A Comprehensive Manual Therapy

Treatment Guide for

FROZEN
SHOULDER

by: Dr. Joe Muscolino ©2017 Learnmuscles.com

© Learnmuscles.com Page 1
 A Comprehensive Manual Therapy
Treatment Guide for Frozen Shoulder
Frozen Shoulder – Introduction

FROZEN SHOULDER INVOLVES THE ROTATOR CUFF MUSCULATURE. PERMISSION: JOSEPH E.

MUSCOLINO. THE MUSCLE AND BONE PALPATION MANUAL: THE SKELETAL MUSCLES OF THE HUMAN
BODY, 4ED. (2016) ELSEVIER.

Frozen shoulder is a condition in which the glenohumeral (GH) joint

loses mobility, in other words becomes frozen, in one or more ranges of
motion. There are two stages to frozen shoulder. The first stage
involves contraction of the muscles of the GH joint and is
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called neurogenic frozen shoulder. The second stage involves the
formation of fibrous adhesions and is called adhesive capsulitis. Frozen
shoulder rarely occurs by itself; rather it usually occurs in response to
another condition of the GH joint.

Causes of frozen shoulder

The GH joint is often described as a muscular joint. This does not mean
that it has more musculature than other joints. It means that
proportionally, the GH joint depends more on its musculature for
stability because its bony shape and ligament/joint capsule complex are
designed for mobility, not stability. The glenoid fossa is a shallow socket
and its ligament/joint capsule complex is lax, therefore when stability is
needed, contraction of the GH musculature is needed to stabilize the
joint.

The most common cause of frozen shoulder is the body’s desire to

tighten the musculature, usually the rotator cuff musculature
(supraspinatus, infraspinatus, teres minor, subscapularis) around the
GH joint after an injury such as a rotator cuff tear or trauma. It is
common for musculature around an injured joint to tighten in an
attempt to splint/stabilize the joint so that it cannot be moved; the
premise being that if the joint cannot be moved/used, it will be rested
and have a chance to heal. However, in the case of the GH joint,
splinting stabilization of its musculature becomes excessive and often
ends up immobilizing/freezing the joint. Often, this response is largely
or entirely unnecessary because it occurs after the initial injury is
mostly or fully healed.

The first “neurogenic” stage is a response to the injury: muscles are

directed to tighten; at this point in time there is no structural
component to the frozen shoulder, it is merely a functional response by
the nervous system to create muscular hypertonicity. However, the
longer the neurogenic stage is allowed to exist, the more fascial fibrous
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collagen adhesions (“fuzz” in the parlance of Gil Hedley) have a chance
to form, beginning the structural “adhesive capsulitis” stage. The
progression of frozen shoulder condition is often a vicious cycle: the
less the joint is moved, the more adhesions form, further decreasing
the joint’s ability to move, allowing for more adhesions to form, etc.

Often, the neurogenic stage is effectively jump started by the client. For
example, if post injury or post surgery the arm is placed in a sling for an
extended period of time, usually a week or more, the neural pattern of
immobilization is initiated, and will more likely become patterned into
the nervous system than if the client had not immobilized the arm. It
also allows for adhesions to begin forming. Therefore immobilization of
the shoulder, or simply not moving it through its ranges of motion,
increases the chances that frozen shoulder will occur. For this reason,
whenever possible, it is important to avoid immobilization of the GH
joint.

Signs and Symptoms of frozen shoulder

SCAPULAR ELEVATION AS A COMPENSATION FOR FROZEN SHOULDER DECREASED GLENOHUMERAL

JOINT ABDUCTION. PERMISSION: JOSEPH E. MUSCOLINO.

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The most common sign of frozen shoulder is decreased range of motion
(ROM). Of the six cardinal ranges of glenohumeral (GH) motion, the
most commonly affected motions are abduction, flexion, and lateral
rotation. It is common for the client to compensate for a decreased
range of GH motion by increasing shoulder girdle or trunk motion. For
example, if arm abduction is decreased, the client might increase
scapular elevation or even laterally flex the trunk to the opposite side in
an attempt to raise the hand higher.

