Adhesive Capsulitis

Adhesive capsulitis, also known as frozen shoulder, is a musculoskeletal condition in which the connective tissues surrounding the glenohumeral joint become inflamed and thickened, causing pain and a significantly reduced range of motion. The etiology of this disease is unclear, with some experts suggesting it begins with an adhesion between the anterior aspect of the glenohumeral capsule to the head of the humerus, and others suggesting it begins outside of the capsule in tissues such as ligaments, the rotator cuff and biceps brachii muscles and the subacromial bursae.  Adhesive capsulitis is classified as either primary or secondary, primary meaning no event or factor leading up to the disorder can be identified and the etiology is idiopathic, and secondary meaning it is preceded by trauma or the subsequent splinting and immobilization that follows an injury.

Adhesive capsulitis is most common in women between the ages of 50 and 70. Once it occurs in one shoulder, there is about a 50% chance it will occur in the other at some point, though a simultaneous bilateral occurrence is rare. Diabetes mellitus is the most common comorbid condition, others include hyperthyroidism, hypothyroidism, Parkinson’s disease, cardiac disease, pulmonary disease, stroke and some surgeries such as cardiac catheterization, neurosurgery and radical neck dissection. A person with one or more of these conditions is at higher risk for developing adhesive capsulitis. Western medical treatments for frozen shoulder include analgesics ranging from aspirin to narcotics for pain management, corticosteroid injections to manage inflammation, arthroscopic surgery to loosen the joint capsule, joint manipulation under anesthesia and simply waiting it out. Many patients are unwilling to wait it out, as the process can be quite disabling and take years to run its course. The three stages of the disease are described below as they would occur in a patient choosing not to receive surgical intervention.

During the first stage, or “freezing” stage, the shoulder gradually loses up to 85% of its range of motion, both active and passive. The pain often presents at night, while the patient is sleeping and immobile. Over the course of 3-9 months, the shoulder becomes increasingly more painful and stiff. Clients in this phase do not always seek treatment immediately because they think the issue will resolve on its own. If a gradual decrease in range of motion and pain are observed in a client, it is necessary to locally contraindicate the area and refer them to their primary care physician for an examination and diagnosis, as direct bodywork over the shoulder could worsen symptoms. Once diagnosed, patients may be taking prescribed pain medications which can mask pain/symptoms and thereby systemically contraindicate massage until the drug is out of the body. If the client has not taken a recent dose, massage to the rest of the body can be helpful by increasing parasympathetic tone and decreasing stress. Extra care must be taken to ensure the client is positioned comfortably on the table. They may need extra pillows or rolled up towels to support the affected joint as to not exacerbate symptoms, which could set the client back. Even with a diagnosis, massage, movement therapy and hot hydrotherapy are locally contraindicated throughout the duration of the freezing phase due to acute pain and active inflammation. 

Once the progression stabilizes, the shoulder enters what is called the “frozen” stage, which lasts between 4 and 12 months. It is characterized by extreme pain at the end of a very limited range of motion, causing the musculature around the glenohumeral joint to be unused and thereby affected as well. It is important that massage therapists be mindful not exacerbate inflammation or pain by over treating or doing intense bodywork on the shoulder, but generally gentle massage and hot hydrotherapy (to the client’s tolerance) are indicated during this phase and can provide the client with short term relief. Massage is systemically contraindicated if the client has taken a recent dose of pain medication.

Eventually, the pain at the end of ROM dissipates and the third and final phase, the “thawing” stage, begins. This stage can last anywhere from 1-4 years and is defined by a gradual and unexplained return of range of motion. Some people with adhesive capsulitis will see their range of motion return to normal, however up to 50% of people suffer a long term deficiency that can last up to 10 years. Massage, movement therapy and warm/hot hydrotherapy are indicated during this phase to restore normal function to the glenohumeral joint and the surrounding tissues and musculature. As with the other phases, extra pillows or rolled up towels may be used to provide the client with the comfort and support they need in order to be able to relax and receive the full benefits of massage. Beneficial homework to give clients may include stretching, strengthening and range of motion exercises for the shoulder. Clients in this phase may benefit greatly from receiving weekly massage, as well as working with another alternative care practitioner such as a yoga therapist or acupuncturist. Movement therapy techniques during a massage session would all be to the client’s tolerance and include pinning and stretching the rotator cuff and biceps brachii muscles, taking the client through passive range of motion, exercising weakened affected muscles and post isometric relaxation to create a new resting length for shortened muscles. It is important to let the client know that movement therapy may cause discomfort in this phase, but that it is necessary for restoring proper function. Verbal and nonverbal communication between therapist and client is essential. 

Overall, massage therapy is beneficial and indicated for normalizing muscle tone, reducing pain and restoring range of motion in clients recovering from adhesive capsulitis, particularly those in the thawing phase. 

Bibliography

Werner, Ruth. A Massage Therapist’s Guide to Pathology. Wolters Kluwer, 2016.

