Frozen Shoulder and Related Conditions

Supraspinatus tendinopathy, bicipital tenosynovitis, infraspinatus myostrain, and subscapularis myostrain can often be diagnosed as Frozen Shoulder.

“Frozen shoulder” is a common diagnosis given for those experiencing shoulder pain, stiffness and a decrease in mobility. True frozen shoulder, which is called adhesive capsulitis, refers to a condition where there is a buildup of scar tissue in the joint capsule of the shoulder. There exist several other conditions which often get called “frozen shoulder,” but those can be more precisely differentiated. The most common of these conditions that I see in clinical practice are: supraspinatus tendinopathy; bicipital tenosynovitis; infraspinatus myostrain; and subscapularis myostrain. Each of these involves different structures, has variation in pain patterns and referrals, and, more importantly, requires a different treatment for a successful outcome.

Frozen shoulder and related conditions affect many people of different ages and they affect both men and women. Those between 40-60 years of age are more frequently afflicted with shoulder problems, and women experience shoulder pain much more frequently than men. 2-5% of the population in this age demographic will experience this problem. There is evidence showing that hormonal changes during menopause are linked to the greater frequency of shoulder pain experienced by women.

These conditions may be caused by trauma or they may come on insidiously, in which case there seems to be no apparent cause, although it’s possible that postural imbalances, age, nutritional deficiencies, changes in hormone levels, diabetes, Parkinson’s and other conditions may be contributing factors. Proper differentiation is crucial when treating so that mechanism of injury can be determined, target tissue can be assessed and treated, postural disparities can be corrected, and proper use of medicinals can be employed (herbals, nutraceuticals, or pharmaceuticals depending on the scope and treatment philosophy of the physician). In Sports Medicine Acupuncture®, this is extremely important as the injury or cause of pain will guide the proper use of acupuncture, myofascial release (a type of clinical, deep tissue massage), corrective exercises, and herbal medicine prescription.

I will discuss the four main causes of shoulder pain and stiffness in future posts and will link these blog posts together. Again, these conditions are:

• Supraspinatus tendinopathy – an inflammation or irritation with fibrosis (extra fibrous tissue) of the tendon of the supraspinatus (one of the rotator cuff muscles). Tearing (either partial or full) may be present;
• Bicipital tenosynovitis - an inflammation or irritation with fibrosis of the tendon sheath of the biceps brachii muscle;
• Supscapularis myostrain - a pain pattern caused by trigger points affecting the subscapularis muscle (another of the rotator cuff muscles);
• Infraspinatus myostrain - a pain pattern caused by trigger points affecting the infraspinatus muscle (yet another of the rotator cuff muscles).

For all of these conditions, mechanism of injury will be discussed (mechanism of injury describes the underlying causes of the injury), treatment options will be explored, and self-help corrective exercises will be discussed.

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Foot Pain and Plantar Fasciitis

Treatment of Foot Pain Caused by Plantar Fasciitis and Plantar Fasciosis.

Fig. 1: Ed Yourdon [CC BY-SA 2.0
'(https://creativecommons.org/licenses/by-sa/2.0)],
via Wikimedia Commons

The new year is here and many people are going to be starting new exercise regimens as part of their resolutions. Some of those starting exercise programs that involve running will develop pain on the plantar surface of the foot (the bottom of the foot) and will develop plantar fasciitis. If the pain persists, the condition may well be reclassified as plantar fasciosis. This post will discuss these two related conditions, will look at self-help techniques, and will discuss treatment options with acupuncture, deep tissue massage, and herbal therapy so that you can quickly get back to becoming more fit in 2016.

Fig. 2: Image from: Sobotta's Atlas and
Text-book of Human Anatomy 1909.
This author uses the term Plantar 
aponeurosis for Plantar fascia

Plantar fasciitis and plantar fasciosis are common pain syndromes involving the plantar surface of the feet, and, since this problem affects us when we are weight-bearing (standing, walking, running, etc.) it is an especially annoying problem. This condition results in pain at the attachment site of the plantar fascia to the calcaneus (heel) as seen in Fig. 2. One of the hallmark symptoms of plantar fasciitis, at least in the early stages, is pain with the first few steps in the morning or upon rising after sitting for a long time, though it can become more severe over time and the pain can persist during weight-bearing activities.

