Frozen Shoulder Treatment Options
Although over 300 million people worldwide suffer with this condition, frozen shoulder (adhesive capsulitis) still seems to be a relatively new condition in the medical world. The percentage of people suffering with this terrible affliction also seems to be growing yearly although the reason for this is still unclear. There are many different opinions on which treatment option is the best route to take.
Physical therapists may recommend lengthy rehabilitation programs while athletic therapists and shoulder specialists suggest surgery followed by a muscle-building program to strengthen the shoulder muscles.
The OAT Procedure, aka Manual Capsular Dissection (MCD) is a revolutionary alternative that has proven to be extremely effective. A Russian medical study was published in 2012 in the Russian Journal of Manual Therapy and a medical peer reviewed study is expected to be released in Canada soon with presentations to physiotherapists and orthopedic surgeons commencing thereafter.
Below is a list of options and expected outcomes so that you can be better informed to decide on your frozen shoulder treatment options.
Though this treatment doesn’t eliminate the root cause of your Frozen Shoulder symptoms, Hydro-Cortisone steroid injections can be administered to provide patients with some temporary pain relief and a very small temporary improvement in range of motion. The challenge is that the effects usually only last 1 or 2 weeks and then the shoulder returns to the same or sometimes even worse state than before the injection. Cortisone is a powerful steroid which targets and temporarily decreases the amount of inflammation in the affected shoulder joint. Inflammation causes tightening and stiffening of an affected joint and pressure from inflammation causes pain. Decreasing the amount of inflammation in the frozen shoulder joint with the steroid injection will sometimes have the almost immediate effect of slightly increasing mobility and somewhat diminishing pain.
The problem is that the inflammation and pain is there for a reason, which is to provide a medium for healing and to protect the joint from further injury. When the inflammation is suddenly unnaturally reduced and the pain lessened with the steroid injection into the joint, patients will tend to use the shoulder more and can often cause more damage because the cause of the frozen shoulder has not been actually treated. Interestingly, cortisone steroid injections have been reported to actually cause an adhesive capsulitis frozen shoulder to develop when it is used to treat a simple impingement or rotator cuff tendonitis.
What’s more is that cortisone is a heavy steroid which actually breaks down and emulsifies the muscle tendons and ligaments. This makes anyone injected with cortisone more susceptible to serious injury of the rotator cuff and tearing of the shoulder tendons. It is for this reason that so many professional and elite athletes who have had cortisone injections later end up partially or completely tearing and severely damaging tendons in their bodies. The steroid drug cortisone also has very many undesirable side-effects that are common with any heavy steroid, all of which can be looked up on the internet under side effects of hydrocortisone.
In light of these facts, The American Medical Association has actually recommended that physicians do not inject any area of the body more than twice in a lifetime with cortisone. In certain cases depending on the patient case history, in the pre-op period just prior to the Trigenics® OAT procedure being performed, a very small amount of cortisone will sometimes be locally injected into the shoulder capsule in addition to the anesthetic lidocaine. This is because, certain cases may be at greater risk of having an increased inflammatory response over the course of a few days following the Oolo-Austin Trigenics® procedure being performed. In these cases, cortisone can be helpful to prevent an inflammatory over-reaction post-op. Patients who have already had 2 steroid injections into the affected shoulder will not, however, receive any cortisone prior to the Trigenics® OAT procedure.
Because of the reasons above, we do not recommend having cortisone injections in an attempt to cure a frozen shoulder. It will never cure it and it could end up making it worse.
WHAT ABOUT SURGERY?
Frozen shoulder surgery, called arthroscopic capsular release, is the among the few frozen shoulder treatment options that has a chance of actually working. In this process an arthroscope cuts through the skin and is inserted into the joint. Using this instrument the offensive adhesions are cut apart around and inside the capsule. If surgery is performed, immediate physical therapy for 2 months following the shoulder surgery is of utmost importance. If rehab does not begin soon after capsular release, the chance of the Frozen Shoulder returning is quite high.
Many people will try to avoid surgery whenever possible and for good reason. Surgery should always be your last option when all else has failed. There is a surgical procedure which cuts open the shoulder that has been shown to sometimes work in restoring range of motion to a frozen shoulder but, according to statistics, the results are about 50/50. The problem with surgery is twofold. Firstly, if the surgery does actually work, there will have been so much cut inside the shoulder capsule that the patient will have to attend for intensive physiotherapy rehabilitation for 6-8 weeks following the surgery to regain proper shoulder movement. The second problem is more serious in that surgery has also been shown in some cases to make the shoulder lay down more scar tissue which actually then worsens the frozen shoulder! No one with frozen shoulder wants this so think twice and think very carefully what your other, more conservative options are, before you consider going under the knife. In addition, the risks of using a general anesthetic are also significant and should not be taken lightly.