Manske, Robert C., and Daniel Prohaska. “Diagnosis and management of adhesive capsulitis.” Current Reviews in Musculoskeletal Medicine, Humana Press Inc, Dec 2008, www.ncbi.nlm.nih.gov/pmc/articles/PMC2682415/.

“Frozen shoulder.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 10 Mar. 2015, www.mayoclinic.org/diseases-conditions/frozen-shoulder/symptoms-causes/syc-20372684.

“Adhesive Capsulitis (Frozen Shoulder).” Practice Essentials, Problem, Epidemiology, 21 Sept. 2017, www.emedicine.medscape.com/article/1261598-overview.

The Rotator Cuff + Biceps Brachii

The rotator cuff is a group of deep stabilizing muscles that all start on the scapula and stop on the head of the humerus.  As a whole they work together to hug the head of the humerus into the glenohumeral joint, but in addition to that the muscles all have their own unique actions based on where they originate and insert.  A review of the bony anatomy of the scapula and humerus may be helpful before reading this post.  

There are four muscles that make up the rotator cuff.  First, a brief overview of everything the shoulder can do at the glenohumeral joint.  Click here for a definition of these terms.

Adduction
Abduction
Horizontal adduction
Horizontal abduction
Lateral rotation
Medial rotation
Flexion
Extension

The muscles of the rotator cuff medially and laterally rotate as well as abduct the shoulder.  They also all work together to stabilize the head of the humerus in the glenoid fossa.

What does what?

Infraspinatus
The infraspinatus muscle is a lateral (external) rotator.  It originates on the posterior scapula in the infraspinous fossa.  Infraspinous means inferior to (below) the spine of the scapula.  That whole space is the origin of the infraspinatus.  From there it inserts on the posterior aspect of the greater tubercle of the humerus.  When the insertion comes toward the origin during contraction (the insertion always comes toward the origin as the origin is the fixed point), it creates lateral rotation of the shoulder.  If you’re reaching your arm overhead to brush the back of your hair, your shoulder is laterally rotated.  The top arm in gomukasana (cow’s face pose) is also in lateral rotation.  

Teres Minor
Teres minor goes with infraspinatus in the same way that teres major goes with the lats.  The two muscles share the same actions and therefore the teres minor acts as an assistant to its larger counterpart, the infraspinatus.  Teres minor originates on the upper two thirds of the lateral (outer) border of the scapula and also inserts on the posterior aspect of the greater tubercle of the humerus.  It shares the same jobs as the infraspinatus:  stabilize the head of the humerus in the glenohumeral socket and laterally rotate the shoulder.  

The term teres translates from Latin to mean rounded or tube shaped.  I love to learn little things like that because they help me remember either where a muscle or structure is, what is does, something about its shape or size, etc.  Learning the language is hugely helpful.  You can also remember which teres muscle assists which larger muscle like this:  The latissimus dorsi is a huge and superficial muscle, so it needs the major helper.  Infraspinatus is a smaller, deeper muscle and so it gets the minor helper.  

Subscapularis
The subscapularis is a mirror to the infraspinatus.  It originates on the anterior surface of the scapula in the subscapular fossa and inserts on the lesser tubercle of the humerus.  This is the only one of the four rotator cuff muscles that inserts on the lesser tubercle rather than the greater.  In addition to helping to stabilize the humeral head it also medially (or internally) rotates the shoulder.  If you take your right arm out to the side and use your left hand to grab the back flap of the armpit, and then press your right hand into your belly you will feel subscapularis engage.  During gomukasana pose with the arms, the shoulder of the bottom arm is medially rotated.  When the hands are clasped behind the back, the shoulders are medially rotated.  The deeper subscapularis medially rotates the shoulder with help from the more superficial teres major, latissimus dorsi and anterior fibers of the deltoid.  

Supraspinatus
The supraspinatus originates in the supraspinous fossa, which means superior to the spine of the scapula.  The fossa is deep, and this muscle sits underneath of the fibers of the upper trapezius and the deltoid.  The long head of the biceps brachii is right here too.  It inserts on the greater tubercle and abducts the shoulder.  When I first learned about this muscle, I learned that it was just an initiator of abduction (taking the arm away from the body), but after more reading I’ve learned it’s more than just an initiator.  It is involved in shoulder abduction up to about 90 degrees.  The supraspinatus, like all rotator cuff muscles, assists in stabilizing the head of the humerus as well as abducts the shoulder at the glenohumeral joint.  When you raise the arms for a sun salutation, the supraspinatus is working to lift the arms away from the body.  When the arms are outstretched in warrior two, the supraspinatus is working. 

Biceps Brachii
I wasn’t going to talk about this one yet since I haven’t made a post on the bony anatomy of the radius and ulna, but I can’t help myself.  I think it’s quite relevant here, so here is a brief introduction.  

Biceps means two heads, so to refer to the biceps brachii as simply the biceps, you could technically be talking about any two headed muscle on the body, particularly biceps femoris which is the two-headed outer hamstring muscle.  Brachii means arm (specifically the humerus), so biceps brachii means two-headed muscle on the upper arm.  