Regarding symptoms, the loss of motion of frozen shoulder often has

no accompanying pain. The client simply cannot move their arm fully in
one or more ranges of motion. Or, if pain is present, it only occurs if the
client tries to move the arm beyond the point of limitation (tissue
tension mechanical barrier). In fact, the lack of pain is often a
predisposing factor in the progression of frozen shoulder. Because their
shoulder does not hurt, the client often does not feel the need to
address the condition until it has progressed to the point that it
functionally limits their ability to perform necessary activities of daily
life. By this point it time, the condition has often existed for many
months and the neural pattern of muscle hypertonicity is more
patterned and the degree of fibrous fascial adhesions is great. And if
pain with attempted movement is present, it further discourages the
client from attempting to remedy the condition.

Assessment/ Diagnosis of frozen shoulder

Assessing/diagnosing frozen shoulder is straightforward. Simply
evaluate the client’s GH motion in all six cardinal ranges of motion
(flexion, extension, abduction, adduction, lateral rotation, and medial
rotation). If a ROM is decreased and there is no evidence of another
pathologic condition that is causing or contributing to the hypomobility,
the assessment of frozen shoulder can be made. Standard ideal ranges
of motion for the arm are shown in Table 1. Keep in mind that these are

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average ideal ranges of motion for a healthy young adult. As a person
ages, it is expected that there will be a decrease in these ranges. Table
2 shows the average ranges of motion for the entire shoulder
joint complex. These motions include the coupling of motions of the
arm at the GH joint with the shoulder girdle at the scapulocostal (ScC;
also know as scapulothoracic), sternoclavicular (SC), and
acromioclavicular (AC) joints; this coupling is referred to as
scapulohumeral rhythm. Therefore, when you are evaluating the range
of motion of the patient’s/client’s arm, you are assessing the complex
of GH and shoulder girdle motions. When performing these ranges of
motion, it is best to assess passive motion, not active, because active
motion could be decreased because of muscle weakness. This would
most likely occur in an elderly client/patient.

Table 1 Average Ranges of Motion in degrees of the Glenohumeral

Joint

Flexion 100 Extension 40

Abduction 120 Adduction 0

Lateral rotation 50 Medial rotation 90

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Table 1 Average Ranges of Motion in degrees of the entire Shoulder
Joint Complex

Flexion 180 Extension 150

Abduction 180 Adduction 0

Lateral rotation 90 Medial rotation 90

Although frozen shoulder is easily assessed with physical examination,

medically, it is common for a physician to order some type of
radiographic examination such as X-ray or MRI. This is often done
primarily to rule out other conditions. The functional aspect of frozen
shoulder is difficult to diagnose on MRI, but can be inferred from the
thickening of the capsule and capsular ligaments.

Differential diagnosis/assessment of frozen shoulder

As stated above, frozen shoulder often follows or accompanies the
presence of another condition. If another condition was present and
has not resolved, this must be considered when determining treatment.
Therefore a thorough diagnosis/assessment that assesses for frozen
shoulder as well as the presence of other possible conditions is
extremely important. Further, because frozen shoulder is somewhat an
diagnosis/assessment of exclusion, meaning that if no other condition is
found, it can be more confidently asserted that the patient’s/client’s
decreased motion must be due to frozen shoulder, then differentially
diagnosing/assessing to rule out other conditions assists in the
assessment to rule in frozen shoulder.

Other conditions that cause decreased shoulder range of motion and

therefore might lead the therapist to incorrectly assess the
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client/patient with frozen shoulder are degenerative joint disease (DJD,
also known as osteoarthritis or OA) of the GH joint, GH hypomobility
joint dysfunction (subluxation/misalignment) due to decreased nonaxial
joint play, and dysfunction/hypomobility of the joints of the shoulder
girdle (scapulocostal, sternoclavicular, and acromioclavicular joints).

Manual therapy treatment of frozen shoulder

Frozen shoulder often responds extremely well to manual
therapy treatment. Depending on how long it has been present, it
might require many months of treatment, but it often fully or nearly
fully resolves with regular care; the emphasis is on consistent and
regular care. Most every neuromuscular condition responds well to the
mainstays of clinical orthopedic treatment; they are moist heat (or ice),
soft tissue manipulation (massage), stretching, and joint mobilization.
With frozen shoulder, moist heat and soft tissue manipulation are
important, but should be performed with the aim of increasing the
efficiency of the stretching and joint mobilization, which are the two
essential treatment modalities.

