I'm Brett DeGoyer. I'm a primary care sports medicine specialist and neuromusculoskeletal medicine specialist practicing for Samaritan HealthCare in Moses Lake, Washington. In this case, we're discussing adhesive capsulitis, or otherwise known as frozen shoulder. One of the things that I have found most effective in my practice is to do some deep tissue work around the capsule in the subacromial space along the front glenohumeral joint as well as the posterior glenohumeral joint. So I'll demonstrate on his left shoulder for this while he's in the supine position or laying face up. This can be done in a seated position as well. I'll grab at the elbow and I'll add traction. So, in this case, pushing towards the feet to gap at the glenohumeral joint and underneath the acromion process. I'm gonna use my thumb to get into those areas starting at the back, so the posterior glenohumeral joint, and I'm gonna get in and really deep massage all along the posterior glenohumeral joint as much as I can and as deep as the patient will tolerate. We don't want it to be painful, but it is going to be uncomfortable. So, starting at the posterior side of the joint capsule, I'm going to come up over the top into the subacromial space and do some deep massage into the joint and then also compressing down towards the feet all in one motion and do that all the way to the anterior glenohumeral joint. At that point, I may switch to my fingers just to be a little bit more comfortable or I can still use my thumb. In addition to doing the compression into those spaces and along the capsule, I can add a little bit of springing motion with the hand that's holding at the elbow to stretch out that capsule that's been tightened down. So, even though it's a little bit uncomfortable, by the time you're finished, there should be a significant amount of relief on the part of the patient. Once I've completed that treatment, stage one, I'll go to stage two, and that is using a technique of muscle energy as well as deep tissue work called the stages of Spencer. We'll demonstrate on the right shoulder, so we'll have the patient roll to lay on his left side. And the stages of Spencer are to take the shoulder joint and capsule through various planes of motion. And the first one we start with is to bring the elbow up in a bent position so that we're putting the shoulder in an extended position. Once I'm up with the shoulder in this extended position, I will stabilize at the shoulder blade. And what I'm doing is I'm grasping on the front part at the clavicle and posteriorly with my thumb at the spine of the scapula so that I can minimize the motion of the scapula during this treatment as much as possible. So, as I'm stabilizing, inducing that extension, the patient is going to push their elbow down towards their feet gently. I'm going to resist that for three to five seconds, and then they will relax. As they relax, after a couple of seconds, I stretch just a little bit further and then repeat that. Relax. And I'll repeat that three, four, maybe five times as much as I feel like I need in order to obtain a good stretch in the extended position for the shoulder. The next position is in flexion. So, I'm going to continue to stabilize like I was earlier for the extended position with my fingers holding front along the clavicle and posterior along the spine of the scapula, but bringing the shoulder into extension. Once I get to the spot of a good tightness, but not painful, I'll have the patient push the elbow down towards the feet. Two, three, five seconds, relax. And then again, after two seconds, I'll move into a little bit further stretch. From flexion and extension, now we're going to do a technique that's called circumduction. We're going to do this twice in two, in different ways. The first way is to continue to stabilize at the clavicle and spine of the scapula, bring the shoulder into 90 degrees of abduction, and then I'm going to compress through the elbow at the olecranon directly up to the glenohumeral joint. And I'm going to induce rotation, a circular motion, while I'm compressing. And it shouldn't be a gigantic force, just enough to feel that I've got tension building at the glenohumeral joint. And I'm going to do that circular motion in both directions, clockwise and counterclockwise. If there's a spot on the clock, say the 12 o'clock to 10 o'clock, then I may spend a little bit more time slowly stretching along there before I continue through the clockwork motion, or counterclockwise motion. The next circumduction, I won't be stabilizing at the scapula because we're going to do this with traction. And so, I'm either going to grasp at the elbow as he flexes his elbow around my hand, or if I'm tall enough, I'll have the elbow locked in extension, and I'll grasp at the wrist and maybe the forearm, and add the traction up towards the ceiling. And same motion of circumduction, small circles, big circles, counterclockwise, clockwise. How much time do you spend on circumduction? It's really up to what the patient feels. Probably, I would generalize the treatment of those circumduction steps, 30 seconds for each step. Once we've done the circumduction, now we're going to treat internal and external rotation. We'll start with external rotation. So, I'm going to stabilize back at the clavicle and the spine of the scapula as I was before on the shoulder blade. And I'm going to induce external rotation, keeping the elbow as close to the rib cage or the torso as possible. And once I get to a point of tightness, then I'm going to ask the patient to push their palm down towards the table, gently. So, as they push, I resist that motion, and then after three to five seconds, they relax. Once they've relaxed for a few seconds, I pull into more external rotation, getting a little bit more tightness and repeat that several times. From external rotation, we go to internal rotation. For this, I have them slide their hand towards their back, right about the level of the pelvic rim, and I'm maintaining hold on the elbow. It's going to be more convenient for the hand that was stabilizing at the shoulder blade to move to the elbow, so I'm going to come with my other hand that's now free and stabilize here, or I'll just shift positions so that I can continue to stabilize. What we're doing here is inducing the internal rotation by lifting the elbow up towards the ceiling, and then the action that the athlete or the patient is going to induce is pushing their elbow back towards the floor. So as I resist that motion for three to five seconds, they'll relax, and then as they relax, I'll gently bring the elbow elevated to induce even more internal rotation at the glenohumeral joint, and then repeat that muscle contraction isometric treatment. And then once we're done with the internal rotation, I'll move around, and we'll do a pumping action at the glenohumeral joint. For this, I'll have the patient rest their arm on my shoulder. I will find that space between the acromion and the head of the humerus, and I'll put my fingers, whether it's clasping my pinky fingers or my ring fingers, right into the space, the subacromial space. I'll add compression down into the joint as I'm clasping my palms around the posterior and anterior parts of the proximal humerus, and then I'm gonna do a milking action in this manner where I'm compressing into the joint, drawing down towards the feet, and doing it in a fairly fluid motion. So it's not a jerky motion, it's a very smooth motion, and trying to get the force from multiple directions. So not just straight into the joint, but refocusing and coming from behind and inducing sort of a milking action, coming from above, coming from the front, just so I'm getting all areas of the glenohumeral joint in this fashion. If I wanna add a little bit more traction to it, then I just pull a little bit further to add that traction and add that milking motion. Now that I've completed the stages of Spencer, I'm going to add one other treatment, and that's to treat the shoulder blade of the scapula itself. And I'm already in the position where I finished from the stages of Spencer with their hand just resting on my shoulder. I'm gonna come behind and grasp the entire shoulder blade, curling my fingers along the medial border of the scapula, and then lifting the scapula superior or up towards the ceiling, as well as trying to gently, with my fingertips, pull the scapula just a tiny bit away from the rib cage, from the thoracic cage. And then I'm going to stretch into protraction, relax into retraction, and repeat that. And if I need to get a little bit more of rotation, I'll take my caudad hand and hook my thumb around the angle of the scapula so that I can get a little bit onto the subscapular muscle and get a little bit more control so that I can induce rotation at the scapula in addition to doing protraction and retraction. Frozen shoulder is not something that will clear up with one of these treatments in a single day. So this is a treatment and a treatment regimen that should be employed weekly over the period of six to 12 weeks.

3rd Edition, CASE 50

3rd Edition

Shoulder

frozen shoulder

Spencer technique

glenohumeral joint

scapula manipulation

muscle energy