Frozen shoulder in bio medical terms is known as adhesive capsulitis. Having consulted with a number of TCM practitioners, it has been confirmed to me that the treatment of frozen shoulder proves to be difficult even to the most seasoned and experienced practitioner.
The aim of this paper is to present a few ideas and experiences of my own and as well as other treatment protocols that have been sourced from various other TCM and acupuncture practitioners.
Firstly I will reiterate the type of treatment I used to give for frozen shoulder when starting out practice in Sydney’s Chinatown. My background in training was heavily influenced by my 1984 internship in the Hangzhou Red Cross Hospital (Zhe Jiang province, China). The points commonly used for shoulder problems were local points Jianyu LI-15, jianliao SJ-14, binao LI-14 and commonly supplemented with Small Intestine channel points on the back of shoulder. As a distal point tiaokou St-38 was used. Moxa box or warm needle was nearly always used as well as alternating with electro-acupuncture and cupping.
Upon returning to Australia I continued with this strategy, in particular using warm needle on jianyu LI-15 and jianliao SJ-14 for frozen shoulder. In most cases of using warm needle for the shoulder, I did this with the patient sitting up so I could use the warm needle technique without guards underneath with the intention to achieve greater benefit because of the direct heat. In my Sydney clinic I often had students from The University of Technology TCM faculty assisting me so extra time could be spent on the moxibustion process. Often up to 5-6 rounds of moxibustion warm needle were used at each session. My idea of the shoulder being “frozen” would benefit from the extra moxibustion, or so I thought at the time. In addition to acupuncture and moxibustion warm needle technique, electro-acupuncture and cupping was also applied.
The result of the cupping in the treatment of frozen shoulder has always intrigued me.
After having applied the cupping, I would commonly notice severe dark purple cupping marks around the shoulder and then be quite confident that the treatment was getting somewhere. I would explain to the patient that this confirmed the deep blood stasis was being resolved and thus the arm would be much better. I would cup again for a couple more visits using different locations, again getting the purple bruising coming out until additional cupping treatments would no longer bring out any further bruising reaction. However, for me, the surprising observation was, once the blood stasis appeared to be resolved, as confirmed by the cupping reaction, there was no change in either pain or stiffness. Some of these cupped patients would drop out of treatment and return a few months later after having tried various other therapists and treatments. Further cupping would reveal purple bruising coming out again but there would still no change in either pain or stiffness.
So what did I conclude from this.
Blood stasis is a coexisting factor of frozen shoulder and treating the blood stasis does not necessarily address the root of the problem. Of course this is quite different to what other TCM practitioners may advocate.
A summary of frozen shoulder according to western medicine is as below as taken from a New Zealand Accident Compensation Corporation (ACC) newsletter.
- Gradual onset of pain
- Often with unknown aetiology
- Possibly history of minor trauma
- Global restriction of active and passive movement of glenohumeral joint
- Pain worse at night
- May take up to 2-3 years to resolve
- More common in women
- Typically seen between ages 40 and 60
- Higher incidence with concurrent diabetes
There are three phases of clinical presentation
- Painful Phase: lasts 2-3 months where the pain is described as an “aching” pain also present at night disturbing the sleep
- Stiffness Phase: This can last up to 12 months with there being a gradual improvement in moving the arm.
- Resolving Phase: The shoulder gradually gets better with a gradual improvement in movement with less and less discomfort and this phase can last from 6-12 months.
What is most interesting to me, from a bio medical viewpoint, is that the condition of frozen shoulder actually gets better without any treatment at all! But it still takes 18 months or so.
Once I started to look into frozen shoulder and analyze simultaneously from a bio medical and Chinese medicine view point I started to ask myself some questions.
- Why does it come up without a history of trauma?
- Why does it get better without treatment?
- Why does is affect more women?
- What is the connection between diabetes xiao ke and frozen shoulder?
- Am I the only TCM practitioner admitting that it is difficult to get results with frozen shoulder?
- Is Frozen Shoulder a replete or vacuous condition?
I communicated with TCM practitioners with the aim to gain their knowledge in the treatment of frozen shoulder by analyzing their personal views on the condition and treatment techniques. I was some what relieved to discover that other seasoned and experienced Auckland based TCM practitioners Phillip Mettrick, Martin Greenleaf and David Craddock all reiterated that frozen shoulder was not an easy condition to treat and results were neither quick nor easy.
Both Mettrick and Craddock had the same view that the reason the shoulder became frozen was because the body was actually healing itself. There was probably an injury such as supraspinatous strain causing the teres, pectoralis and/or deltoid muscles to become tight. The shoulder becoming frozen was the natural way of preventing further tissue damage.
