Trigger Points and Adhesive Capsulitis (Frozen Shoulder)

Trigger Points and Adhesive Capsulitis “Frozen Shoulder”

Adhesive capsulitis causes that nagging and aching pain deep in the shoulder. You can’t move it, you can’t lay on it… the more you struggle with it the more painful and inflamed it becomes. Everyone offers the advice to “just move it.” But It Hurts!

I wish I had the panacea for this never too infrequent malady. It would be welcoming news especially for women over 50 years of age since they represent approximately 70% of frozen shoulder clients; not to be out done however, males with frozen shoulder stand a larger risk for an extended recovery period with greater disability.

Research suggests that the cause of the disorder is enigmatic. Idiopathic or “primary” adhesive capsulitis occurs spontaneously without a specific precipitating event and results from a chronic inflammatory response with extensive tissue repair, which may actually be an abnormal response from the immune system. Secondary adhesive capsulitis occurs after a shoulder injury or surgery, or may be associated with other conditions such as diabetes, rotator cuff injury, stroke or cardiovascular disease, which may prolong recovery and limit outcomes.

The presentation of adhesive capsulitis is defined in three distinct phases. The first stage is called the “freezing” or painful stage which lasts between 3 to 9 months. Active and passive range of motion becomes more restricted. Clients feel a false sense of hopefulness that the pain will subside through self treatment and thus delay medical consultation. The second stage is called the stiffness or frozen stage which lasts between 4 to 12 months. Pain does not necessarily worsen however there comes a point when pain does not occur at the end range. The third stage is called the Recovery or Thawing Stage which lasts between 12 to 42 months and is defined as a gradual return of shoulder mobility with or without disability.

Pain and the client’s resistance to pain can cause a limitation or selective immobilization of the affected shoulder. Prolonged immobilization affects the speed and quality of recovery due to detrimental physiological changes in the structure of the soft tissues associated with tissue repair as mentioned earlier. Mobilization of the affected joint within an increasing pain free range of motion is the advised strategy of treatment.

According to Travell and Simons, myofascial trigger points of the subscapularis muscle are rarely considered when making the diagnosis of frozen shoulder, however the same literature and clinical experience suggest that trigger points may be a major factor in producing the symptoms. Adding to the insult is the involvement of many of the other shoulder-girdle muscles, each with their own pain patterns and restrictions of movement.

Clients must be advised to keep ALL shoulder movements within the pain free range and force of motion. Education is a must. Clients must understand the chronic nature of the condition… that it may be several years before symptoms are resolved. This may alleviate feelings of urgency for functional return and the frustration that goes with it.

Sources:
1. MYOFASCIAL PAIN AND DYSFUNCTION THE TRIGGER POINT MANUAL
David G. Simons, M.D., Janet G. Travell, M.D., Lois S. Simons, P.T.
2. ADHESIVE CAPSULITIS: USE THE EVIDENCE TO INTEGRATE YOUR INTERVENTIONS
Phil Page PhD, PT, ATC, FACSM, CSCS1,2, Andre Labbe PT, MOMT3
3. DIAGNOSIS AND MANAGEMENT OF ADHESIVE CAPSULITIS
Robert C. Manske, Daniel Prohaska