be known as Frozen Shoulder and I’ve treated thousands of patients who have suffered from it. Having knowledge can be very powerful and truly knowing kn owing the facts about frozen shoulder can give you the strength you need to deal with your condition and the problems it causes. I can’t promise you a miracle but I can promise you that this book will make your life a lot lo t easier. Stay well and be happy Doctor Gordon Cameron
P.S. – you can read a lot more about me and my qualifications by visiting my Shoulder Pain website at www.jointenterprise.co.uk at www.jointenterprise.co.uk You’ll find details of my background and experience – as well as a lot more information about other aspects of shoulder pain and neck pain
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Frozen Shoulder and How to Survive It About this book I’ve tried very hard to make this book easy to read. The style is best described as “comfortable” and “relaxed” – chatty almost, and I’ve done that quite deliberately. There is nothing complicated about how your shoulder works and I want you to be able to understand it for yourself. I’ve avoided using medical language or big words and I’ll try to use pictures whenever I can. My aim is to have you understand your own shoulder in as much depth as I do. I want you to “become your own shoulder expert” because only then will you really take charge of your life again. Only then will you start the process of breaking free from your pain.
A word of caution This book can never be a replacement for your own doctor or for a qualified therapist. You should not rely on this book as your only source of medical m edical advice. If you haven’t already done so then you should see an experienced physician or therapist so that a proper diagnosis can be made for your condition – and investigations carried out if need n eed be. In general, frozen shoulder is not difficult to diagnose dia gnose but there are other conditions which can mimic it. It’s important to ensure that other o ther conditions have been ruled out – either by having the appropriate examinations or tests, or by your doctor’s clinical examination. Please don’t be foolish. Seek help and guidance and make sure you have your condition properly diagnosed before starting or seeking treatment.
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Frozen Shoulder and How to Survive It
Part One How your shoulder works – understanding shoulder anatomy Let’s begin the process of getting to grips with the workings of your shoulder. The shoulder is the most mobile joint in the body and is often affected by painful problems which limit movement. What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion to the arm. Some terms to remember before we begin delving deeper. • •
•
•
•
humerus. The arm bone is called the humerus. The shoulder blade is called the scapula but different parts of the scapula have different names. fossa – The bit of the scapula where the arm bone joins is called the glenoid fossa – joint, and so the joint where the humerus joins it is called the gleno-humeral joint, it’s this joint that most people mean when they talk about the shoulder joint The bone bump we can feel at the top of our shoulder is part of the shoulder blade and is called the acromion The collar bone comes across the front of our upper chest to form a joint with the acromion. The anatomy name for the collar bone is the clavicle – so the joint formed between it and the shoulder blade is called the acromioclavicular joint. This is sometimes shortened just to “AC joint.”
This picture shows the main parts of the shoulder
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Frozen Shoulder and How to Survive It The movements of the shoulder mostly take place at the gleno-humeral joint – the ball in the socket in other words. This is true for movements of the arm around and away from the body – but in most of these movements there is also a bit of movement of the shoulder blade or scapula, which has the ability to rotate around on the chest wall. Most but not all of the t he shoulder movements involve involve a degree of rotation. Even movements where the arm seems to be simply moving forward or back have a rotation element to them. The group of muscles that surround the shoulder and do most of these movements are called the Rotator Cuff muscles. The rotator cuff muscles act partly to move the shoulder – and partly to stabilise and support it when it’s moving. Problems with the rotator cuff muscles can cause several painful conditions such as tendonitis, impingement and rotator cuff tears.
You can see the bones of the shoulder in the picture here:
The shoulder joint is called a Ball and Socket Joint – and if you look at the picture you’ll be able to see why. The ball shaped upper part of the humerus sits snugly in the socket on the scapula – an arrangement that allows movement freely in all sorts of directions. But hang on a minute – you don’t need to be an engineer or a surgeon to realise that simply sitting the ball end of the humerus into the socket on the shoulder blade is not going to be a very stable arrangement. The socket needs to be deeper to give the humerus head a snug fit and nature achieves this by putting a donut shaped ring of
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Frozen Shoulder and How to Survive It
This donut shaped ring is called the glenoid labrum – and you can see it illustrated in the picture below. Injuries to the glenoid labrum are not unusual in sports people and in athletes and are often referred to as a “labral tear” or “SLAP lesion”.
The glenoid labrum
The shoulder joint capsule OK – I guess by now that you are starting to understand how the bits of the shoulder fit together. Let’s add in another important bit of anatomy for you to understand, in fact, probably the most important bit when it comes to considering frozen shoulder. The capsule is simply the name given to a tough bag of gristle that completely surrounds the glenohumeral joint and helps to support the joint as it moves. It also contains the synovial fluid that the joint needs for friction free f ree movement. Synovial fluid is like oil for joints – it lubricates and allows movement without friction or roughness.