The long head originates at the supraglenoid tubercle (the bony prominence above the glenoid fossa), while the short head starts on the coracoid process (beak-shaped bony prominence on the anterior scapula).  Before becoming the meaty belly of muscle on the anterior surface of the upper arm that probably nearly everyone could point out, the tendon of the long head of the biceps brachii passes through the glenoid fossa as well as the intertubercular groove.  The intertubercular groove is the space between the insertion points of the rotator cuff muscles.  The glenoid fossa is, of course, the shoulder socket.  Looking at the photo below you can see how interrelated the rotator cuff and the tendon of the long head of biceps brachii really are.  

It plays a role in shoulder flexion but an even bigger role in supinating the forearm.  It also flexes the elbow.  More to come on the biceps brachii as well as bony anatomy of the radius and ulna in a later post. 

Side view of the right shoulder without the humeral head. Clemente Anatomy.

The Shoulder: Joints + Other Structures

The shoulder is a synovial diarthrotic joint, which means it secretes synovial fluid and is freely moveable.  There are 6 different types of synovial joints, two of which are found in the shoulder.  The shoulder is made up of three bones and two joints, or three depending on whether or not you’re counting the scapulothoracic as a joint.  

First let’s go over some terminology.  All synovial joints have the following structures:  articular cartilage, a joint capsule and a joint cavity.  Most, but not all synovial joints also contain a structure called a bursa.  

What is articular cartilage?

The ends of bones that articulate, or connect, with other bones are covered in a layer of connective tissue called hyaline cartilage. The hyaline cartilage creates ease of movement and protects the bones from wear and tear.  The degeneration of this cartilage is known as osteoarthritis.  

What is a joint capsule?

The joint capsule surrounds and encloses the entire joint, like an envelope.  The outer layer is fibrous and dense, though it varies in thickness depending on the stresses placed on the joint.  It also thickens in some places more than others to form capsular ligaments.  The purpose of a joint capsule is to provide stability so these thickenings, such as the coracohumeral ligament that connects the coracoid process to the humerus, are meant to restrict movement in such a way that injury and harm can be prevented.  The joint capsule weaves itself into the periosteum of the connecting bones, so in the case of the shoulder... the scapula, clavicle and humerus all articulate with each other inside of the joint capsule.  Remember from a previous post that the periosteum is the layer of fascia that surrounds each bone. 

The inner layer of the joint capsule is a synovial membrane.  It secretes synovial fluid into the joint cavity which lubricates the joint, creates cushion for the bones and supplies the articular cartilage with nutrition.  

What is a joint cavity?

A joint cavity is the space between connecting bones and is encapsulated by the articular cartilage and a synovial membrane.  The synovial membrane secretes fluid into this space.  

What is a bursa? 

A bursa is a little fluid filled sac that lives between a bony projection (like the acromion) and surrounding tendons, muscles and ligaments.  It’s role is to provide cushion and reduce friction between these structures as we move.  You may have heard of bursitis?  -itis means inflammation so bursitis means the bursa is inflamed.  Bursitis is most commonly experienced at the shoulder, hip, elbow, heel and knee.  

OTHER STRUCTURES OF THE SHOULDER

Subacromial bursa - sits under the acromion to reduce friction and prevent impingement.  This bursa is actually not all that small, the lateral portion allows the acromion and deltoid to slide smoothly over the humeral head and rotator cuff tendons while the medial portion puts a cushion between the coracoacromial ligament and supraspinatus tendon.  

Coracoacromial ligament - The coracoacromial ligament is unique in that it doesn’t connect one bone to another but rather a part of the scapula (the coracoid process) to another part of the scapula (the acromion).  It forms an arch across the top of the shoulder that helps protect both the rotator cuff tendons and the subacromial bursa from injury by the acromion. 

Glenohumeral joint - A ball-and-socket synovial joint, this is where the head of the humerus (the ball) articulates with the glenoid fossa (the socket).  The socket in this case is pretty shallow, so we need the stability of the joint capsule and the strength of the rotator cuff to hold the head of the humerus in place.  The rotator cuff muscles originate all over the scapula and insert on the humeral head but the just barely cross the joint, which is why rotator cuff injuries are pretty common.  

Labrum - this is a fibrous, cartilaginous structure that's attached to the rim of the glenoid fossa.  Its purpose is simply just to create a lip to deepen the shallow socket.  It is important for the health of the labrum that we properly stabilize the whole shoulder before bearing weight, otherwise this structure can sustain wear and tear and painful injury.   

Acromioclavicuar joint - this is the articulation between the acromion, which is the lateral end of the spine of the scapula, and the lateral or acromial end of the clavicle.  The articulation surface is small, and it’s classified as a gliding joint as the surfaces glide past one another.  It’s a small amount of movement, and injury can happen in this joint in the form of a separation.  Ouch. 

Scapulothoracic joint - this is where the scapula articulates with the rib cage, but even though it’s called one, it isn’t really a true joint.