On this episode of the #AskMikeReinold show we talk about how to identify and treat early-stage adhesive capsulitis. Maybe we can keep people from freezing, here are some of our thoughts.. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 217: Treating Early Stage Adhesive Capsulitis
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- Identifying Early Signs and Symptoms of Adhesive Capsulitis
- How to Know When to Push a Stiff and Painful Shoulder
Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about some ways that we identify and treat early-stage adhesive capsulitis.
Mike Reinold: We have a great question today from Cecilia, from Brazil. I thought this was a good question and I sent it to you guys a bit little early, I hope you guys took a peek at it so you could think about it. But Cecilia asks, I want to read it well, if diagnosed early enough, can adhesive capsulitis be treated so that way the actual encapsulation process does not develop?
And you know what, why don’t we approach this question as this, if we catch early adhesive capsulitis in a irritable or even a freezing phase, if we want to use the less-scientific terminology, can we prevent them from getting further off, like frozen in that process? So who wants to start? I’m sure we all have some experience with this. Maybe Len, you can talk about some people that you’ve seen that maybe you think that you think you’ve helped.
Lenny Macrina: Yeah, yeah.
Mike Reinold: Why don’t you start off, Len, with your experience and then Dave and Mike, chime in as you get some ideas?
Lenny Macrina: Yeah. And no doubt, I’ve treated a bunch of people with this. And a lot of times when they come to me, it’s well… I think of it two different ways. They come to me and it’s way too late and the are way beyond this because they thought it was just a rotator cuff or they just thought they had shoulder pain or rotator cuff tendonitis. And they come to me and they just can’t raise their shoulder up. I think that’s more deep into the freezing or frozen phase.
Lenny Macrina: But I get a lot of people that come in that are in that early phase, and I think if you can recognize it early, meaning they’re having this pain that, without a specific onset, a very benign kind of reaching back, I hear a lot. Pulling luggage, reaching to my back seat, my shoulder started to ache. It’s been a few weeks as throbbing now. And I have good motion, but just doesn’t feel right. And it’s not that true rotator cuff pain that you get down. Another clue that I get from people, and I think I got this from Kevin Wilke in Birmingham, is that they had this horizontal pain, this band of pain, that goes along the shoulder that tends to be more synovitis, which we think is the precursor to frozen shoulder, versus the pain coming down, which is rotated cuff. Not the pain going all the way down, that’s going to be more neck, but the pain coming down rotator cuff horizontal band, more synovitis.
Lenny Macrina: So for those people, I’ll go cortisone injection. I’ll try to get them in to see a doctor and get a cortisone injection. So that’s where the relationship with a doctor is critical because they need to trust your judgment and try to recommend, hopefully, that the patient can get one, because I think that’ll help them in the long run to avoid, I think, the full blown, I think I’ve definitely seen people where I’ve gotten them a cortisone shot early and we were able to manage their symptoms, manage their loss of motion. They still got a little loss of motion, but not the full blown months and months and months of that freezing, frozen, thawing phase. And I’m pretty convinced that we were able to recognize early. Could be biased, maybe I want to pat myself on the back, but I don’t know. I’m pretty convinced that their symptoms really matched what was going to be a bad episode or could have been a bad episode, and we were able to help him with early cortisone. And research has shown that really cortisone is definitely beneficial to people.
Mike Reinold: It’s interesting. It’s a biased question a little bit, because if you address it early enough, you never really know if it was adhesive capsulitisis.
Lenny Macrina: Right, I know. I know exactly. Yeah.
Mike Reinold: You only know until it’s too late. I thought that was pretty cool though. A good way to differentiate some differences in whether or not it’s rotator cuff. Like Lenny said, rotator cuff kind of radiates down almost, whereas the other one, sometimes they almost do this, like what we say about the hip.
Lenny Macrina: Yeah.
Mike Reinold: They almost kind of grabbed that.
Lenny Macrina: [inaudible 00:04:30]. Yeah.
Mike Reinold: It’s almost like more joint-y, versus rotator cuff-y. You brought up a good point that you brought up somebody that reaching in the back seat, stuff like that. Sometimes it takes an incident and then it trips this cascade of inflammation they can’t get out of.
Lenny Macrina: Yeah, yeah.
Mike Reinold: I don’t think we completely understand that, but you just brought up a really good example. So that person would almost look like a rotator cuff impingement type person because they strain their rotator cuff, or whatever, picking up something, and then that could turn into it. But yeah, I think you kind of alluded this too, sometimes people just come in and they just have some goofy pain and we’re not a hundred percent sure why, and it doesn’t add up to impingement signs either.
Lenny Macrina: Yeah.
Mike Reinold: And you’re like, “Man, I don’t know. You’re too young. I don’t know why. You don’t have OA, you don’t have osteoarthritis.”
Lenny Macrina: Another thing is the medical history too. Make sure you [tease out 00:05:27] a couple… Do they have diabetes? Do have thyroid issues? Those two have been linked to a higher incidence of frozen shoulder as well. So maybe their medical history could give you a clue, along with their symptoms and maybe an onset. So those are my go-to questions.
Mike Reinold: Dave, Mike, anything you guys want to add?
Dave Tilley: My 2 cents, I think Lenny hit it really well, is often these things are multifactorial and I think we get kind of stuck in the research of looking at the shoulder capsule itself. And I think, as Lenny as you pointed out, there’s a lot of issues that could possibly mitigate the longterm progression of it. But at the same time, I think we don’t really know a lot about exactly what’s going on and exactly the time courses people have, so I think to some degree, you may be able to reduce the intensity or severity of that onset.
