Frozen Shoulder/Calcific Tendonitis

[riversinger]

Would love to hear treatment suggestions others may have for this condition. I have an artist friend online who has this & I would like to provide her with both practitioner references and ideas for possible treatment, near Dana Point, California. I've already sent her some info, but would appreciate more input from others. So far as I know she has only done 1 cortisone injection, at this point, & I'm hoping to help her find better alternatives.

[pueppi]

I do my frozen shoulder work, mainly supine. I catch one hand under the shoulder blade and one in the pec region. Then, while sitting on a rolling stool, I work my way upward with the arm (abduction with slight traction)... a little at a time... pull, work, move, rest, pull, provide stability, work and then move the arm again. Each case is different, but it is effective. I also work the bilateral neck & traps, bilateral chest/pecs, the affected deltoid and into the scapular region. Most of the abduction is performed with a lateral pulling of the scapular region, so it is all one movement to produce the small amount af abduction with each movement. Each session will give the shoulder more range of motion, in the cases I have worked with.

I am much less aggressive than the physical therapist down the road, but end up with the same results in roughly a 1/4 more time. I prefer the less aggressive method, as a frozen shoulder just hurts a lot when worked too aggressively.

I work via a lot of intuition and feedback from the client. I also suggest finger wall crawls for homework - similar to the quote below --- except that I suggest the client finger crawl higher than shoulder level, when they are able, and only have them walk the fingers, without placing the palm on the wall.

Finger Walk
•Stand straight facing a wall at a distance from which you can comfortably touch the wall with the palm of your hand.
•Now, place the palm on the wall and crawl the fingers along the wall so that you raise the arm to the shoulder level. Do not use your shoulder muscles for this exercise.

PM me if you need more details.

[riversinger]

Thank you for the reply Pueppi - it's much appreciated & I'll pass on the info to her.

Would love to hear back from anyone else who would like to chime in!

[athletica]

Pueppi - I'm curious to know how successful you are in treating frozen shoulder?

In my experience I have had a bit of luck at restoring complete ROM in instances in which there was a previous surgery or immoblization. But in cases which appear to be systemic I have rarely had immediate success.

I hate wasting patients time & money so I always give them the worst case scenario before suggesting treatments that might be ineffective.

I work the patient in a seated position primarily using ART. I mainly focus on increasing abduction. If I can improve abduction I can get a lil more picky in subsequent appointment looking to clear out internal, external, ect.

[JasonE]

Pueppi - I'm curious to know how successful you are in treating frozen shoulder?

In my experience I have had a bit of luck at restoring complete ROM in instances in which there was a previous surgery or immoblization. But in cases which appear to be systemic I have rarely had immediate success.

I hate wasting patients time & money so I always give them the worst case scenario before suggesting treatments that might be ineffective.

I work the patient in a seated position primarily using ART. I mainly focus on increasing abduction. If I can improve abduction I can get a lil more picky in subsequent appointment looking to clear out internal, external, ect.

I often find that abduction improves more rapidly if I have restored some/all of their medial and lateral rotation. To do so, I need to get the scapulae back and down into a more relaxed position. To do that, I may need to get the pecs and biceps and lats to lengthen... perhaps the abdominals, too.

While I may use a seated position for Active Isolated Stretching, I do more of my shoulder work with the client on the table, either supine or sidelying. When the client is lying down, they are usually able to move more freely than when upright, partly because they don't have to fight against gravity in the same way, and partly because they have less body positioning and control to distract their CNS from improving its use of the tissues around the joint.

In most cases, I am able to achieve significant positive change within 2-4 visits, but caution my clients that the full recovery process can take a year or more.

[pueppi]

Pueppi - I'm curious to know how successful you are in treating frozen shoulder?

I apologize for not responding sooner, as I didn't notice your question, until checking the most recently replied to threads today.

I will get positive results within the first visit, however, that does not mean I will achieve full range of motion. I'd say I can give them about 5-10% better ROM in the first visit. Within 2-4 visits I will have clients mention things like... "I was able to tuck my shirt in again".

However, it can take up to a year, as Jason mentioned.

I often find that abduction improves more rapidly if I have restored some/all of their medial and lateral rotation. To do so, I need to get the scapulae back and down into a more relaxed position. To do that, I may need to get the pecs and biceps and lats to lengthen... perhaps the abdominals, too.

I agree with JasonE, but never thought of the abdominals. I will keep that in mind for future reference.

