Frozen Shoulder

Mark: Hi, it's Mark from top local. I'm here with Wil Seto of Insync Physio in Vancouver. One of Vancouver's top rated physiotherapy clinics, many time winners of best physios in Vancouver. And today we're going to talk about frozen shoulder. How are you doing Wil? 

Wil: Yeah, I'm doing great. Thanks.

Mark: So frozen shoulder, what is it?  What the heck is this anyway? 

Wil:  So the technical term for frozen shoulder is adhesive capsulitis. So what it is is it's basically a progression of like a restricted movement in your shoulder joint. So what we call the glenohumeral joint in terms of its range of motion, that's primarily what it is.

And it's really tough to really determine what causes it, but essentially going back to what it is, you have this permanent scarring or this fibrotic scarring that actually occurs. And there's this sort of a neuralpathic and sort of a vasal motor or vascular process that occurs within the shoulder that just can't be really explained yet and what causes that. 

So there's that sort of neurological aspect that really still you know, causes a lot of questions as to where does it come from? And really the other aspect of this too, is that what we're looking at is the side effects of that. You know, so as you get all this fibrotic scarring and all this permanent scarring into the shoulder and the shoulder joint and the rotator cuff area, then you're getting a lot of those effects in terms of the function of that rotator cuff and what that means essentially.

So this isn't something that necessarily appears from a fall or an injury necessarily. This could be just an over use thing. How does it present?

That's a really great question. So in the research and also just with my experience, you know, working with people and seeing this condition, it seems like 70%, first of all, like, you know, we're looking at prevalence, 70% of people that actually get frozen shoulder are usually females.

So when you're talking about what this whole condition is, then it sort of points to the whole. Is there a hormonal aspect of this. And then, you know, what's going on with that. And then also the found that you know, if you're between ages 35 to 65, then you're also at more increased risk of getting this as well.

And it seems like generally speaking, you know, like it's in 2 to 5% of the population. And so when you talking about how does this actually happen? Like, does it occur from overuse or is it a traumatic injury? Well I think when you talk about sort of the primary part of what frozen shoulder is, the onset of it is usually something that's without any known cause.

They call it idiopathic. Where there really isn't any reason. And they still don't even know, what it is exactly that causes this. And the jury is still out on that. Now, when do you start to look at, what we talked about secondary causes, you know, like where you're talking about, oh, is it an overuse thing? Is it like traumatic? 

Yeah. So it can actually occur alongside with things like trauma, so a surgical event. So you get an operation like for your shoulder for something else, and then you develop a frozen shoulder. And you can also have other things like overuse is another good example. Or falling on the shoulder you have an injury?  So those are definitely factors. 

And then there's also like within those sort of secondary factors, you have like other things too. There's systemic. So if you have diabetes, like diabetes mellitus, which is basically type two diabetes, then you can actually have an increased chance of getting this. So this sort of circles back to, is this a hormonal thing . Is this a neuroendocrine thing? 

 And then there's also extrinsic factors like is this like someone that has cardiopulmonary disease or you know, someone that has like a cervical disc issue, like post breast cancer, a meniscectomy and all that stuff. So that goes in line with the surgical. 

And then there's intrinsic factors, which we talked a little bit briefly about like rotator cuff pathologies. And then people that have had like you know, things around there too, or maybe like overuse and then maybe around that shoulder, not exactly in that shoulder joint, but like the AC joint, which is the acromioclavicular joint. So there's all these different things involved. 

Mark: In other words, to sum all that up, the shoulder is really complicated and it can go south in immense amount of ways, basically. Surprise. 

Wil: Yeah, it is. But the shoulder joint is just, is such a beautiful, like marvel of a joint, it's just amazing. 

Mark: So when you're going to treat this, what's your kind of first step? How do you diagnose it and how do you go about then doing a course of treatment? 

Wil: Yeah. That's a really good question too. And so actually funny enough, I was actually just In the process of treating someone that has frozen shoulder and there's specific assessment criteria that they fall in line with like being diagnosed as having frozen shoulder.

And so this particular patient of mine, she's an accountant and relatively fit, 41 year old accountant and she fell in that first primary category. Unknown reason. She didn't fall on it. Nothing really happened. Relatively fit. She fits in that age range and it was like classic range of motion limitation.

And so what I looked at was definitely wanting to improve that range of motion and also looking at how her actual, when we talked about intrinsic factors, how her rotator cuff has been affected by it. You know, and obviously, for someone like her who, you know has been really scared to use it.

Now starting to reactivate that part of the shoulder, the rotator cuff. So we actually started off you know, some simple stuff. Just working on her mobility and then an activation of that rotator cuff. And then we started doing some more specific stuff like neural muscular reactivation. Hands-on stuff with her that actually really started making a lot of progress. The other thing that we were also doing as well was a little bit of dry needling and IMS to kind of help that whole process of the muscles that are just sort of like this, which is essentially responding to a lot of stuff that's happening in the capsule of the shoulder.