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Frozen Shoulder and How to Survive It
The picture above shows you the joint capsule and – although this particular illustration doesn’t show it very clearly – there is a small fold or pouch of the capsule that hangs downwards into the armpit or axilla. It’s this pouch or fold that forms the key to understanding much of what goes on inside a frozen f rozen shoulder. This little fold of shoulder capsule is important in normal life because it’s what allows us the flexibility to move our shoulder in all the directions that it travels – particularly when we try to move the arm upwards. If we lose the use of this pouch then our shoulder flexibility is dramatically reduced.... reduced.... but, more of this later.
A bit about Synovial Fluid and Synovial Joints Nearly all the moving joints of the body are what is known as “Synovial joints” – they need oily fluid to bathe the joint surfaces and keep them moving freely – just like the joints in a machine really. The shoulder is a synovial joint and it needs the bag of gristle or capsule that surrounds it to stop the synovial fluid from escaping away from the joint. Synovial fluid is produced inside our shoulder by a layer of slippy, spongy cells that cover the inside of the capsule in the same way that the inside of your mouth is covered by a slippy spongy layer of cheek cells. The oil producing cells inside a joint are called the synovium.
The shoulder joint muscles For the last bit of our shoulder anatomy jigsaw we need to look at the muscles around the shoulder. Muscles create and control movements and the engineers and scientists who construct artificial joints have found that the shoulder is one of the t he “busiest” joints in
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Frozen Shoulder and How to Survive It
We are looking side on at a shoulder with the back of the shoulder towards the right margin of the page and the front of the shoulder facing towards the left margin. You can see the large beef steak muscle of subscapularis in front of the glenohumeral joint, the supraspinatus muscle above and two t wo additional muscles – called infraspinatus and teres minor behind. Together these four muscles make up what’s called the rotator cuff group of muscles. They are not the only muscles that move or control the shoulder, but they are certainly the most important. The rotator cuff functions to give the shoulder stability as it moves – often of ten very rapidly – through the tasks of day to day life. Another thing to notice in this picture is the arch like shape that the acromion and clavicle make above the shoulder joint. It’s this arch, or problems with it, it , that lead to impingement problems at the shoulder.
The Rotator Cuff The Rotator cuff group of muscles m uscles consists of the following four muscles: •
Supraspinatus above the joint and mostly responsible for
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Frozen Shoulder and How to Survive It Shoulder joint stability Fundamentally, the shoulder is an unstable joint. In normal life it pulls off quite a remarkable balancing act between extreme mobility and extreme potential instability on a daily basis. It’s a joint that needs to cope with huge forces on a regular basis if it is to fulfil the tasks t asks we ask of it. To remain stable the shoulder relies on a fascinating interplay between many of the structures you have just been reading about. If any of the following things go wrong with the shoulder then the end result is often a sense of the joint being unstable – with associated pain on day to day function. These fairly common injuries can trigger shoulder instability: • • •
A tear in the glenoid labrum A tear in a rotator cuff muscle A tear in the capsule – particularly at the t he front of the shoulder
More gross and more immediate instability will follow after a complete dislocation of the shoulder. This usually occurs only in situations of trauma. The conditions above can usually be picked up fairly f airly readily by using modern imaging techniques such as MRI scan or scans with additional contrast medium injected into the joint – usually called an MRI Arthrogram.
The shoulder bursa – a spongy bag of fluid Nature is the most amazing thing. Engineers spend lifetimes trying to design moving systems and then stand back in amazement and dismay when they realise that nature has beaten them to it by many thousands of years. Think again about the muscles of the rotator cuff. What did I say they did thousands
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Frozen Shoulder and How to Survive It
There are several bursae around the shoulder. The largest one - and the commonest one to cause a problem is called the sub deltoid bursa or the subacromial bursa (two names for the same bursa). Sub means beneath and the bursa lies beneath the deltoid muscle and beneath the Acromion bone which is part of the shoulder blade. The muscles of the rotator cuff around the shoulder are called subscapularis, supraspinatus, infraspinatus and teres minor are small muscles that stabilise the shoulder. Collectively, these four muscles are known as the rotator cuff. Within the shoulder, bones and ligaments form an arch over the top of these rotator cuff muscles. In between the rotator cuff muscles and the arch is the Subacromial space, which is filled by the Subacromial bursa, a sac of fluid that t hat is designed to prevent any friction at the shoulder.
