Bone on Bone – Treating Frozen Shoulders and Shoulder Impingement Syndrome

 

by Erik Dalton, Ph.D.

The term frozen shoulder has been around since the early 1930s, but recent research by Drs. Andrew and Robert Neviaser found that a stiff, painful glenohumeral joint doesn’t necessarily mean the shoulder is “frozen.”1 According to these authors, frozen shoulder and adhesive capsulitis are not the same thing. Since many manual and movement therapists (myself included) lump these two conditions together, let’s take a closer look at what some believe makes them different.

On the famed Cleveland Clinic orthopedic hospital website they say: “Frozen shoulder is a general term used to describe any shoulder that is stiff. Adhesive capsulitis is a very specific term for a condition that involves the spontaneous, gradual onset of shoulder stiffness and pain caused by tightening of the joint capsule.” (Fig. 1)

The problem seems to be that some consider frozen shoulder a vague term similar to saying something like “you have a limp when you walk.” Obviously, that description doesn't tell us much about the client’s problem, the cause of the problem, or how to treat it. Following this line of reasoning, a frozen shoulder may be described as rotator cuff spasm, impingement syndrome with protective guarding, or, micro ligamentous adhesions around the joint capsule or bursae (Fig. 2). So, this diagnosis would describe the actual ‘physical condition’ behind the shoulder pain, i.e., loss of normal glenohumeral movement, but not address other disorders that may be causing the client’s complaint. 

Some believe chronic inflammation of the joint capsule to be the main distinction between adhesive capsulitis and frozen shoulder.2 As the inflammatory process causes the capsule to thicken and tighten, an extra fold of capsular tissue gets stuck to itself. Adding to the glenohumeral “gluing” problem is the loss of normal synovial fluid and hyaluronic acid hydration in the joint (see “Motion is Lotion” article here: http://mail.aol.com/38079-111/aol-6/en-us/suite.aspx

The combination of fibrosed capsular folds, chronic inflammation, and reduced hydration, prevents the humeral head from sliding and gliding smoothly through its full range of motion. As the capsule looses its ability to stretch, the shoulder gets stuck and becomes stiff and painful, just like a frozen shoulder. In chronic cases, inflammation is gone, but many believe it was the first step that got the adhesive capsulitis process started. In any case, treatment is still directed at the joint capsule. When a joint is not free to move, the muscles that move it cannot be free to move, and compensations occur. Therefore, the goal for manual and movement therapists is to establish optimal joint play and joint centration by allowing forces to be transferred in the most efficient way possible. Balance of muscle mobilizers and stabilizers will result in optimal joint centration.

When osteoarthritis attacks the body’s shoulders, hips, knees or intervertebral joints, lubricating fluids breakdown, the articular cartilage wears away, and, in time, a bone-on-bone adhesion may develop. (See Mark’s bone-on-bone osteoarthritis case study video). This is typically what makes arthritis so painful and debilitating. Although Myoskeletal mobilizations don’t actually add synovial fluid or hyaluronic acid to joints, they certainly disperse the existing fluids allowing for increased joint play and joint centration, and that can be very therapeutic.

• 1. http://my.clevelandclinic.org/orthopaedics-rheumatology/diseases-conditions/frozen-shoulder-vs-adhesive-capsulitis.aspx.
• 2. Andrew S. Neviaser, MD, and Robert J. Neviaser, MD. Adhesive Capsulitis of the Shoulder, Journal of the American Academy of Orthopedic Surgeons, September 2011. Vol. 19. No. 9. Pp. 536-543.