Frozen shoulder



Chris Giordano, a student at NYCTCM, gave an overview of Frozen Shoulder from a TCM perspective for his Clinical Acupuncture Practice II class "Treatment of Modern Diseases with Traditional Chinese Medicine". 


He describes the basic bioscience of frozen shoulder, then tells us the basic TCM knowledge about frozen shoulder, including major pattern differentiation and major treatment points and needle techniques. He gives techniques for prevention of frozen shoulder, then summarizes current research on the treatment of frozen shoulder with Traditional Chinese Medicine.


 "The cause of frozen shoulder is unknown, but it probably involves and underlying inflammatory process. The capsule surrounding the shoulder joint thickens and contracts. This leaves less space for the upper arm bone (humerus) to move around. Frozen shoulder can also develop after a prolonged immobilization because of trauma or surgery to the joint... The symptoms are primarily pain and a very reduced range of motion in the joint. The range of motion is the same whether you are trying to move the shoulder under your own power or if someone else is trying to raise the arm for you. There comes a point in each direction of movement where the motion simply stops as if there is something blocking the movement. The shoulder usually hurts when movement reach the limit of the range of motion, and can be quite painful at night. 


Major Treatments or Medications 


Treatment of the frozen shoulder can be frustrating and slow. Most cases will eventually improve, but it may be a process that takes months. Initial treatment and increasing the range of motion of the shoulder with a stretching program. Anti-inflammatory medications may be prescribed. 


It is critical that a Physical Therapy program be started and continued to regain the loss of motion. An injection of cortisone and long-acting anesthetic, similar to novocaine, may bring the inflammation under better control, and allow the stretching program to be more effective. In some cases, injecting a long-acting anesthetic along with the cortisone right before a stretching session with the Physical Therapist can allow the therapist to break up adhesions while the shoulder is numb from the anesthetic. 


If  progress is slow, your doctor may recommend a manipulation of the shoulder while you are under anesthesia. This procedure allows your doctor to stretch the shoulder joint capsule, and break up the scar tissue while you are asleep. In most cases, a manipulation of the shoulder will increase the motion in the shoulder joint faster than allowing nature to take its course. It may be necessary to repeat this procedure several times. 


Related terms in TCM 


The first description of frozen shoulder was provided by the French physician E.S. Duplay in 1872. During the 20th century a corresponding Chinese term arose: "50-years shoulder" (wushi jian), referring to the typical age of onset of the disorder; the term frozen shoulder (jianning) is also used in China. While there are numerous references to traditional style Chinese medical treatments for problems of the shoulder area, investigations into the use of the therapies specifically aimed at frozen shoulder have only been described in the last few years. 




Traditional Chinese Medicine differentiates frozen shoulder into three types:

                  Wind cold dampness, the most common type

                  Blood stasis


Frozen shoulder is mostly caused by weakness of the nutrient and defensive systems, asthenia of muscles and joints as well as wind-cold invasion. However, twisting and contusion due to careless exertion or stagnation of Qi and blood due to habitual one-sided sleep pressing the channels and collaterals may also cause "50 year shoulder". 


Clinical Manifestations 


Pain initially starts on one or two shoulders. It alleviates in the daytime and worsens at night. The condition also aggravates with cold, but alleviates with warmth. Prolonged "50 year shoulder" may result in muscular atrophy. 


Major Pattern Differentiation 


In TCM, "50 year shoulder" may be differentiated into three types:

                  More wind pathogen invasion: this will present with more lesion in the tendon. Shoulder pain will extend to the nape and fingers.

                  More cold pathogen invasion: this will present with more lesion in the bone. Shoulder pain will be severe in the deep area, but will be alleviated by heat.

                  More damp pathogen invasion: this will present with more lesion in the muscle. The shoulder pain will be fixed, worsening with pressure. There will be local swelling .