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Frozen Shoulder and How to Survive It
Part Two – Where Does Shoulder Pain Come From? It’s just not possible to discuss pain at the shoulder or frozen f rozen shoulder without looking a bit more widely at the ways that your shoulder can become painful. We also need to consider how other joints near the shoulder can also cause pain in the same region.
Referred Pain Please don’t forget that not every pain felt in the shoulder region is actually caused by a problem in the shoulder joint. The pain you feel can sometimes be coming from somewhere else in the body – but the pain centre in the brain gets muddled and blames the pain on the shoulder muscles. Pain. This phenomenon is common and is called Referred Pain. Common sources for pain being referred to the shoulder include the neck, the heart or lungs and the organs in the upper abdomen like the liver, gall bladder or diaphragm muscle. The picture below shows you how internal body organs can cause a pattern of referred pain to areas of skin or areas near joints. For example – you can see that the liver and gall bladder shaded orange will typically cause pain in the upper right abdomen but also around the right side of the
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Frozen Shoulder and How to Survive It
When the problem really is starting in the shoulder joint or in the shoulder muscles then the pain is felt over the front of the shoulder or in the upper part of the arm. This area of the upper and outer arm is called the “deltoid area” – named after the large deltoid muscle that lies beneath it. This kind of shoulder pain can appear to spread down the arm towards the elbow and this is another example of referred pain. However, if your pain spreads further down into the hand itself or if you have tingling or pins and needles in your hand or fingers then your pain is probably arising from a problem in the neck.
Neck and shoulder pain For the purposes of educating you about frozen shoulder and the pain it causes, we need to keep two things in mind about the neck and how it can trigger shoulder area pain. Firstly – the main large nerves that exit the t he neck to run down the arm pass very close to the shoulder joint. Secondly – if the joints, or muscles or gristle of the neck become inflamed then they can send a pain message to the brain in such a way that the brain becomes
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Frozen Shoulder and How to Survive It
The numbers and letters in the picture above relate to the cervical (or neck) vertebrae. So C3 is the third vertebra of the neck. C6 is the sixth and so on. C3-4 means the segment of the neck consisting of the third vertebra, the fourth vertebra and all the muscle and gristle that surrounds them. The picture shows you that if something is inflamed in the C5 -6 area of the neck then the patient feels pain over the red area in the picture – over the shoulder in other words. Likewise, if the structures around C6-7 are inflamed then the pain spreads over the shoulder and down the inner part of the shoulder blade.
All of this means that it’s very important to think about possible problems in the neck when assessing someone who has pain in or around their shoulder.
Shoulder tip pain Pain at the very tip of the shoulder may come from the small joint at the end of the collarbone – called the acromio-clavicular joint or the AC Joint. The bony bump at the tip of your shoulder blade is called the acromion and the collar bone is called the clavicle so the joint where they meet is called the acromio-clavicular joint.
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Frozen Shoulder and How to Survive It
Pain Patterns at the Shoulder One of the most confusing things about the pain from a frozen shoulder is that the pain can often seem as if it isn’t coming from the shoulder at all. Frozen shoulder pain can often spread all the way down the arm as far as the t he hand. In my experience people are often confused by this but the explanation lies in what’s called referred pain. You’ve heard a bit about referred pain in general above but now we’ll look at the specifics of referred pain from f rom the shoulder.
In simple terms referred pain is what happens when the brain gets a signal of pain from a part of our body but interprets the signal as coming from somewhere else. Many of us will have had this experience with toothache. A pain from a tooth can be blamed by the brain on the ear or the jaw or the cheek or even up around the eye. This system of pain referral applies throughout your body and it often comes into play with shoulder pain conditions – sending the pain down towards the hand from the brains view point.
Referred pain patterns are usually based on the nerve pathways that arise when we are still an embryo in the womb. All of the parts of the shoulder, the joint, the bursa, the ligaments and the muscles are part of the same embryonic segment. The fifth
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Frozen Shoulder and How to Survive It
It often seems to spread down towards the wrist but stops short of the hand. Normally the distance down the arm that the pain spreads is governed by how inflamed your shoulder is – the angrier the inflammation in your shoulder, the further the pain will spread.