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 JOINT MOBILIZATION OF THE GLENOHUMERAL JOINT INTO INFERIOR GLIDE PERMISSION: JOSEPH E.
MUSCOLINO.
Begin by spending approximately 10 minutes warming up the entire
upper quadrant from the mid thoracic region down to the forearm;
gradually increase the pressure from light to medium intensity. Now
return to the shoulder region with a more intense exploration of the
muscles of the GH joint, working with medium to deep pressure into
any global tightness, myofascial trigger points, and fascial adhesions
found; depending on what is found, spend anywhere from
approximately 10-20 minutes. Place moist heat on the anterior and/or
posterior sides of the GH joint for five minutes and then begin
stretching the region.

Stretching should be focused on each ROM that is restricted. The pace

of stretching should be slow and deliberate, but firm and assertive.
Each repetition should gently but firmly challenge the client’s shoulder
to increase its ROM, but it is important to not be heavy handed or
impatient and force the stretch beyond a degree or two of motion with
each repetition. Always let the patient’s/client’s response to your care

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be your guide. To focus the stretch to the capsule and capsular
ligaments of the GH joint, it is extremely important to stabilize
the scapula to prevent it from moving when stretching the arm at the
GH joint.

To the degree that the neurogenic phase is present, utilization of a

neural inhibition technique such as contract relax (CR, also known as
PIR or PNF), agonist contract (AC), or CRAC (contract relax agonist
contract) is beneficial and should be used. Theoretically, if the client’s
condition is purely adhesive capsulitis, then muscle tone is the not issue
and spending the extra time for a neural inhibition stretch would not be
efficient. However, even in later stages of frozen shoulder, there is
usually some component of neurogenic contraction present, so always
try neural inhibition stretching to see if it is more effective than simple
mechanical stretching. Given how stubborn frozen shoulder can be, it is
important to perform two sets for each ROM that is being treated.

Now perform Grade IV joint mobilization (arthrofascial stretching; AFS)

of the GH joint. Mobilize the head of the humerus in all directions
(anterior, posterior, inferior, and superior glides, as well as spin
mobilization in both directions and axial distraction/traction). If
abduction is restricted, focus on inferior glide; if lateral rotation is
restricted, focus on anterior glide. If flexion is restricted, focus on
inferior glide and spin mobilization. Whenever possible, it is always
helpful to add an element of traction to all joint mobilization directional
glides.

If time remains, repeat the stretching protocol to the restricted GH

joint ranges of motion. If further time remains, work the
patient’s/client’s other upper extremity to prevent possible problems
there due to the increased compensatory use/reliance on it because of
the frozen shoulder. Note: Icing only needs to be done if the depth of

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work is very strong and the icing is necessary to either minimize
swelling and/or client/patient pain/discomfort.

SUMMARY OF MANUAL TREATMENT PROTOCOL FOR FROZEN SHOULDER

1. WARM UP THE UPPER QUADRANT WITH LIGHT TO MEDIUM PRESSURE

2. DEEP WORK TO THE MUSCLES OF THE GH JOINT
3. MOIST HEAT
4. STRETCHING
5. GRADE IV JOINT MOBILIZATION (ARTHROFASCIAL STRETCHING)
6. REPEAT STRETCHING
7. ICE IF APPROPRIATE
8. WORK OTHER UPPER EXTREMITY IF TIME ALLOWS

Precautions/contraindications when treating frozen shoulder

There are no specific precautions or contraindications when working on
a client/patient with frozen shoulder other than being careful to not be
overly forceful when stretching the tissues. Stretching should be firm
and assertive, but not aggressive.

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Self-care for the client/patient with frozen shoulder

SELF-CARE STRETCH FOR LIMITED ABDUCTION RANGE OF MOTION IN A

CLIENT WITH FROZEN SHOULDER. PERMISSION: JOSEPH E. MUSCOLINO.
Self-care for the client/patient with frozen shoulder is very important.
Recommend stretching at home or work as many times as possible,
with a minimum of three times per day. If possible, the stretching
should be done after the shoulder is warmed up with some form of
heat, preferably moist heat. An extremely effective and easy self-care
stretch is performed against the wall. Have the client/patient stand
away from the wall and place their fingers on the wall. They should
then gradually “walk” their fingers up the wall or up and out to the side
on the wall, going as high as they can. Over time, as they progress,
instruct them to gradually stand closer to the wall. It can be helpful for
them to mark in pencil how high they have reached with the date that
mark was reached, with a goal of gradually increasing the excursion of
their movement each day or so. If a wall is not available, a simple
stretch for limited glenohumeral joint abduction is to use the other

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hand to lift the arm into abduction (perhaps with a little flexion given
that the arm will be in front of the body).