First off, it is important to understand the difference between plantar fasciitis and plantar fasciosis. This is rarely discussed, even by most physicians, but it is very important when considering treatment. For plantar fasciitis, the suffix -itis means inflammation, so this would imply that there is an inflammation of the plantar fascia. In the very early stages of pain of the plantar fascia, this could very well be the case. This would be especially evident if someone starts a new exercise regimen that involves weight-bearing activities such as running, jumping, martial arts, etc. Conventional medical treatment might consist of corticosteroid injections or the use of NSAIDs (non-steroidal anti-inflammatory drugs) to reduce the inflammation. In my clinic I would consider a Traumeel injection and/or would use herbal medications that have an anti-inflammatory action. Other treatment strategies will be discussed below.

For those suffering from chronic pain of the plantar fascia, the inflammation model is likely not correct. There is a significant amount of research now which shows that inflammatory cells are often not present in these types of chronic pain conditions which affect connective tissues such as tendons and aponeurotic structures (such as the plantar fascia). Usually these signs of inflammation are no longer present after about two to three weeks after the initial tissue insult.

Fig. 3: Image modified from:
Phulvar (Own work) [CC BY-SA 3.0
(https://creativecommons.org/licenses/by-sa/3.0)],
via Wikimedia Commons

Researchers and, increasingly, some physicians are now referring to chronic pain associated with the plantar fascia as plantar fasciosis. The suffix -osis­ indicates a diseased state, in this case involving a degenerative process which results from a decreased blood flow to this tissue. This decreased blood flow is caused by an increase in scar tissue and fibrosis (fibrous tissue buildup) of the region. For these chronic cases, breaking up this scar tissue and actually causing a mild inflammation in the area is necessary to bring an adequate supply of blood to the region. Acupuncture and deep tissue massage techniques such as myofascial release are very effective for accomplishing this, especially when combined.

Fig. 4: Deep myofascial release to the attachment of the plantar fascia. Very little to no lotion is used and the a slow gliding movement is used to break up fibrous adhesions. This is especially effective after acupuncture.

In either case, whether the pain is acute or chronic, the localized treatments described above are just one aspect of recovery from these painful conditions. It is crucial to look at strain and tension patterns in the legs, especially the calves, and it is also necessary to look at how weight transmits through the foot.

Fig. 5: Foot overpronation. This image also
illustrates inhibition of the gluteus medius 
and minimus leading to  an elevated right ilium. 
Due to this, the knee moves in during weight 
bearing and the foot overpronates.

Over-pronation (a collapse into the medial arch of the foot) is a common contributing factor. In addition, restriction in the muscles of the calf (the gastrocnemius and soleus) are very often contributing factors. When these muscles are restricted, they transmit too much pull on the Achilles tendon during walking, which prevents proper ankle movement and requires the foot to undergo too much movement to make up the difference, therefore overstretching and irritating the plantar fascia.

Stretching these calf muscles to return proper flexibility can be very helpful for plantar fasciitis. Improving flexibility here allows proper ankle movement and takes the strain off the plantar fascia. Besides this, the calf muscles are continuous with the plantar fascia via their fibrous connective tissue components. These muscles and the plantar fascia are on the same fascial plane, so increasing flexibility and suppleness in the muscles will reinforce an increase in suppleness at the plantar fascia.

For chronic cases, self-massage can be a helpful tool. I give a very simple, yet useful, self-help technique to patients suffering from plantar fasciitis. When waking in the morning, but before getting out of bed and stepping on the foot, I recommend using the thumb to perform a circular massage at the attachment of the plantar fascia to the calcaneus (heel bone). This is the most common site of pain and inflammation; the goal of this circular massage is to warm up and create suppleness in the plantar fascia before putting an abrupt and forceful motion through it by stepping on the foot. For many people, doing this every morning (and even after sitting for several hours) is very helpful. However, for more recalcitrant pain and dysfunction, this will not be enough and other measures need to be looked at.

A combination of acupuncture and deep myofascial release to these and related regions yields excellent results and is often necessary when dealing with the pain associated with plantar fasciitis. If it is painful to stand and walk, exercise becomes difficult and people become more sedentary, leading to other health complications. It is essential to deal with this problem so that you can do all the things that are important to you and start your new year off right.

Note: In Sports Medicine Acupuncture® we first assess the condition to see if it is truly plantar fasciitis. There are many other conditions which can cause pain in this region and they need to be ruled out. Included are tarsal tunnel syndrome and tibialis posterior tendinopathy. Proper treatment of these conditions will be much more successful if the condition can be properly diagnosed.

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