Introduction 

I would be shocked to hear of any person who has worked in a Pilates or yoga studio, or at a gym, and has not encountered a client with a frozen shoulder or at least that special beast I call the cold shoulder. For those unfamiliar with the cold shoulder, it is the precursor to its frozen sibling and begins with a niggling and annoying tightness in the shoulder area. As it progresses, it results in an insidious loss of range of movement (ROM) which interferes with important day-to-day function and causes sleep depriving pain. Clients who experience the cold shoulder are often forced to “do the rounds” of visiting countless physiotherapists, chiropractors, osteopaths, acupuncturists in their search for more than temporary relief.

Having experienced both a frozen left shoulder and a cold right shoulder, I can personally attest to the frustration that accompanies such injuries. By the time my second shoulder started to “cool”, I had a clearer understanding of what was going on, and what was needed to regain mobility and function. Over the years, I have observed many clients struggling with these icy issues. They have often “done the rounds” of visiting countless physiotherapists, chiropractors, osteopaths, acupuncturists in their search for more than temporary relief. In my experience, locating clear guidelines and strategies for working with such clients has proven as illusory as achieving permanent relief by way of various manual therapies. This article aims to improve understanding about these common conditions and provide practical movement strategies.

We will explore:

• The anatomy and structures of the shoulder joint involved when working with a cold shoulder

• How anatomy and physiology are relevant to the common presentation of cold / frozen shoulders

• The stages of the frozen shoulder

• Strategies that can be used to support a cold or fully frozen shoulder and help to achieve a warmer, more supple shoulder joint

Your shoulder cohort

Frozen shoulder affects approximately 3% of the general population and is more common in women aged 40 to 70 (Allen GM., 2018). Common risk factors include diabetes mellitus, connective tissue diseases, thyroid disease, and heart disease, with highly active antiretroviral therapies also implicated( De Ponti A et al., 2006).

When I read these statistics, several alarm bells went off in my mind. My first thought was that the women and age group most affected by this injury are in what we call the “sandwich” stage of life. These women are usually working in some capacity while balancing caring for children and supporting their ageing parents. This means it can be challenging to find time for managing niggling injuries. Often issues such as the cold shoulder are pushed aside until they can be ignored no more, particularly if the shoulder has frozen over. It is for this reason I believe places like Pilates studios are crucial for supporting women. Our studios are supportive spaces, particularly for this cohort of middle-aged women who often attend Pilates as part of their self-care routine. We are ideally positioned to provide them with good strategies for mitigating the risks of or managing a cold shoulder.

The overlay of autoimmune diseases in the risk factors for these types of shoulder problems also reminds us that healing and the impact of the immune system in delaying healing needs to be factored into our strategies.

En-capsulating the anatomy (A review of some shoulder anatomy)

When approaching any condition, it is useful to begin with some reflection. We will begin by considering:

What is the capsule?

What is the capsule’s purpose?

What is fibrosis, and how does it affect the capsular structure?

What is the capsule?

 

Articular capsules surround the body’s synovial joints and provide important protective functions. While the mechanics vary slightly for different joints, the articular capsule (capsule) of the glenohumeral (shoulder) completely surrounds the glenohumeral joint. It spans from the superior aspect of the glenoid fossa beyond the glenoid labrum to the anatomical neck of the humerus.

The capsule provides some passive stability by limiting humeral distraction. The numerous proprioceptive nerve endings embedded within the capsule relay mechanical information back to the central nervous system, facilitating active stability. (Ralphs and Benjamin, 1994).

The articular capsule has two layers: an external fibrous capsule and the internal layer which is part of the synovial membrane. The external fibrous layer intermingles and attaches. Intermingling occurs with the tendons of the rotator cuff muscles (i.e., supraspinatus superiorly, infraspinatus and teres minor posteriorly, and subscapularis anteriorly) and the tendon of the long head of triceps brachii inferiorly, where it attaches to the infraglenoid tubercle. Hence, correct patterning and activation of these muscles is essential for capsular health and function.

The external fibrous layer attaches:

• Medially to the neck of the glenoid process at variable distances from the glenoid labrum.

• Laterally to the anatomical neck of the humerus. These lateral fibres are thicker at their end attachments above and below. The central components are relatively loose and lax facilitating the bony rhythm and supporting the necessary range of movement of the humeral head. When these fibres tighten and shrink, they become fibrotic. This is when we start to see the process of adhesive capsulitis.

Fibrosis is scar tissue that interferes with the capsular fibres and forms in response to injury, trauma and inflammatory responses. In a fully functioning capsule, the fibres run in a spiral pattern following the lines of tension from the movement of the arm. When we experience small injuries, the fibrotic tissue can be laid down in a disorganised manner different to the functional fibre patterns of an uninjured capsule or tendon. With this fibrositic tissue, the shoulder capsule becomes inflamed and taut, leading to stiffness, pain, and limited range of motion in the shoulder area.

The flow of synovial fluid is part of the healing process, as it nourishes the articular cartilage of the glenohumeral socket. When the humerus has reduced movement this impacts on the internal layer of the capsule’s fluid release. Thus, maintaining appropriate movement is part of the body’s multi-layered healing mechanism for the shoulder. When we avoid movement as a pain management strategy we can actually interfere with the tissue healing response.