Dave Tilley: But I think a lot of times these people have a lot of other low hanging fruit that we can help them with, that they don’t realize is linked to maybe why they have shoulder issues. So looking at thoracic spine motion, looking at neck motion, looking at soft tissue stuff, you’re not going to maybe prevent the capsule itself from becoming really irritable, but you can give that person 10% motion from their upper back and from their soft tissue. That’s probably going to be a big deal for them because they can move a little bit more with less pain. So I think we often look at the pathology, and I’m guilty of this when I was a kind of a newer clinician and just hyper focusing on the capsule, but there’s a lot of other things that we can do for these people, I think in the short-term, to help them, and I think it’s not only about looking at the capsule, but many other things as well.
Mike Reinold: Yeah. I mean, we don’t know a lot about this. We don’t know who turns into this and who doesn’t. And in a lot of times it’s chicken or the egg. And I think that you kind of alluded to that, Dave, a little bit of it’s chicken or the egg a little bit, like where is it the capsule that is getting a little tight and irritable for whatever reason, maybe something systemic that we don’t understand, like linked to their diabetes or something like that. But maybe it’s the capital getting irritated and then they’re causing a little bit more impingement and it’s causing a little bit more pain, and then you start to get that cascade.
Mike Reinold: Or maybe it’s the opposite. Maybe you get a traumatic incident or you get some rotator cuff impingement, and then for whatever reason, the capsule becomes inflamed. Because we see this both. We see the idiopathic, and then we see the post-injury type adhesive capsulitis. They both seem to happen. So that’s pretty interesting.
Dave Tilley: Yeah.
Mike Reinold: Mike, anything on your end?
Mike Scaduto: Well, I think from a treatment perspective, if someone’s presenting with loss of motion that could be painful, especially into external rotation, I’m going to make that a focus of my treatment, especially early on. So we’re going to do a lot of active assisted range of motion, some soft tissue, maybe some joint moves. And that’s going to be our monitor of progress, is how well are they maintaining motion? Are they losing motion? If so, maybe we reassess where we’re at. Maybe then we’re sending off to doctors doctor to get a cortisone injection if you haven’t done that already. But definitely want to try to maintain and gain motion, especially into external rotation, which seems to be the capsular pattern for something like adhesive capsulitis.
Mike Scaduto: And then probably just not… With joint mobs, I tend to go not super aggressive with my joint mobs. So I guess there would be great for joint mobqs, but maybe I’m not doing a lot of them. The thought in my mind is we don’t want to stimulate that inflammation or that inflammatory process, but we want to do it until we get a little bit of motion, and then have them passively move their shoulder or active assisted range of motion from there to maintain motion.
Mike Reinold: I like it. So if we kind of put it all together, I think we talked a lot about what’s going on, or as much as we know what’s going on, which is pretty good. So it sounds like maybe an early cortisone is pretty helpful, which is great. I’m on board with that and I think that helps quite a bit. But otherwise I think the concept of this is you got an irritable shoulder that maybe has a little bit of loss of motion. It’s about getting after that a little bit early. And I think if you take some of what Mike said there, we focus more on the frequency of the mobility, because again, maybe self-immobilization is part of why they got into this mess, because they said, “Oh, it kind of hurts. I’m going to just not use my arm for a few weeks.” And maybe that kind of got into it. So it’s a lot of frequent motion. So yeah.
Mike Reinold: So I guess to summarize for Cecilia, how do we treat it? Well, I think we treat it just like anything else, but I think the number one key to treatment is identifying that this may be what’s happening. And I think I would just add this to the discussion here, is that I think a lot of times what we think is impingement or even early rotator cuff-like issues, inflammation type things, may in fact be early adhesive capsulitis, that if we address right away, I think we save them from going down that road. I think it happens almost every day in your clinic, I bet, and you don’t even know it’s happening. That’s my guess, just because I’ve seen people noncompliant or people not take care of themselves, spiral down out of control and you can’t stop that. So I actually think we’re doing more helpful things to them by trying to get them to break that cycle before the cycle even begins. So I think that’s kind of the key.
Mike Reinold: So Cecilia, I think you’re right. I think there’s some things we can do. Now you talked about before the actual encapsulation, I mean I don’t know. I don’t know about that. That’s like late-phase type of adhesive capsulitis. I think just even focusing on it earlier. You got to notice, hey, somebody’s got just a loss of like 10% of their very end-range of range of motion. That’s weird, right? That’s weird. Makes sure they can get that motion back and make sure they’re frequently moving it. So we can do a ton of good for these types of patients if we are thinking that way. Because if you’re thinking rotator cuff impingement and that’s it, you might not focus on assuring that the capsule stays mobile and their range of motion stays mobile, you just might focus on strength, for example. So kind of keep that in mind as well.
Mike Reinold: Anytime you see an irritable shoulder, we’ll call it that, I want you to think that going forward, that this may be like a phase one freezing kind of adhesive capsulitis. It might even be pre-freezing. I just made up a new stage. That’s a thing, that’s a thing. Pre-freezing. What would pre-freezing be? It would be wet. It’s wet. It’s the wet phase. All right. Not funny. Okay. It’s early, we’re doing this early in the day, but anyway. Awesome.
Mike Reinold: Well great question Cecilia, we appreciate it. Thanks for listening and watching from Brazil. That’s awesome. If you have a question like that, head to mikereinold.com and click on the podcast link and you can fill out the form to keep asking us some amazing questions. So keep them coming. Anything you can do to help support the show we’d appreciate it. Head iTunes, Spotify, rate, review, and we will see you on the next episode.