Part Three – Frozen Shoulder What is a frozen shoulder? Pain is the major issue for most people. Frozen shoulder is also known as adhesive capsulitis and the two terms are used almost interchangeably. The problem can either start quite quickly after an injury – or it can arise very slowly as if out of nowhere and with no obvious trigger involved. Doctors first recognised the condition about two hundred years ago when it was first described as being a different condition from arthritis of the shoulder. Let’s repeat and rephrase that for emphasis. Frozen shoulder is not the same as arthritis and it does not develop into arthritis. Frozen shoulder can cause severe pain. Even when sufferers are frustrated by the stiffness in the joint, pain relief is the real priority for most of them. Almost without exception people with frozen shoulder say that they could put up with the stiffness –
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Frozen Shoulder and How to Survive It
since. Adhesive because of the stickiness he found f ound and Capsulitis because the capsule was inflamed.
Some Extra Information – All about “- Itis” The suffix “ –itis” –itis” crops up a lot in medicine and it simply means “inflamed.” So tonsillitis is inflamed tonsils, dermatitis is inflamed skin, sinusitis is inflamed sinuses and so on. The capsule – as you now know – is the bag of gristle that surrounds the joint capsule so capsulitis is simply another way of saying an inflamed joint capsule.
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Frozen Shoulder and How to Survive It
The end result of the above process is that the capsule shrinks and tightens around the joint and stays that way for many months before it gradually begins to recover again.
Still a mystery Although in recent years we are getting closer to understanding what goes on inside a shoulder with adhesive capsulitis there are still a lot of questions to be answered. New research is beginning to hint that there might be a connection to genetics or to the way our individual immune systems work. Other scientists have found changes in nerve function in the capsule of frozen shoulders – perhaps again hinting at some of the underlying triggers. The connection between frozen shoulder and diabetes is also provoking a lot of interest. No doubt a lot of this will become clearer in years to
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Frozen Shoulder and How to Survive It
The Story So Far Let’s pause and review what you now know about frozen shoulder
•
The shoulder is a ball and socket joint
•
Its formal name is the glenohumeral joint
•
The joint is surrounded by a tough bag of gristle called the capsule
•
The rotator cuff muscles control movements around the shoulder and keep the joint stable and strong
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Frozen Shoulder and How to Survive It
Please remember however that most cases of frozen shoulder have none of these things associated to them – they just simply seem to arise from nowhere and are called “idiopathic cases” or “idiopathic frozen shoulder” – idiopathic is just a medical word meaning “cause not known.”
Idiopathic Frozen Shoulder This group of patients are by far the most common group that I see with frozen shoulder pain. I think it’s also true that many people who remember an injury at the start of their t heir frozen shoulder episode only do so with the benefit of hindsight. Some research doctors believe that the problem was already brewing up in these people – just sitting quietly waiting for a minor tweak to come along and unmask the symptoms
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Frozen Shoulder and How to Survive It We know some details about shoulder pain in general but not about frozen shoulder in particular. Out in the real world about a quarter of us experience shoulder pain of some kind every year. Only about one in every twenty of those who have pain will bother to see their family doctor about it – and from that small number only about one in every ten will be seen by a specialist. Now ... research is only really done by specialists, so can you see where the problem is? Any research being done is being conducted on a very small select group of shoulder pain patients – a group whose problems are likely to be more severe and quite different in nature to those of the rest of the population.
Primary and Secondary Frozen Shoulder Some authors divide frozen shoulder cases into Primary and Secondary cases. I must say that I don’t always find this separation helpful in day to day practice when
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Frozen Shoulder and How to Survive It
Diabetes and Frozen Shoulder Diabetic patients are much more likely to suffer from frozen f rozen shoulder than the rest of those in the population – by about seven to one for those who have insulin dependent diabetes.
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Frozen Shoulder and How to Survive It
We don’t yet really know why diabetic frozen shoulder problems arise but it seems to relate in part to how well each individual controls their blood sugar levels. Textbooks tell you that all shoulder complaints are more common in diabetes but in my experience diabetic frozen shoulder is the most troublesome and most frequent. f requent. Diabetics not only get frozen shoulder more often than others but it lasts longer and is more painful for them when they do.
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Frozen Shoulder and How to Survive It
Frozen Shoulder Diagnosis Is my shoulder frozen? How to diagnose adhesive capsulitis and frozen shoulder It’s not hard for an experienced doctor to diagnose frozen shoulder – the story that the patient tells and the findings on examination are very typical and tend to be very
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Frozen Shoulder and How to Survive It
Frozen shoulder pain is felt in the C5 dermatome area – and as it becomes more severe it seems to spread all the way down the arm towards the wrist. You can usually tell when recovery is starting because the pain seems to spread back up the arm towards the shoulder – almost as if it was retracing its steps.