Exercise is an important component of the treatment strategy of frozen shoulder and patients must become involved in their own recovery process if any favorable prognosis is to be expected. (Greenleaf). Craddock suggested that the acupuncture treatment will benefit only 30% of the condition and 70% recovery is actually due to the exercise. In fact, Craddock has developed a specific exercise regime that he prescribes to his patients with frozen shoulder. It is beyond the scope of this article to go into an in depth description of these exercises that involve using a 2 kilogram weight, specific wall stretches and other exercises done in the water. In terms of acupuncture, Craddock also has various methods of needling that are specific to getting the most favorable outcome which involve needling into the abducted joint and angling the needle across the joint and superiorly. Martin Greenleaf on the other hand advises that there may well be an underlying mental component to frozen shoulder with Liver qi stagnation being the foremost pathology coexisting with frozen shoulder. He suggests supplementing Liver points such as taichong Liv-3 to the treatment regime to improve results.
Greenleaf also advocated that massage is a necessity in order to achieve results with frozen shoulder. In fact, other practitioners have stated that acupuncture on its own is of little benefit in providing a favorable outcome and tui na is the treatment method of choice. In particular Gavin Hurlimann and Vitalis Skiauteris, also Auckland based practitioners, confirm that view point. In communication with Skiauteris, I mentioned that when I did my internship in China I treated many acute shoulder injuries and bi syndromes of the shoulder joint but not many true frozen shoulders. Skiauteris commented that with his experience working in the hospitals in Beijing, frozen shoulder patients would rarely get to the acupuncture departments in China, as they were always referred to the tui na departments.
Standard acupuncture treatment for frozen shoulder had proved to have a poor prognosis for me so I looked into changing my treatment strategy and reviewing the diagnostic criteria. Where would I start?
Could the eight extra ordinary or luo vessels play a role in the treatment of frozen shoulder?
The luo vessels are not deep placed vessels like the main vessels and as opposed to be being vessels are really like a network and have been imagined to trap pathogens like fish being caught in a net.(Pirog) When acupuncture was first practiced it resembled magic and shamanism, and the luo vessels were most commonly bled to dispel pathogens. In fact the modern day charts of the luo vessels reveal that some luo vessel pathways ramify in regions where superficial veins and capillaries are plentiful such as lieque Lu-7, zhizheng SI -7 and gongsun Sp-4. Early viewpoints of the luo vessels indicated that they could become trapped with pathogens. For instance, pathogens in the Stomach luo would give swollen glands in the neck and fenglong St-40 an indicated point to address this symptom.
So I asked myself do any luo vessels go to the shoulder and if pathogens accumulated there, could this cause shoulder problems such as frozen shoulder? Referring to a diagram of the Small Intestine luo vessel may provide insight for such a theory.
Could using the luo point of the Small Intestine would help expel pathogens associated with the area of the Small Intestine Luo distribution? Pirog does suggest using luo vessel points in conditions of old traumas, chronic pain in a localized area, pain and swelling in the joints and knotty muscle tissue. This then provided me with knowledge to substantiate the use of zhizheng SI-7 for frozen shoulder. Unfortunately though, as recorded in the Great Compendium of Acupuncture and Moxibustion, there are no indications for zhizheng SI-7 being used to treat the shoulder. For excess conditions of the Small Intestine luo, it states only slackness of joints and inability to move the elbow. (Deadman and Al-Khafaji)
Theories and the use of the 8 extra ordinary vessels have evolved and changed over the centuries with the first official reference to the “eight extra ordinary Vessels” being in the Nan Jing.(Pirog) Early references to the 8 extra ordinary vessels described them as being storage pits for pathogens similar to luo Vessels. In fact the yinqiaomai and yangqiaomai were originally classed as luo vessels. By the Ming dynasty they were said to contain surplus reserves of Jing (essence) and Blood (xue) and that this could be moved to the main vessels and back again. (Pirog)
The method in which the 8 extra ordinary vessels can be “activated” via their master and couple points is also beyond the scope of this article and interested readers can refer to numerous journal and book sources on this matter. However, one development worth mentioning is that of Dr Manaka of Japan utilizing copper wires connecting the master and coupling points with a diode in one end of the wire.
One example of using the 8 extra ordinary vessels is to use the relevant master and couple points of the vessel required to be activated, in order to enhance the effect of a specific channel point you have chosen for a treatment. This is more easily explained with an example using frozen shoulder. Jianyu LI-15 is recommended in many texts a useful point for frozen shoulder as a local point for frozen shoulder and is fact it is part of the trio jianyu LI-15, jianliao SJ-14 and an extra point as suggested by O’Connor and Bensky. By activating the yangqiaomai using shenmai Bl-62 and houxi SI-3, it will thus improve the function of jianyu LI-15 when it is needled. The deeper level of the extraordinary vessels, in this case the yangqiaomai, can connect via its crossing points, in this case, jianyu LI-15, and supply the point function with its store of Jing. This is how some theorists would see it but I also posit that pathogens causing the frozen shoulder in the area of the point may be able to retract back to the extra ordinary vessel involved. The use of the yangqiaomai can be used to absorb excess yang, such as in ascendant Liver yang from the head. (Maciocia)
So could the yangqiaomai not also absorb pathogens that may have accumulated in the shoulder?