When I am working with traction and abduction, I am also adding in things like traction and circular movement as indicated, and also provide range of motion where I will put the client through external rotation similar to this movement (below visual) while they are supine. Sometimes I will even take that shoulder complex off the table while in the movement in order to get a little more motion going. It all depends on the client and where we are at within their sessions.



I've only had a true 5 or so people I have worked with through the whole process. So, it's not the best cross section to make a determination with.

My most recent was a client who had rotator cuff surgery with a frozen shoulder to follow. We got into about the 15th visit weekly (note: there are a few appts she had to spread out over two weeks instead of one, but only about 3 of them) when we started making some real progress (75% ROM). It went from clinging onto about 50% (which it after about 6 visits)--- to opening to 75% in about 3 weeks time. At week 18 we went to every other week. At vist 21 we went to every 3 weeks, and I have not seen her in a month, at this point. The original incident occurred in May... it's now November. (I forgot to add that some of her work was also performed prone, as she had some relatively stubborn knots under the scaps as well.)

I think it is safe to say that within about 10 weeks, I can have the client in a relatively good place where they are functioning much better than previously. Unfortunately many clients do not want to hear it may take that much time... and will go off looking for someone to "fix" them faster - taking a lot of pain and moderate results when they drop out of that plan too. Many timesthey could have avoided the sever pain of those sessions had they just stuck with my suggestion ( I hear it from clients occasionally, after the fact and 6 months down the road, but didn't want to come back to see me for whatever reason... sometimes embarrassment, which is crazy... I don't care what choice they make... it's their body... I only wish they would allow me to help them without being put through so much pain - if that makes sense). However, when I do get someone who sticks with it, I find that I can reasonably help the process unless there is some funky complication.

I also visualize an "accordian" of the glenoid labrum and work with that thought in mind. From my experience, I get better results when I work with this pattern in mind.



(11/15/11: edited to add in prone work note)

[riversinger]

Thank you all for the replies. There was a good deal of very helpful advice given & realistic treatment recovery times as well - which I will happily pass along!

[athletica]

Thanks, Pueppi & JasonE -

Do you go after the joint capsule as part of your internal and external rotator treatment?

How do you measure improvement from session to session? Patients ability to do certain tasks or measurement?

[pueppi]

Do you go after the joint capsule as part of your internal and external rotator treatment?

How do you measure improvement from session to session? Patients ability to do certain tasks or measurement?

I am working the entire shoulder, not just the muscles surrounding it. A good portion of the work I do is geared toward slow movement and traction. So when I work there is a definite movement of that entire shoulder complex.

I measure improvement by increased function and range of motion.

[JasonE]

Do you go after the joint capsule as part of your internal and external rotator treatment?

How do you measure improvement from session to session? Patients ability to do certain tasks or measurement?

I am working the entire shoulder, not just the muscles surrounding it. A good portion of the work I do is geared toward slow movement and traction. So when I work there is a definite movement of that entire shoulder complex.

I measure improvement by increased function and range of motion.

Like Pueppi, I work the entire shoulder complex, and frequently spend some time working on the other shoulder as well. Movement can be accomplished with traction, joint mobilization, active stretching, etc. I also measure improvement by improved function and ROM, and also by reduced discomfort - even when ROM and function remain the same.

When you ask "Do you go after the joint capsule...", I think of the joint capsule work promoted by James Waslaski. His "myofascial plunging" method is gentle and can be very helpful, and I do use it frequently. However, I have learned that some people are so tender that I must do other work to relax the surrounding tissues and gain the trust of the client's CNS before it will permit me to do that work.

Aaron Mattes teaches an alternate method as part of his Active Isolated Stretching that I have found helpful, and it seems to work about as well as the Waslaski method. Which one works better seems to depend on the client... Waslaski's method requires the client to be passive and yielding, while Mattes' method requires the client to be an active participant. If the client's tissues are doing too much "guarding", both of those will be less effective until I can get the CNS to relax and/or become actively engaged in effecting a functional change.

The best strategy is whichever one that client's body best tolerates, so sometimes I will try both methods in separate sessions, and other times I may try combining them. I tend to employ a combination of methods within a session, preferably those that cause the least amount of discomfort as we seek to increase ROM and tolerance for movement.

I always give these clients "homework" so they become actively engaged in their recovery. That homework is always gentle and includes simple movements that can be easily learned and which may stimulate some type of positive change. The nature of their homework will change as appropriate throughout the recovery process.