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Frozen Shoulder and How to Survive It
Stage One Frozen Shoulder – The Freezing up Stage The pain and stiffness of a frozen shoulder often just start in a gradual manner. To begin with the pain can be no more than a vague niggle that you might hardly even be aware of. It gradually worsens but there is often oft en very little stiffness to start with and you might not even be aware of anything significantly wrong.
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Frozen Shoulder and How to Survive It muscles and the bursa. With practice it’s usually easy for an experienced doctor to
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Frozen Shoulder and How to Survive It
Who can’t have a shoulder injection? The following are the main reasons not to have a steroid injection into or around your shoulder •
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Shoulder injections (and any other injections too) should be avoided by anyone taking warfarin treatment or other anticoagulant treatment to thin the blood. Hemophiliacs cannot have shoulder injections because of the risk of bleeding into the joint after the injection has been performed. Your doctor will not consider doing an injection if there is a possibility of infection in or around the joint. There is a risk that steroid drugs can worsen an infection if they are injected near the infected area. You can’t have a joint injection if you have had a shoulder joint replacement operation
Doctors will not do shoulder injections if they suspect you could have a fracture inside the joint, or severe degeneration in the joint or osteoporosis in the bones around the joint.
What does the research say about steroid injections? All doctors who use steroid injections for shoulder pain can give many, many examples of patients who have gained benefit from this kind of treatment.
But despite this, the research studies that have been done are still up for debate on whether the injections are really helpful or not. This is probably because the research is of poor quality because the few good trials that have been done are indeed clear that the injections produce big benefits. The American Academy of Orthopedic Surgeons has decided that steroid injections can be recommended for the treatment of rotator cuff disorders and AC joint pain. Likewise, the American College of Rheumatology says that injections should be offered to patients suffering from arthritis in the shoulder, from frozen shoulder and
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Frozen Shoulder and How to Survive It
Summary of Steroid Injections for Shoulder Pain
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Steroid injections are a safe and often effective way of treating pain around the shoulder You should try to find a doctor with experience in the techniques if you are thinking about having a steroid injection done.
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Lots of different conditions can be helped or cured by a steroid injection
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The evidence is good that injections work well for most but not all patients
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Some patients should not have steroid injections because of a risk of bleeding or a risk of interfering with other ot her medications. Some people get pain after the injection but this is usually very short lived
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Frozen Shoulder and How to Survive It
Hands On Treatment For Frozen Shoulder All of the treatments mentioned above have been directed at easing the pain from frozen shoulder in the knowledge that the stiffness will eventually take care of itself. But the hands on type of treatments available from a massage therapist, an osteopath or a chiropractor are intended to both ease pain and to increase the range of movement – all in the hope of gaining a faster recovery. The kinds of treatments you might receive from a manual therapist of the type t ype described above include local heat, laser therapy or electrotherapy. All of these are designed to warm up the joint capsule and make it more elastic before a session of stretching, manipulation or mobilisations of the joint. Osteopaths and chiropractors also try to focus on adjusting the joints alignment.
There’s no doubt that hands on treatments for frozen shoulder can be beneficial but the downside is that they are sometimes painful and also that a large number of treatment sessions can be required before benefits are obtained. Each treatment session is also often quite prolonged. I’ve also found that most patients in the stage two or really stuck phase of frozen shoulder simply can’t tolerate this kind of treatment because it is too painful during the stretching or mobilising phase. In simple terms, the therapist needs your joint to be a little bit stretchy stret chy – and the joint capsule to have a little bit of give in it – before he or she can make any headway in improving your symptoms. This elasticity or “give” in the capsule is present in the first stage and the third stage of frozen shoulder – but not in the completely stuck frozen stage two.
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Frozen Shoulder and How to Survive It
Massage Treatments for Neck and Shoulder Pains Neck And Shoulder Massage The neck and the back and the shoulder are the most common areas of the body that are prone to stiffness and accumulated tension. Continuous build up of stress and tension in the neck and shoulder region lead to stiff necks, aching shoulders and headaches .Desk jobs, long working hours and incorrect sitting position may all add to problems in the neck and shoulder region. A neck and shoulder massage is primarily done to relieve the tension and stress around the neck and shoulder area. The importance of the neck and shoulder region lies in the fact that the neck is a flexible structure that connects the brain to the rest of the body. Tension in this important part of the body invariably causes overall pain and poor posture. A neck and shoulder massage can eliminate stress and relieve the neck and shoulder of any signs of discomfort. You can give yourself a neck and shoulder massage, ask friends or loved ones to do it or you can seek help from a professional.
Neck and shoulder massage can be given either in a seated or lying down position. If traditional massage is too expensive or time consuming then you can check out the latest electronic neck and shoulder massagers that may provide some beneficial results.
