How to fix a frozen shoulder. TWD Osteopathy and Clinical Pilates, Footscray.
As an osteopath I see lots of people for shoulder pain, frozen shoulder, rotator cuff injury and more. Sometimes people have had multiple failed treatments including cortisone injection, hydrodilatation, physiotherapy, other osteopaths and chiropractors, massage etc.
There are many mistakes made when treating shoulder pain:
1. Misdiagnosis (a.): the most common misdiagnosis is to assume that it is a supraspinatus or rotator cuff tear/strain. In the vast majority of cases, a localised shoulder pain is due to the deltoid muscle, plain and simple – “you have a torn rotator cuff” just sounds more impressive and old tears will often show up on an ultrasound. Lots of time, effort and money are spend in a futile attempt to fix an old tear that has little or nothing to do with the patients pain.
2. Misdiagnosis (b.): the next common misdiagnosis is to call it a frozen shoulder when it is plainly not. A true frozen shoulder will mean that the arm is almost immobile – in my opinion, any movement greater than 30 degrees really isn’t a frozen shoulder. Frozen shoulder requires quite a lot of work in and around the joint capsule to free the joint up. It can sometimes respond quite well to hydrodilatation, but may not. “Frozen shoulder” for that matter is really not much of a diagnosis, because it does not specify exactly what is causing the immobility – only skilled physical examination will reveal what precise tissues are causing restriction.
3. Ineffective treatment (a.): in almost all cases, treatment that is properly directed will result in fairly quick results – basically it should start to feel better and move better. This improvement typically happens within the first few treatment sessions, and improvement should occur with each successive treatment. Be wary of practitioners who say “this will take 18-24 months to resolve” – that is the length of time it will take to resolve if you do absolutely nothing at all. Treatment should always provide benefit by way of pain relief and improved range of motion.
4. Ineffective treatment (b.): the other problem is in failing to address related joints and muscles. In almost every case of shoulder pain, there is an underlying dysfunction of the upper ribs, clavicle and scapula. The shoulder joint (gleno-humeral) relies on good movement and muscle control in the whole shoulder girdle. In my opinion, shoulder injuries (apart from traumatic) are always preceded by problems in these related areas.
So what do I do with shoulders? In every case, the aim is always to improve function – not just treat sore muscles/tendons etc. A shoulder that functions (moves) properly will heal quickly without complication.
The first step is to identify what hurts, and there are a few muscles that typically cause most of the pain. I always ask the patient to show me exactly where they think it hurts. When they point to a specific spot, then there is always a dysfunctional muscle exactly where they indicate. When they gesture to a broad, diffuse area then there is an element of referred pain. I am constantly amazed at the number of patients I see who have had other treatment, and no one has bothered to ask them exactly where it hurts.
Physical examination is the next step. After the patient indicates where it hurts, I already have a good idea what the problem is. Examination of the shoulder and shoulder girdle should confirm what I already suspect. The examination will then direct what gets treated first. I get the patient to move their arm – the best tests are abduction (lifting the arm to the side) flexion (lifting the arm straight up in front) and internal rotation (reaching behind to place the hand up between the shoulder blades) to see what it can and can’t do.
Successful treatment will improve how far the arm can move, and with with what degree of discomfort. There should be reduced pain – the most common feedback will be: “I can sleep without pain”, “I can do up, or undo a bra without pain”, ” I can lift or carry without pain” etc.
The techniques I use are always directed by the physical examination, and are aimed at improving function. They include muscle and connective tissue release, with the arm usually held at or close to its restrictive barrier – there is no way of really accurately describing these techniques, only the purpose of the therapy. Manipulation of joints in the upper thoracic spine, ribs, clavicle (collar bone), and scapula (shoulder blade) is often used – these can be the chiro/osteo “cracking” techniques, or the old-school osteopathic articulation (usually much more effective than simple cracking). I also sometimes use some dry-needling for specific muscle trigger points (tender spots in the muscle) with good effect.
This is just a general guide. I will discuss specific cases of frozen shoulder and other shoulder problems in future posts. The take home message is – whatever treatment you get, you should expect to have reduced pain and improved movement. Don’t wait too long before you seek a second (or third) opinion. If it’s not at least starting to get better with your chosen treatment within a few weeks, then try something else.
Dr. Jim Pattinson (osteopath) is Clinical Director at TWD Osteopathy and Clinical Pilates, Footscray.