Frozen shoulder/Idiopathic Adhesive Capsulitis (IAC) is one of the clinical areas that has long held a fascination for me, largely because of the paradox between pain and range of motion. Whenever it is mentioned I prick up my ears, hoping for a silver bullet to use to assist my clients. While no single Lone Ranger moments have occurred, I have picked up some interesting clinical pearls that I discuss below. This recent case report is a good starting point for discussion.
Trigger Point Dry Needling as an Adjunct Treatment for a Patient With Adhesive Capsulitis of the Shoulder
My Classical Presentation
Female > male, presenting with increasing degrees of shoulder pain and stiffness over several months. Can’t recall specific injury. Not being helped by NSAIDs and taking occasional paracetamol. Finding pulling up pants or doing up bra from behind, overhead activities, reaching across into back seat of car or removing wallet from back pocket increasingly difficult.
On assessment pain is often global around shoulder NRPS 4-8/10 (depending upon activity). Getting comfortable at night is difficult, both lying on the shoulder and the other side (drags the irritated shoulder). Active external rotation in neutral is limited to 20, flexion & abduction 60 to 80 before hitching starts. I find the degree of external rotation to be the key. If external rotation in neutral isn’t greater than 40 degrees, they just don’t get flexion above approximately 140 degrees. Palpation often reveals increased sensitivity in supraspinatus, infraspinatus, subscapularis, pectorals, upper trapezius and levator scapulae. Neural tissue provocation tests are –ve, isometric testing in neutral is good.
Perform neuro provocation tests because the cervical neural plexus passes anterior to the glenohumeral joint and length tension increases with abduction and external rotation. This was pointed out to me by Bob Elvey, who explained that a percentage of presentations of IAC he had seen, had restricted external rotation and abduction due to protective muscle guarding of sensitive nerve tissue. Treating the neural sensitivity, resolved the false IAC. An awareness of red flags is required because of chronic nature of presentation.
- type 1 or 2 diabetes mellitus
- thyroid disease
- age of between 40 and 65 years
- pro¬longed immobilization
- autoimmune disease
- myocardial infarction
Treatment & Discussion
From clinical observation the pain and lack of function/range don’t seem to be strongly related. This is a paradox, as a general axiom in musculoskeletal medicine is that by reducing the pain, range will naturally increase. This assumes the lack of shoulder range is due to pain. Generally with true IAC, I don’t find this the case.
In my earlier days I tried several variations of prolonged heat, shoulder joint mobilisations and in clinic prolonged stretching using varying degrees of load. I didn’t notice any significant improvements and often the client reported increased pain. Griggs et al (1) have shown that a passive stretching home program is effective in increasing ROM but the limitation is client’s tolerance of pain. Practically speaking if it is painful resistive muscle tension will increase and psychologically clients ‘forget’ to perform their stretches on a regular basis. Fair enough! So we need to assist in pain relief.
NSAIDs and paracetamol don’t seem to work (2). However clinically it needs to be stressed that paracetamol MUST be taken appropriately, so 2 tablets 4 hourly to get the clinical dosage of 1gm in the blood stream before a decision can be made as to whether it is or is not effective. Clients often don’t understand this and under dose themselves as they don’t like being ‘pill poppers’. Education is required.
Cervicothoracic manipulations are worth considering if appropriate (3) and followed up with thoracic extension exercises (foam roller, back of chair) to increase thoracic contribution to shoulder girdle range of motion.
Hydrotherapy is also a useful adjunct in the early stages of pain and stiffness, providing warmth and a physically supportive environment in which to exercise.
Reasons and effectiveness of using dry needling to treat shoulder trigger points has been discussed (4)and has been documented in elite volleyball players (5) and recreational athletes (6). I have found that using dry needling is highly effective in reducing clients pain levels, enabling them to then work on their structured home program of strength and flexibility exercises.
If it is true IAC, meaning there is some internal joint component, their pain will reduce significantly to around NPRS 0-2/10 (therefore seemingly the pain was arising from the trigger points) but their range will not correspondingly increase. Range improvements are much slower and over a longer period of time. For this reason development of a comprehensive home program and intermittent reviews over a 3-6 month period seems more appropriate than ongoing passive treatment.
Itching to Know More? Plenty of Options
You can learn how to perform these dry needling techniques safely as part of our Dry Needling Program starting with the Introductory Course and Advanced Upper Quadrant Course.
You can learn correct real time and musculoskeletal ultrasound imaging techniques from physiotherapist and sonographer Peter Esselbach in his Level 1 & 2 Rehabilitative US Course.
You can learn more about shoulder assessment, treatment techniques and clinical reasoning from Dr. Jeremy Lewis (UK physiotherapist) in his upcoming September course The Shoulder: Theory & Practice.
- Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am. 2000;82-A:1398-1407.
- van der Windt DA, van der Heijden GJ, Scholten RJ, Koes BW, Bouter LM. The efficacy of non-steroidal anti-inflammatory drugs (NSAIDS) for shoulder complaints. A systematic review. J Clin Epidemiol. 1995;48:691-704.
- Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. Phys Ther. 2010;90:26-42.
- Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ. Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs. Am J Phys Med Rehabil. 2007;86:397-403.
- Osborne NJ, Gatt IT. Management of shoulder injuries using dry needling in elite volleyball play¬ers. Acupunct Med. 2010;28:42-45
- Ingber RS. Shoulder impingement in tennis/racquetball players treated with subscapularis myofascial treatments. Arch Phys Med Rehabil. 2000;81:679-682.
Adding your Thoughts
Please add your experiences and thoughts about IAC and in what you have found important when managing clients with IAC.
All the best,
Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education
ph/fx: 08 90715055
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