Neck and Shoulder Massage Techniques Here’s a selection of neck and shoulder massage methods that can be done yourself or suggestions for simple techniques you can do for others:
Self Massage Techniques - For the Shoulder:
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Frozen Shoulder and How to Survive It • Apply either the Jojoba or Massage Oil directly on the skin to ensure smooth, frictionless movements.
Techniques to give others a quick massage for the Shoulder: • Ask the person to lie sideways, with a pillow for head support and the top leg bending forward for steadiness • Gently massage the arm and the side of the neck • Hold the shoulder with both hands and gently move the shoulder up and down, then forward and backward. • As the shoulder and arm relaxes it gets heavier, now start making m aking circular movements with the fingertips under the shoulder blade to release tension. • Replace the arm and repeat with the other arm.
Self Massage For the Neck – technique one
• Hold the back of the neck with one hand and squeeze firmly to ease muscle tension. • Shrug the shoulders and bring them up close to your ears. • Hold the shoulders in this position and count up to 5 and release. • Relax the shoulders down and feel the tension drain away. • Repeat this exercise two more times.
Self Massage For the Neck – technique two
• Clasp the hands together and place them on the back of the neck. • Squeeze hands together and press gently. • Breathe deeply as you enjoy the stretch.
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Frozen Shoulder and How to Survive It Self Massage For the Neck – technique three • Using one hand, move the fingers in a circular motion on the neck on one side of the spine. • Apply deep pressure one feels accumulated tension in this area. • Repeat on the other side using the other hand. • Breathe deeply and slowly to maximize the benefits of the neck and shoulder massage.
Benefits of Neck and Shoulder Massage Quite apart from making you feel better and reducing pain or tension there t here are several well known and well proven benefits from neck and shoulder massage. In no particular order they are: • Massage brings renewed mobility in the neck and shoulder region. • It alleviates stiff neck and/or shoulder muscles and promotes flexibility. • The action of massage stimulates blood circulation and creates an overall feeling of well being. • Neck and shoulder massage relieves pain and stress and it relaxes and soothes the mind and body.
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Frozen Shoulder and How to Survive It
Home Exercises for Frozen Shoulder If I’m honest I feel a little uneasy about including a section on how to do home exercises in a book like this. The best way by far is to work closely on a one to one basis with a physical therapist who can show you the techniques, do any fine tuning needed and then monitor your progress, making adjustments as you go.
But that’s not the real world is it? it ? I know that for a whole host of reasons, many of you would find it difficult to work directly with a therapist. So here’s my brief introduction to exercises for a frozen shoulder. You can read more about it on my website at www.jointenterprise.co.uk – or there are a number of good online programs with DVD instruction that t hat you can tap into and gain benefit from.
So – here are a list of some simple self stretches and exercises that will help in some cases of frozen shoulder. shoulder. Caution however however – remember this. These These work best in the third or thawing out stage of frozen f rozen shoulder. They will not have any benefit and may simply be too painful in the second or frozen stage – and in the t he early months of stage one, trying to do these might only serve to aggravate things and make your pain worse.
Try these exercises in order – and then experiment a bit to see what works for f or you. If it makes your pain worse then don’t do it and seek some professional input.
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Frozen Shoulder and How to Survive It
Hold the stretch for about 10 seconds and repeat 3 or 4 times.
Exercise 3. Sit on a chair in front f ront of a desk or table. Place your painful arm on the t he table with the elbow supported. Position your chair at a distance as shown in the image below. Let the weight of your upper body sag forwards and downwards and feel the stretch through your shoulder as you do so. Hold for a slow count of five f ive (ten if you can manage) and then repeat x 6
Exercise Four Find a door frame or use the corner of a room. Place both hands on the edge of the frame and gently lean forward. Hold the stretch for ten seconds and repeat 3-4 times.
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Frozen Shoulder and How to Survive It
New Techniques for Frozen Shoulder Treatment When I wrote the first edition edit ion of this frozen shoulder ebook in 2004 there really wasn’t any need for a section like this. In truth, t ruth, nothing much had changed in respect of frozen shoulder in the preceding ten years or more. All that has now changed however, and in the recent few years we’ve seen big changes in newer and more innovative approaches to frozen shoulder treatment. The results seem promising and many people seem to be benefiting greatly – but finding enough doctors skilled in their use is delaying the roll to a wider group of the population. First let’s look at distending the shoulder capsule with warmed salty water solution. A process called Hydrodistension or Hydrodilatation.