Major Acupuncture Points & Needle Techniques for Frozen Shoulder


In TCM, the treatment principle for "50 year shoulder" is to:

                  Expel wind-cold

                  Promote Qi and Blood circulation

                  Remove the obstruction from the channels and collaterals

The following acupuncture points may be selected:

                  3 Needle Hegu Puncture may be applied to:

                  LI-15 Jianyu

                  SJ-14 Jianliao


                  SI-9 Jianzhen

                  LI-11 Quchi

                  SJ-5 Waiguan

The following points may be added to support for pain in the following locations:

                  Pain in the medial shoulder: LU-5 Chize, LU-9 Taiyuan

                  Pain in the external shoulder: SI-3 Houxi, SI-8

                  Pain in the frontal shoulder: LI-4 Hegu, LU-7 Lieque

                  Pain radiating to neck and back: BL-10 Tianzhu, SI-12 Bingfeng, SI-13 Quyuan

                  Limited Movement: ST-38 Tiaokou accompanied by active movement and moxibustion

As an alternative to these points, Auricular Therapy may be employed.

                  Shoulder, Shoulder Joint, Clavicle, Sympathetic, Subcortex

                  The method used is strong stimulation, while patient is asked to rotate his/her shoulder.

                  Needle should be retained for 10-20 minutes.

                  As a further alternative, Cupping Therapy may be used on the following points:LI-15, SJ-14, SI-10, and the extra point Jianneiling

Acupuncture with Distal Points 


One of the earliest Chinese reports of acupuncture treatment of frozen shoulder was published in 1991, based on a simple treatment method. The author of the article, Zhang Maohai, claimed to have found an effective therapy through his experiences. He focused on one acupuncture point, yanglingquan (GB-34), located on the leg, which he said seemed more effective than treating multiple points. The point was needled on one side only, the same side as the affected shoulder. In rare cases where this same side treatment did not seem to be helpful, the point was needled on the other leg instead. 


The technique used was deep insertion (2.0-2.5 cun), followed by rotating and thrusting to get the qi reaction; the reducing technique was used for all patients, but deficiency patients were administered the treatment with both reducing and reinforcing techniques. The needle was maneuvered again every 3-5 minutes to maintain the stimulus. In the meantime, the patient was advised to move the shoulder joint. Total needle retention time was about 30 minutes, and five daily sessions made one course of treatment. 


After two courses of treatment (with a break of a day or two between courses), the frequency of treatment was reduced to every other day until the condition was resolved to a satisfactory extent. In the event of acute shoulder pain, electro stimulation of the needles was used (intermittent waves, strong intensity). It was claimed that as a result of this therapy, 64% of the 172 patients so treated were cured, and all the rest (except 8 patients) showed some degree of improvement. In two cases that were detailed, the total treatment involved 10 sessions in one case and 20 sessions in the second case.


 The selection of this acupuncture point is of interest. Traditionally, yanglingquan is mainly indicated for treatment of lower limb disorders, such as pain and numbness in the legs and knees, but the effects of stimulating this point are thought to also extend upward along the gallbladder meridian, which traverses the costal region to the shoulder. There, the meridian passes through the point jianjing (GB-21), indicted for stiffness of the neck, pain of the shoulder and upper back, and for difficulty moving the arm. A further basis for using yanglingquan is its reputation for soothing and moistening the sinews. Since the shoulder capsule is contracted, this action is considered important to healing the disorder...


 A similar method was described in a report by Feng Zhengen (4), using the extra point lingxia, located 2 cun below yanglingquan (GB-34). The point on the same side as the affected shoulder was needled, while sanjian (LI-3), on the hand, was needled on the opposite side. The patient would move the affected arm during the acupuncture therapy. Treatment was given daily for 10 sessions, followed by a 2 day break and then another 10 sessions. It was reported that of 210 patients treated, 158 cases were resolved, and that all but 12 cases showed some improvement. 


