Mr. S, a 67 year old man, came in last year complaining of left shoulder pain that was causing him to have difficulty turning his neck, as well as lifting up his shoulder to do his daily activities. The main difficulty that he was having was actually putting his arm through his shirt sleeve as he ‘had done for the past 50 years of his life’!
When we did an assessment, it was quite clear that it was a frozen shoulder:
- Limited active movement of his left shoulder and pain pulling down the biceps, especially trying to lift it beyond 90 degrees
- A classic ‘hitching’ or hiking of his left shoulder whenever he attempted lifting up the arm, due to poor movement of the shoulder joint and shoulder blade
- Inability to put his left hand behind his back, with a sharp and pulling pain when attempting it
- Passive movement of his shoulder was limited when testing for rotation (A classic sign of frozen shoulder is loss of range in rotation, either actively and passively)
In addition to that, he was also a long-term smoker and diabetic, which are risk factors for developing frozen shoulder conditions (1). His pain and stiffness had also been increasing the past 3 months which is in line with the first phase of frozen shoulder (2).
Treatment 1 – Manual Therapy
As mentioned in our previous blog post talking about the different treatment options of frozen shoulder, manual therapy is one of the recommendations according to UKFROST guidelines for frozen shoulder conditions.
These manual therapy techniques are called shoulder mobilisations. It involves the therapist placing their hands on the frozen shoulder and gripping it in a stable way, then applying pressure in different directions to encourage movement of the stiff joint.
An example of how our shoulder joint and shoulder blade has to move to bring our arm upwards
Because our shoulder works in different planes of movements (going forward and backwards to flexion and extension, across your chest and away from it, and even turning in and out like putting your hand behind your back), your therapist needs to be aware of the ranges that you are limited it as well as the correct direction of pressure to apply for treatment to be effective.
For Mr. S, his main shoulder joint restrictions were internal rotation (turning inwards), abduction to beyond 90 degrees, and poor shoulder blade movements. We focused on inferior glides, and a method called MWM (mobilisation with movement, either Maitland or Kaltenborn) to help with rotation, as well as passive mobilisation of his scapula.
Treatment 2 – Rehabilitative Exercises
Frozen shoulder doesn’t just affect the passive structures of the joint. Your surrounding tendons and muscles also tend to tighten up as stiffness increases and range reduces. Because therapy is limited to 1-2 hours a week in the clinic, it really matters what you do at home!
We started Mr. S on a regime of shoulder exercises including stretches and strengthening within his tolerable range. Pushing to the end limits of the movement can be painful, so we guided him through each exercise so that he was familiar with what ‘good’ pain felt like versus ‘bad’ pain, where he should stop and rest.
An example of two movements that we had him practise regularly – the Sleeper Stretch (a passive stretch) and resisted external rotation (to strengthen the rotator cuff)
Treatment 3 – Shockwave (ESWT)
Shockwave, also called extracorporeal shockwave therapy, was used as an adjunct to treatment. A meta-analyses that compared the effectiveness of ESWT on patients with frozen shoulder in 20 studies showed that shockwave was beneficial by alleviating pain and improving function when used as an adjunct treatment.
Some benefits of ESWT:
- Upregulation of nitric oxide, which is implicated in improved blood flow and physical movement function
- Cavitation effect between tissues promote the separation of adhesions or reduced fibrosis, and stimulates tissue regeneration
- Creates changes in nociceptors (pain receptors) which helps to inhibit pain and reduce pain signal transmission
- Stimulates growth of new blood vessels – important for conditions like frozen shoulder, as inflammation in the shoulder capsule is what contributes to stiffness and pain. New blood vessels means better circulation to increase cell oxygen carrying, produce anti-inflammatory effects, and move away inflammatory products.
Watch how we do shoulder ESWT
Mr. S went through once a week of shockwave throughout the shoulder joint as well in addition to the first two treatments, and saw good effect. His recovery was complete within 6 months, and now has no issues with putting his arm through his shirt sleeve as he has always done!
Frozen shoulder can be distressing and painful, but it doesn’t have to last forever. If you are in the Kuala Lumpur region and need help with recovery for your frozen shoulder, contact us to get started!