Hydrodilatation of the Shoulder Capsule This treatment is sometimes also called hydrodilation or hydrodistension of the joint. I’ve also seen it described in some research as “Distension Arthrograpy.” The concept was originally pioneered in the 1980’s but fell from use at the time. It has made a comeback in popularity in recent years and several good quality research studies support its use. In simple terms a doctor uses local anaesthetic and inserts a wide bore needle into the joint capsule by using an x-ray to guide the position and thus to make sure that the needle is inside the joint.
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Frozen Shoulder and How to Survive It The different doctors (usually radiologists or x-ray doctors) who do the technique have different exercise and stretch routines for the weeks following the procedure but they are all intended to keep the joint mobile and to try to stop it gumming itself up again.
A scientific trial of hydrodilatation has that it works well – at least in the short term. When it was compared to placebo it showed better outcomes at the six weeks stage. Further research showed that a 6 week course of physiotherapy following the hydrodilatation has shown to be effective to decrease pain, improve range of motion, and seems to shorten the duration of frozen shoulder. I’ve met with many patients who have tried this treatment approach and all have found it easy to tolerate and helpful.
Manipulation of the shoulder under a general anaesthetic OK – well this one certainly is not for the faint hearted – although the outcomes are actually quite good for the few patients who eventually undergo it. As you know by now, the main problem in a tight and painful frozen shoulder is that the joint capsule gristle has shrunk and become sticky with inflammation. This stickiness causes the gristle to stick to the bones inside the joint – resulting in a loss of the normal range of movement and a loss of function. The concept behind manipulation under anaesthetic (often shortened to MUA) is actually a very simple one: put the patient to sleep so that t hat they don’t feel it, and then forcefully (very forcefully sometimes) move the shoulder around until you break up all the sticky adhesions and return the joint to its normal range of movement. If you ever see a video of a procedure like this the t he degree of apparent violence involved is actually quite disturbing to watch – although the end result for the patient is often good.
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Frozen Shoulder and How to Survive It
Keyhole surgery for frozen shoulder – arthroscopic release procedures With the rise in the skills of surgeons who do keyhole surgery or arthroscopy we have seen new approaches to operations to treat frozen shoulder. The surgeon goes into the shoulder using the endoscope or arthroscope through very small incisions. This is why it’s often called “keyhole surgery.” By using the camera to see what the inside of the joint looks like – and with the help of other instruments – the surgeon can divide or burn away any tight sticky adhesions and in doing so can free up the tightness in the capsule. The results of Surgical or Arthroscopic Capsular Release operations are often good – although some patients see their symptoms come back a few months later. The release operation needs to be backed up by an intensive program of exercises and stretches to make sure that the operation benefits are maintained.
Recovery time is variable depending on how severe your shoulder pain and stiffness
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Frozen Shoulder and How to Survive It
Other conditions that cause shoulder pain There are a number of other common shoulder pain conditions which can sometimes mimic the presentation of a frozen shoulder problem. It’s not usually difficult diff icult to sort them out for an experienced doctor or therapist but the pages that follow will summarise them for your information.
What is shoulder bursitis? What is a bursa? The bursa at the shoulder is a friction reducing device. The body places these small fluid-filled sacs any place where muscle lies close to bone or where muscles lie over one another. The bursa is responsible for producing a gliding surface to reduce friction between tissues of the body. The plural of bursa is bursae and in total there are well over one hundred bursae in the body although most of them are small and do not ever cause any symptoms.
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Frozen Shoulder and How to Survive It The muscles of the rotator cuff around the shoulder are called subscapularis, supraspinatus, infraspinatus and teres minor are small muscles that stabilise the shoulder. Collectively, these four muscles are known as the rotator cuff. Within the shoulder, bones and ligaments form an arch over the top of these rotator cuff muscles. In between the rotator cuff muscles and the arch is the Subacromial space, which is filled by the Subacromial bursa, a sac of fluid that t hat is designed to prevent any friction at the shoulder. The major bursae in the body are all to be found near to the tendons and muscles around the largest joints like the shoulders, elbows, hips, and knees.
What is “itis” In medicine the suffix “itis” means inflammation. Tonsillitis is inflammation in the tonsils. Appendicitis is inflammation in the appendix, dermatitis inflammation of the skin and so on. Bursitis therefore is inflammation of a bursa. When injury or inflammation of a bursa around the shoulder joint occurs, shoulder bursitis is present.