Medical approach to frozen shoulder

The medical approach to frozen shoulder is essentially manual therapy;
most physicians refer patients with frozen shoulder to a physical
therapist for care. For more marked cases, manipulation under
anesthesia may be done. For severe cases that have not responded to
manual therapy, surgery can be done.

Manual therapy case study for frozen shoulder

Kalinda is a 27-year-old volunteer librarian who recently helped
reorganize the library one weekend. This entailed doing a lot of lifting
and moving of books. Afterward, her right shoulder was sore and
painful. The pain lasted about a week. When the pain passed, her
shoulder felt stiff and it was hard reaching for things. But she could still
do most of her activities of daily life without too much difficulty, so she
ignored it. Also, she was glad that the pain was gone and she figured
that her shoulder would gradually get better and loosen up. However,
as the weeks passed, she noticed that not only was the stiffness not
improving; it was slowly getting worse. By the time two months had
passed, she was having difficultly moving her shoulder in most
directions and she finally recognized that that she had a problem. She
went to her medical doctor who took X-rays and diagnosed her with
frozen shoulder and recommended that she go to physical therapy.
Because she once had a bad experience with physical therapy, she
decided instead to see a clinical orthopedic manual therapist who had
helped her with another problem years ago.

The therapist performed active and passive range of motion (ROM)

examination of her right and left shoulders. The motion on the left side
was full and healthy. With both active and passive ROM on the right

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side, she was able to abduct only to 20 degrees, flex to 30 degrees, and
laterally rotate to 30 degrees. She had no pain at rest and no pain
during her active ROM; she simply was unable to move farther. The
only time she felt pain was if the therapist tried to passively move her
into abduction, flexion, or lateral rotation beyond her limits. No
swelling was noted. All musculature around her right shoulder joint was
mildly to moderately tight, but the most tightness and trigger points
were found in her subscapularis, posterior deltoid, and teres major.
Joint mobilization assessment (motion palpation) revealed a decrease
in inferior and anterior glide motions. Orthopedic assessment tests for
thoracic outlet syndrome and a space-occupying lesion in the neck
were negative.

Given the assessment of frozen shoulder, the therapist recommended

to begin with three one-hour massages per week for three weeks. Each
session consisted of the treatment regimen for frozen shoulder that
was recommended in an earlier blog in this series. Namely, light to
medium work to warm up the right shoulder girdle and upper
extremity, followed by deeper work to the myofascial trigger points and
tight musculature found. Moist heat was applied for five minutes and
then stretching was done, including contract relax (CR) and agonist
contract (AC) stretching techniques. The therapist then performed joint
mobilization (arthrofascial stretching) to the client’s right shoulder,
followed by another three sets of stretching to the shoulder. At the end
of this care, because some very deep work was done to the posterior
shoulder region, the therapist elected to ice the client for five minutes
before the end of the session. Kalinda was also given self-care
instructions. She was told to apply moist heat to her shoulder followed
by the wall stretch and asked to do this at least three times per day.
She was also instructed to try to use her right arm in everyday life as
much as possible.

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At the end of three weeks, lateral rotation had returned fully, her
abduction was 100 degrees, and her flexion was 120 degrees. The
therapist recommended continuing at a pace of twice per week. After
four more weeks of care, Kalinda was only missing 10-15 degrees of
abduction and flexion. The therapist recommended continuing care at
twice per week until a full 180 degrees of motion had been returned to
both RsOM, however, Kalinda felt that money was getting tight and
that she had achieved sufficient improvement, so she decided to wean
down her care. She and the therapist discussed the treatment plan and
it was decided to gradually wean the care until she was coming in once
per month. Kalinda agreed to continue care at once per month on a
regular basis to prevent the condition from regressing. Kalinda also
continued with her self-care exercises.

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