May 16, 2013


Frozen shoulder treatment, supraspinatus impingement, and poor practitioners

Yesterday I had a wonderful opportunity to work with a woman who came to see me because she had a “frozen shoulder“, often re-described as ‘adhesive capsulitis’. One of the many interesting things about this condition is how many potential causes it has. A quick review of the literature on the subject suggests at least half a dozen different causes. The problem that I have with the term frozen shoulder is it appears to be a “basket” category (where you put something when you do not understand its cause). In my 30 years as a practitioner and having treated many examples of this problem (many of which appeared to have different causes) I am wary of this term; it is a descriptor at best (that is, it describes the problem, but does not suggest a causal perspective).

So after talking to each other for a while, I asked her to show me how each of her shoulders moved. The right side moved normally through all planes of movement but not the left. When she tried to abduct her left arm the initial movement was trapezius and levator scapulae elevating the scapula; only when this movement was over 50% complete did the arm abduct from the body. My first thought was perhaps there was some impingement of supraspinatus or its innervating nerve.

I also noticed the position of the left shoulder girdle on the rib case; it suggested tight pec. minor and possibly tight external rotators (infraspinatus and teres minor). I gave her a very gentle external rotator cuff stretch and then followed this up with a different supraspinatus stretch.

I shower her how to use latissimus dorsiserratus anterior, and pec. major to maximally  depress the L shoulder girdle. I asked her to gently press her straight right arm out to the side directly away from the body, while holding the shoulder girdle in the depressed position. Lo and behold, supraspinatus fired and produced the desired effect (pressure on my hand in the part of the ROM that supraspinatus classically is supposed to control (the first 10 degrees of abduction, roughly).

Immediately, I asked her to raise her arm gently and slowly; this subsequent attempt did not involve trapezius at all until the arm was almost horizontal. Visual inspection showed that supraspinatus was doing the job it was supposed to do (that is, abduction the first 10°). End of the first 10° was achieved with absolutely no shoulder elevation meaning that supraspinatus was doing what it was supposed to do.

After a little rest I asked her to move the right and left through the full range of movement and she was able to move both easily and without pain. Further questioning revealed that the frozen shoulder had presented itself immediately following an extremely traumatic emotional event.

The key to understanding this effect of innervation and activation is the reciprocal inhibition reflex. In this example, watching her initial attempt at abducting the arm revealed that trapezius was doing the job of elevating the shoulder girdle to the point where deltoid’s mechanical advantage could be used. This meant two things: one, that supraspinatus was for some reason inactive and two, as a solution, the body had employed a fallback pattern of using trapezius to raise the shoulder girdle.

A partial solution lay in asking her to activate all of the muscles which depressed the shoulder girdle which meant necessarily that trapezius was both stretched gently and momentarily inhibited. Then, maintaining these conditions, I asked her to press her arm directly to the outside (abduction). The brain immediately realised that only supraspinatus could do this task and it switched it on immediately. Speaking to her today, the shoulder area is a bit tender, but everything is working properly.

Stretching of the external rotator cuff muscles was only done to ease this process in the sense of getting her shoulder blade to sit flatter on the rib cage and more vertically. It also had the secondary effect of increasing her awareness of the position of this part of the body. Another benefit is that a more vertical positioning of the scapula means there is less likelihood of the acromiom abrading the supraspinatus tendon, another potential cause of this problem.

The longer term follow-up will involve stretching her rib cage backwards over a passive support, stretching pec. minor (so that the shoulder girdle sits in a more mechanically sound position) and some strengthening work. An RMT colleague will also do some abdominal release fascia work; there is a slight ‘head forward’ posture there, too.

The last exercise I gave her to do was a floor lying scalene stretch, shown HERE. Her scalenes were very tight to palpate and my concern here was that perhaps some impingement of the supraspinatus nerve may have been happening via the TOCS phenomenon. Regardless of the diagnostic/causal story, once again restoration of a normal movement pattern appeared to have solved the problem, and the total treatment time was about 15 minutes.

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