How does inflammation start in a bursa ? Any of the body’s bursae can become inflamed as a result of injury, infection (rare in
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Frozen Shoulder and How to Survive It
Bursitis can exist on its own or in association with inflammation of the shoulder tendons. Shoulder tendon inflammation is called tendonitis
I often describe an inflamed bursa as being like a deep blister under the muscles. If you had a blister on your heel then the constant rubbing of your shoe would keep it grumbling and painful. An inflamed bursa is no different – the constant rubbing effect of the overlying muscle moving is enough to keep the symptoms going for many weeks or months. Because of its position, the Subacromial bursa can become irritated and inflamed during repeated overhead shoulder movements as a result of being squashed or 'impinged' between the muscles and the bone, Sometimes, because the bursa lies so close to the rotator cuff, it can become irritated and inflamed when the rotator cuff is injured. Shoulder bursitis is sometimes related to rotator cuff tendon problems and disease or degeneration in the rotator cuff muscles can be a trigger tri gger for the bursitis to start. Likewise, anyone with bursitis who fails to improve with normal treatment may need further investigation to look at their rotator cuff – this might need an ultrasound or an MRI scan.
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Frozen Shoulder and How to Survive It the arm by the side but increasing pain as the arm is elevated to about ninety degrees – only for the pain to ease again thereafter as the arm goes higher.
If a doctor or therapist resists the t he patients attempt to lift their arm outwards from the side then the pain will become more pronounced. Your doctor may perform a manoeuvre called the Impingement Test to determine whether there is inflammation in the bursa or the tendons of the shoulder.
How is shoulder bursitis diagnosed?
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Frozen Shoulder and How to Survive It
In simple terms the treatment options for shoulder bursitis include: •
painkiller or anti-inflammation medication
•
physical therapy from a physiotherapist, chiropractor or osteopath
•
injection of a steroid drug
•
strapping or taping of the shoulder
•
acupuncture
•
arthroscopic surgery
These choices need to be tailored to you as an individual and will depend in part on the underlying cause in your own case.
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Frozen Shoulder and How to Survive It In rare cases if the antibiotics don’t work quickly then an operation might be needed to remove the infected bursa.
Preventing shoulder bursitis or preventing recurrence of the problem The key to preventing shoulder bursitis is to figure out if there is narrowing of the subacromial space or not. If the space is too narrow then the bursa (or the “deep blister” I mentioned above) is going to be constantly rubbed against the nearby bone as the shoulder moves – causing it to become inflamed over and over again. In many cases the size of the subacromial space can be optimised by practicing shoulder stability exercises with a physiotherapist. These exercises concentrate on controlling the movement of the shoulder blade, by ensuring that muscle contract in the correct sequence during shoulder movements, to ensure that the ball of the upper arm remains stable in the shoulder socket during
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Frozen Shoulder and How to Survive It
Rotator Cuff Injury Rotator cuff tendonitis is inflammation of the tendons of the rotator cuff. The rotator cuff muscles have been described in detail in the early chapters of this book – they are the muscles that help move and stabilise the shoulder joint. Rotator cuff injury can be caused by overuse, by repeated impingement of the tendons against the bone above and also by shoulder joint instability where the muscles and tendons of the rotator cuff are called upon to stabilize the shoulder joint over and above the call of duty due to loose or weak ligaments.
People who regularly participate in certain sports are more at risk of rotator rot ator cuff injuries than others. Swimmers, pitchers (or others who engage in sports involving a
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Frozen Shoulder and How to Survive It you can do is give your body every possible chance to utilize utili ze its amazing capacity to heal itself. You can encourage self healing in a number of ways including, applying ice or heat to reduce pain and speed healing, avoiding certain movements and activities until the injury is healed, exercising to strengthen the muscles and gentle stretching to keep the muscles flexible and the joint mobile.
At the first sign of rotator cuff tendonitis, especially where the culprit is likely to be overuse or repetitive strain, the most important thing to do is stop doing the activity you suspect to be causing the problem. Now this may seem like common sense but often athletes will try to “train through” pain or “train around” an injury by just going lighter on the weights or trying to train t rain body-parts around the affected area.
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Frozen Shoulder and How to Survive It
Everybody is different so it is important to listen to what your own body is telling you and adjust your actions accordingly. As a general rule: if a movement m ovement hurts (especially if it causes sharp pain) - don’t do it. Also remember that, as with all overuse injuries, by the time you start feeling the pain the problem has already existed for some time so the sooner you take remedial action to manage and treat the injury the better.
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Frozen Shoulder and How to Survive It
Closing words So – here we are at the end of this book. You now know pretty much as much as I do about frozen shoulder and that makes
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Frozen Shoulder and How to Survive It
Frozen Shoulder Your main take home messages
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Frozen Shoulder and How to Survive It
Websites for further reading about frozen shoulder and other aspects of shoulder pain
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Frozen Shoulder and How to Survive It