The selection of lingxia, rather than yanglingquan was based, according to the author, on the fact that he found a marked tender point at this spot which, when pressed, alleviated the shoulder pain. Another acupuncture point in this same area of the leg that is used for shoulder disorders is tiaokou (ST-38). It is especially considered for treating acute shoulder pain, and is stimulated while the patient moves the shoulder. Jorge Vas and Emilio Perea-Milla compared the effects of needling tiaokou on shoulder pain when the treatment either did or did not elicit deqi, finding that deqi was important to gaining the desired prompt alleviation of pain. The successful use of tiaokou for frozen shoulder had been mentioned in an early publication by German acupuncturists. 


yanglingquan_GB-34.jpgAcupuncture with local points 


The points chosen to treat frozen shoulder are often selected from those on the small intestine meridian, especially from SI-9 through SI-12, which run across the shoulder area. A key point is bingfeng (SI-12) at the attachment zone for the shoulder capsule. Bingfeng (grasping the wind; which became the title of a book about the names of acupuncture points; 8), is located by raising the arm, which produces an indentation at this spot. It is used to relieve disorders where there is shoulder pain accompanied by difficulty raising the arm, as occurs with frozen shoulder. In a report published in 1998 (9), results from treating 60 patients with "shoulder-arm" syndrome were relayed. 


Although this report did not address frozen shoulder, it claimed to produce marked effects through use of this single point (a second point would be treated for manifestations of the disorder in the forearm or hand). Local treatment was the primary focus of a recent report by Jin Dongxi and Li Zhingtai, who described treatment of 50 patients with frozen shoulder using acupuncture and massage (10). They stimulated several points on the shoulder, including bingfeng, as well as others on the hand and arm of the same side as the affected shoulder. The points selected for treatment were:


                  extra point taijian (the name means "lift shoulder;" it is located 1.5 below the anterior part of the acromiom);

                  extra point jubi (the name means "raise arm;" located 3.5 cun below the anteroinferior part of the acromiom)

Ashi or trigger points around the shoulder should be carefully sought and needled superficially; tiaokou (ST-38) with strong manipulation is useful. Deqi should be sought in the robust patient, with less stimulus in the weak patients. Electroacupuncture at quchi (LI-11), jianyu (LI-15), jianjing (GB-21), and jianzhen (SI-9) at 5 Hz helps; yanglingquan (GB-34) bilaterally for 2 minutes alone often controls pain and releases stiffness. Auricular therapy at shenmen, shoulder, shoulder joint, clavicle, and adrenal points is helpful. The patient should exercise faithfully with a slow warm-up. Finally, the use of scalp acupuncture should be mentioned. This treatment is frequently used for chronic pain syndromes and was the subject of an evaluation involving 210 cases (15). A point was treated along the vertex-temporal line, which runs from the head vertex baihui (GV-21) to the temple at xuanji (GB-6), about 40% of the way from the vertex to GB-6, which is in the zone corresponding to upper extremity disorders. 


The needle was threaded about 30 mm (about an inch) towards the temple (a second needle, inserted close to the same point but angled 45 degrees to the first and crossing its path, was often used to get more intense stimulus). If only one shoulder was affected, the contralateral side would be treated; with both shoulders affected, both sides would be treated. The patient was advised to relax, focus on the affected shoulder, and carry out shoulder movements during the treatment, while the practitioners manipulated the needles (with repetitive rapid withdrawal about 3 mm, then slower return) at least every 5 minutes and sometimes also massaged the shoulder. The needles would then be retained for 1-2 hours, or up to 1-2 days for severe cases. Typically, treatment was carried out every 1-2 days with seven sessions as a course of treatment. " 


 Chris then explains how Tai Chi can help prevent frozen shoulder, and gives some exercises and nutritional recommendations, including vitamin D supplementation. If you suffer from frozen shoulder, the exercises and diagrams are very useful. 


You can read the whole paper here. It is a swf file which should open in your browser as a slide show or with Flash. Diagrams and pictures of the acupuncture points are included in the paper.


  Frozen Shoulder Causes & Treatment with TCM.swf