Surprisingly so I've been seeing her since October. And surprisingly you know, within the first three sessions and she was seeing me once a week, her range of motion was like less than 25%. And her strength was so weak. She wasn't even using it. Within the first three sessions, three weeks of coming in to see me, we got her range of motion to over, definitely over 50% close to like 65-70% kind of thing.

And then, so that was like back in October. And then now you know, she still comes in once a week and we're at like 90% range of motion and she wants to have that last little bit, like she's like we can do it. And typically with the prognosis of a frozen shoulder, they do consider it self limiting, it can last up to two years. Is sort of the prognosis on a medical indicator.  

Mark: So when people get this, this is the typical thing that doesn't, they don't want to use it. It hurts a lot. They don't want to move it and they can't really sleep on that shoulder too. Is that right?

Wil:  Yeah, definitely. That is another big symptom of it as well. And that's all coincided with the fact that as it gets stiffer and then things get in this chronic inflammatory process, that's producing more and more scar tissue. And what ends up happening is a part of their psychology is affected too, and they don't want to use it. And then as we go through the rehab with them and we help them with that, they build that confidence. And they start to realize that as the range is getting better, we also have to retrain the neural muscular activation patterns to be able to help reinforce that mobility gain as well.

So that's actually really, really important in this whole process. And I think this goes back in line with talking about, you know, the side effects of frozen shoulder, I guess, or the secondary effects, which is basically the rotator cuff stuff and the really stiff shoulder. 

Mark: So would you say that's a more typical response then at about three, four months of pretty steady work on it can get somebody back to 90% mobility and a lot less pain and issues with their shoulder?

Wil: Yeah, I would say like just recently with this particular individual and also a couple of others that have had worked with that, that seems to be what I'm finding and what we're finding in our group. Whereas you know, I've seen people that have suffered with frozen shoulder and didn't want to do anything about it because they've, you know, they've consulted Doctor Google, or even their family doctor even have said, yeah, you know, it'll be self-limiting within two or three years. But then, you know, they'll come in two years later and they're still right. You know, really super stiff and that's obviously a lot tougher to deal with because the other thing that I didn't actually mention was that she had been suffering with a frozen shoulder since last March at the start of the pandemic. And I think a lot of it was maybe she started to do more computer work at home and all those effects of what we've been experiencing with the pandemic. 

The other really interesting fact that we found, a group of clinicians and also sports medicine doctors and rehab specialists in Australia have found that if this is a true frozen shoulder and you catch it within the first three months of its onset, doing a specific type of injection has been really helpful to help with that. But that's actually very key to be able to diagnose it within the first three months because the effectiveness of that injection is no longer as effective. So it starts to get less and less. 

Mark: And you work a lot with sports medicine doctors. You guys co help each other basically. They refer patients to you. You refer patients back to them based on what their needs are. Is that right? 

Wil: Yeah, for sure, definitely my experience and our experience as a group, we have worked with a lot with sport medicine doctors. And currently right now we actually have sort of a specific sport medicine doctor that we can actually do direct referrals to without having to have a referral from a family physician. You know, and I know that with this time of the pandemic, it's really changed how things have been operating with the healthcare system. And this has been an example of being able to help our patients and our clients be able to get moving better the way that they want to again.

Mark:  Anything else you'd like to say about frozen shoulder? 

 Wil: Well I think it's a really tough thing to wrap your head around when you think you have it. I think honestly, like as much as you consult Dr. Google and family physicians like you know, they're great. I have some really good family physicians that we work with, like our group works with. But sometimes they're just not as knowledgeable cause it is like this orthopedic type of condition, but it's got a medical aspect to it as well. But they don't really know the rehab side of it as as much and we try to work with them and help family physicians. But I guess my biggest take home is like, if you're not really sure if this is what it is and you have stuff going on, get it checked out. You know, general rule of thumb is that if you have stuff going on and if it's like severe enough to even give you pain, like without using it, if it's not going away within like the first week or even two weeks, get it checked out. Get it checked out and at least figure out what's going on. Have a register physiotherapist take a look at it. And really you know, someone that has a little bit of a specialty in orthopedics and even in sports to be able to really ascertain, a little bit more and help you with your specific issue with that. 

Mark: So bottom line don't suffer. If you've got a shore shoulder, sore shoulder, you want to give Insync Physio a call. If you're in Vancouver, in the Cambie, King Ed area, anywhere in that general vicinity, you can call them at (604) 566-9716 to book your appointment. Or if you're in North Burnaby, the North Burnaby office is at (604) 298-4878.

Get yourself looked after, get on the path to healing, and you're going to feel a heck of a lot better really fast. And you can check out the website insyncphysio.com. We've got dozens and dozens and dozens of videos on there on all kinds of exercises and stuff. If you want to try and play doctor yourself, you can, don't recommend it. The faster way is to get in and get a professional helping you. Diagnosing and giving you hands on treatment that will make you feel better. Thanks Wil. 

Wil: Thank you, Mark.