Monday, June 30, 2014

Massage and TCM for Frozen Shoulder Syndrome FSS

Frozen Shoulder Syndrome (FSS) also known as adhesive capsulitis, rarely is a result from an underlying illness or pathology. It is fairly common affecting 2-5% of the population and is considered a medical enigma, once cured rarely comes back to the same side. It is often misdiagnosed and Western Medicine defines it as “a stiff shoulder with less than 50% of normal range of active and passive motion in any direction.

 The initial phase maybe characterized by an exquisite sharp catching spasm either spontaneously or due to trauma and pain at night, by phase II the night pain has gone away but ROM has decreased further.

The shoulder ball and socket joint is surrounded by a fluid filled bag containing 35-70ml of synovial fluid. During FSS the capsule thickens and becomes tight, fluid levels drop to 5-10ml of fluid, this is a 75% decrease in fluid. Stiff bands of tissue (referred to as adhesions) may start to develop in and around the capsule due to inflammation. Inflammation may start in the groove behind the biceps tendon, (long head of the biceps also known as the rotator interval).

The stiffness is due to an over reaction of the body to the inflammation. The body then switches off the muscles of the rotator cuff in a coordinated fashion. Without treatment this condition will last an average of 30 months (3yrs). This is fascinating as the body will eventually recover if you are too lazy for the possible treatments that will be discussed later.

The stages are as follows:
I) pre-freezing 0-4 weeks II) Freezing 1-8 months
III) Frozen 9-16 months IV)Thawing 12-40 months

FSS is more common in diabetics as 10-20% of the population are affected as opposed to 2-5%, this is due to the accumulation of sugar and alcohol in the tissues and specifically collagen. It is also more common in women than men 60%-40% and of course more common in women going through menopause.
A major factor causing FSS according to Janet Travell, author of “Myofascial Pain and Dysfunction: The Trigger Point Manual” are trigger points in the subscapularis muscle. The subscapularis muscle is one of the four muscles that comprise the rotator cuff. This muscle attaches to the inner surface of the scapula and to the front of the humerus, mainly responsible for holding the humerus in place during arm movements.

Trigger points are sensitive nodules in musculature that cause referred pain. Research shows that the pain referral pattern for the subscapularis is as follows: Pain concentrates on the back of the deltoid, extends back over scapula, then down the back or side of upper arm, pain skips forearm but appears again as a band around the wrist with more intense pain on the back of the wrist.

During phase I a person can reach up but experiences pain reaching backwards so FSS can be referred to as pitchers arm. This article goes into healing with acupuncture and it refers to SI-3 located on the side of the hand, this point is used to alleviate shoulder and upper back pain around scapula. It also stresses having good posture and not slouching or collapsing forward.
Traditional Chinese Medicine
The Chinese term for FSS is “wushi jian”, 50yr shoulder referring to the typical age of onset of the disorder. The Chinese Medicine patterns of FSS are as follows:
  • wind-cold-dampness invading
  • kidney and liver deficiency 
  • and Qi and blood stagnation. 
The meridians associated with the pain referral path of FSS correlate to the Fire Element. Indicating that the fire meridians are weak and not able to warm the shoulder area enough. The invading wind is related to the Wood Element, so these are two elements that you could start looking at while evaluating your client. An herbal formula would contain herbs to vitalize and nourish the blood while dispelling wind and warming the meridians.

One of the earliest Chinese reports of acupuncture for FSS was published in 1991. Zhang Maohai focused on on Pt (yang ling guan) GB-34 located on the leg, needled on the affected side only. He used a deep insertion needling technique (2.0-2.5 cun deep). Followed by rotating and thrusting to get the Qi reaction, needle in the Pt for 30min and maneuvering the needle every 3-5 mins while patient was attempting to move the shoulder joint. The selection of this point is interesting, traditionally GB-34 is indicated for treatment of lower limb disorders, but effects of this Pt are also thought to extend upward along the GB meridian which traverses the costal region of the shoulder. GB-34 is indicated for soothing and moistening the sinews.

Another distal Pt for FSS is ST-38, Tiao kou, located 8 sun below ST-35, one finger width lateral from the anterior border of the tibia. ST-38 is indicated for shoulder pain and specifically adhesive capsulitis. The local Pts proven to be effective for FSS are SI-9 through SI-15, a key point being bing feng SI-12, found at the attachment zone for the shoulder capsule. These points are located over the entire scapula and costal region.
Shoulder issues and specifically FSS will be a common syndrome that clients will come to Massage Therapists with. Alaska Institute of Oriental Medicine, Acupuncture and Massage Therapy teaches a massage treatment for FSS that involves acupressure points.

The protocol is as follows and can be incorporated into a full body massage or just a spot treatment for the affected shoulder.

Warm up the affected arm and hand then treat the Large Intestine (LI) pain pathway: LI-11 located at the elbow crease 8x, move down to the belly of the brachioradialis LI-10 8x, move down 1 cun to the flat tendon LI-9 8x, then down to LI-4 at the thumb crease mountain 8x. Do this pattern 3x then connect LI-11 with LI-4 8x. Then work directly over the scapula on the affected side with the Small Intestine acupressure points SI-9-SI-15 8x each 3x through.

The information presented in this article should provide you with some good guidelines to get you started on your own research.


1) Neil-Asher technique

2) "The Cure for Frozen Shoulder That No One Talks About" by Sara Calabro

3) "Treatment of Frozen Shoulder Using TCM" by Subhuti Dharmanada, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

4) Alaska Institute of Oriental Medicine, Acupuncture & Massage Therapy, Cynthia McMullen, TCM Instructor

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