WHAT ABOUT MANIPULATION UNDER GENERAL ANESTHETIC?
Alternately, a surgeon or qualified and specially licensed manual medicine specialist such as a Chiropractic or Osteopathic physician may also perform a manipulation under anesthesia. This is called MUA. These heavy and quite drastic manipulations are performed with the patient sedated in the operating room on the table under general anesthesia. The attending doctor suddenly forces the shoulder into end range positions to literally break and tear up adhesions caused by Frozen Shoulder. The problem with MUA is that the performing doctors also often break up the shoulder capsule–causing serious damage to the shoulder.
There is no actual surgery involved, meaning incisions are not made when a manipulation is performed. However this procedure is very forceful and is performed without any conscious input from the patient. As a result, research studies and statistics on MUA prove that many patients undergoing this procedure end up with permanent damage to the shoulder capsule and soft tissues of the shoulder joint. Damage to the nerves and breaking of the bones as well as shoulder dislocations have also been reported to occur with some frequency using MUA. It is for these reasons that MUA has largely fallen out of favor amongst health professionals as a treatment for frozen shoulder. Of the frozen shoulder treatment options, we strongly advise against MUA!
Diligent physical therapy is often essential for recovery of many conditions but not for adhesive capsulitis frozen shoulder. There is no evidence that physiotherapy helps frozen shoulder at all. Physical therapy targeting frozen shoulder adhesive capsulitis will take months to years of treatment for recovery, depending on the severity of the scarring of the tissues around the shoulder. Over aggressive physical therapy has also been shown to significantly worsen the frozen shoulder as the body responds to additional trauma by over-reacting and laying down more scar tissue around the shoulder capsule. All forms of physical therapy for adhesive capsulitis frozen shoulder are basically useless, can often be torturous and have sometimes been known to significantly worsen the condition. Frozen shoulder sufferers have notoriously spent thousands of dollars and countless hours attending for treatments over months and years which do nothing to help and sometimes worsen the condition. We believe you will find yourself wasting your time and money attending for physical therapy sessions to alleviate your adhesive capsulitis frozen shoulder. Before you attend for physical therapy, be sure to ask the physiotherapist if they have ever had much success with frozen shoulder. The only cases, they may site as being successful, would most likely have improved of their own accord during the timeframe of treatment.
It is very important for people with a frozen shoulder to avoid aggravating the shoulder tissues during the rehabilitation period. These individuals should avoid sudden, jerking motions or heavy lifting with the affected shoulder.
Almost all cases where the Trigenics® OAT procedure was successfully conducted had first tried physiotherapy with no success.
NEIL ASHER TECHNIQUE (NAT):
The Neil Asher Technique is a gradual multiple-treatment osteopathic method of treating frozen shoulder. Although their web site posts a study which they did to prove that this technique is more effective than physiotherapy, the form of physiotherapy they used for comparison is, itself, notoriously ineffective for frozen shoulder. Either way, the technique is basically a soft tissue pressure technique which still requires many months of therapy for those in which it is reported to help. On the other hand, there are certainly patients who have come to our clinic for the Trigenics® OAT Procedure and said that the NAT had not worked at all. This being said, the Neil-Asher Technique is quite passive with no apparent risks for further damage and as such, if you feel you have the time and the money to try it out, we do not recommend against it. It’s better to go the conservative route first than to subject yourself to potential serious damage from treatments like surgery or MUA.
A number of cases where the Trigenics® OAT procedure was successfully done had first tried NAT with no success.
A number of adhesive capsulitis frozen shoulder patients, where the Trigenics® OAT procedure was successfully performed by Dr. Austin Oolo, have said that they had first tried a chiropractic technique called “OTZ”, to treat their frozen shoulder with no success. Investigation revealed that the OTZ technique is a new chiropractic method of treating what OTZ practitioners advertise to the public as, “frozen shoulder syndrome.” These practitioners claim to be able to cure frozen shoulder by manipulating or adjusting the occiput (skull) and upper neck vertebrae (bones). This claim, however, is seen by most medical professionals as absolutely impossible as the heavy scar tissue and adhesions which surround the capsule of the shoulder cannot possibly be separated with a chiropractic adjustment of the neck vertebrae. To support the claims of OTZ practitioners, there are a number of YouTube videos showing apparent before and after videos and a number of patient testimonials on their web site. These patients in these videos are obviously real. The confusion, however, lies in the fact that the condition the OTZ practitioners refer to as “frozen shoulder” is actually not adhesive capsulitis frozen shoulder. The condition they post on their video and website appears to be classic shoulder impingement syndrome which, in some ways partially mimics adhesive capsulitis frozen shoulder in the way that side raising of the arm is restricted. What is apparently occurring with OTZ technique is a misinterpretation of the term frozen shoulder. (To their credit, in the courses they teach to chiropractors, they refer to the kind they treat as “type 1” frozen shoulder with “type 2” being the adhesive capsulitis variety.) The theory proposed by the OTZ camp with respect to the “true cause” of type 1 frozen shoulder, which is also medically termed “shoulder impingement syndrome”, is seen by Dr. Austin Oolo as having some credibility. All this being said, although the OTZ chiropractic technique cannot be successful in treating adhesive capsulitis frozen shoulder, Dr. Austin Oolo’s experience of OTZ practitioners is quite positive and he is of the opinion that the chiropractic manipulation, which OTZ practitioners perform for the occiput, is quite advanced.
Shoulder Impingement Syndrome can have many causative components including compression of the upper neck nerves (spinal accessory nerve) causing contraction of the upper trapezius muscle and restriction of shoulder bones and joint movement. Other factors include inflammation of the shoulder bursa (pads under the bones) at the top of the shoulder (bursitis) and rotator cuff muscle tendon inflammation (tendonitis). If the upper neck and skull alignment is involved, he recommends the patient see a chiropractor who is highly proficient in “atlanto-occipital” manipulation. (OTZ practitioners would fall within this category.) If the condition is due to the very common causes of subacromial bursitis or tendonitis he recommends the patient attend to a Registered Trigenics® Practitioner near them who has completed a Trigenics® shoulder course and who can perform the Trigenics® Shoulder Impingement Procedure (TSIP).
ACTIVE RELEASE TECHNIQUE (ART):
Many practitioners advertise that they can treat adhesive capsulitis frozen shoulder using a muscle stripping soft tissue technique called “active release technique” aka ART. Although this technique is designed for and has good results with conditions caused by tissues that have adhesions which have developed in the fascia between the muscles, it is not a technique which is effective in being able to separate the much heavier and thick adhesions which encapsulate the shoulder joint itself in cases of adhesive capsulitis. The myofascial adhesions treated with ART are completely different and in different anatomical locations, being found between the muscles than the adhesions which surround the shoulder joint with frozen shoulder. A great many cases presented to the Trigenics® Frozen Shoulder Clinics have had unsuccessful ART treatments. Cases of reported improvement with ART still take many months or years to recover fully. These cases and others which still take a long time for recovery following treatments like ART or NAT, cause one to question whether or not the patient’s frozen shoulder would have recovered anyway without these treatments. Although there are numerous cases of frozen shoulder which can last for 5, 10 or more years, many cases of adhesive capsulitis will also mysteriously resolve themselves with no treatment at all within 2-3 years. But again, the problem with waiting so long is that 15% of the population never recover full mobility after natural resolution of adhesive capsulitis frozen shoulder. As such, one must always consider at which point in the lifeline of the shoulder condition was the therapy applied to be able to judge whether it was the therapy or the natural course of evolving resolution.
A number of cases where the Trigenics® OAT procedure was successfully performed first tried ART with no success.
Hydrodilatation is a new invasive medical method sometimes used in an attempt to cure frozen shoulder. With this procedure, the shoulder joint is injected with a lot of fluid until it is literally “blown up” from the inside out so as to tear up the shoulder joint adhesions using excessive pressure from within the joint capsule. The intended effect is to cause the offensive scar tissues and adhesions surrounding the joint capsule to explode and break open. A number of studies have shown some improved movement and pain reduction but there are no good published studies in the medical literature to confirm even these quite modest results. Medical studies do cite that this method has not been shown to be any more effective than cortisone injections (see above). An interesting point is that many subjects chosen for hydrodilatation studies have not been able to be used for the study because they have pleaded that the procedure be stopped due to severe excruciating pain from the procedure as more and more fluid is injected into the joint in an attempt to cause it to burst apart. From a risk factor and complications perspective, damage to the shoulder joint capsule has been reported as have shoulder joint infections and premature shoulder joint arthritis . As the verdict is still really out on hydrodilatation, we do not, as of yet recommend this method.
A number of cases where the Trigenics® OAT procedure was successfully conducted first tried hydrodilatation with no success.
In our opinion, physiotherapy, aggressive massage and chiropractic manual treatments are actually contraindicated and should not be conducted on cases of adhesive capsulitis frozen shoulder as research and clinical evidence shows that these kinds of physical therapy can often cause more inflammation and adhesion with a resultant prolongation of the condition. There have been many cases of adhesive capsulitis which have attended to Dr. Austin Oolo for the Trigenics® OAT operation which have existed for 3-20 years. In all these cases, the patient had been told that the condition would finally resolve after 1-3 years and they had all been attending for multiple painful physical therapy sessions which reportedly aggravated their condition. These are the cases, not listed in the literature.