The body and main vessels in a reaction to dealing with pathogens will off load pathogens as a first line of defense to the luo vessels. If we postulate that pathogens have gone to the Small Intestine channel and then off loaded to the Small Intestine luo, which is in the shoulder region and connects with jianyu LI-15. If the pathogens in the luo vessels become too saturated, they are then directed to the 8 extra ordinary vessels, in this case the yangqiaomai. Is it feasible that frozen shoulder can actually resolve itself without having any treatment is because pathogens eventually leave the shoulder and settle deep in the yangqiaomai or yangweimai which has connecting points in the posterior of the shoulder.
An analysis of traditional and modern uses for the yangqiaomai include the indications of hemiplegia and imbalances between left and right sides of the body such as one scapula higher than the other. Could we include frozen shoulder to be included as part of the yangqiaomai indications?
What I do find interesting is that none of the eight extra ordinary vessels go to the arms and that jianyu LI-15 and binao LI-14 are the most distal points on the arm that connect to the eight extra ordinary vessel systems.
In conclusion, I posit a theoretical channel connection that may have relevance to treating frozen shoulder.
Zhizheng SI-7 luo point connects with shoulder. The distribution of the Small Intestine luo vessel goes to outside of shoulder. Zhizheng SI-7 connects with jianyu LI-15. Jianyu LI -15 connects with yangqiaomai.
The above treatment protocol using yangqiaomai and Small Intestine luo along with alternation of treatments using the yangweimai with its meeting point’s naoshu SI-10, binao LI-14 and naohui SJ-13 is also suggested.
I have used this approach in treating frozen shoulder with results that show promise, in particular if compared to just resorting to using the standard distal and local treatment selection of points.
Electro-acupuncture for shoulder problems is used commonly by many practitioners but my personal experience is that sometimes electro-acupuncture on local points such as jianyu LI-15 in frozen shoulder may actually aggravates the condition. Communication with Tom Xu, TCM practitioner currently practising in Christchurch, has the view that this aggravation is because electro-acupuncture is reducing and should not be used on frozen shoulder. However, other practitioners such as David Craddock use local electro as the norm for frozen shoulder who uses the pulse mode around 1 pulse each second.
Tom Xu who interned at Huaqiao hospital (华侨医院) in the town of Yonghe in Jinjiang city of Fujian province has provided some additional useful information in the understanding of frozen shoulder. There is more than one name for frozen shoulder in Chinese.
Dong Jie Jian (冻 结 肩) – frozen shoulder
Jian Ning (肩凝) – shoulder fixed
Jian Bi (肩痹) – shoulder blockage
Luo Jian Feng (漏肩风) – naked shoulder wind
Wu Shi Jian (五十肩) – 50’s shoulder
Tom Xu also put some insight as to why women may get more frozen shoulder than men. Frozen shoulder affects women more than men because females when working have a disposition to Liver qi insufficiency and blood drainage and thus the ligaments and tendons become weakened. In addition, the 7 year cycles influence women and as the tian kuei diminishes, Liver and Kidney problems result. His observation in China was that frozen shoulder when treated with herbal medicine by doctors at the hospital preferred to use tonics such as bu zhong yi qi tang (Ginseng and Astragalus Combination) and didn’t waste their time using Blood quickening medicinals, qi regulators or medicinals to address bi syndrome.
His experience also confirmed that tui na was more useful than acupuncture in frozen shoulder treatment.
Tai Qi was also recommended in the hospitals even if the patient was unable to move the frozen shoulder. This was because the Tai Qi as a therapy would help circulate qi through the whole body including the shoulder and the Tai Qi instructors would advise the student to visualize the damaged arm doing the movements to encourage the qi to travel into the shoulder. The view of Tom Xu and the doctors of Huaqiao hospital was that frozen shoulder was due to Liver and Kidney vacuity with qi and Blood vacuity that allowed wind cold and damp evils to attack the weakened sinews. Their explanation for the worsening of frozen shoulder at night time is that during the day time the yang qi is stronger than at night time. (Note: Western medical research has documented that that frozen shoulder gets worse at night) My own theory as to why frozen shoulder gets worse at night is because of the yangqiaomai involvement. There is ebb of flow of the yinqiaomai and yangqiaomai with the qi of the yinqiaomai moving in to the yangqiaomai at night. If the qi of the yangqiaomai becomes replete at night, insomnia can result. Then why not if the qi of the yangqiaomai becomes replete could it not cause more pain at night.
Tom Xu has helped compile some other ideas from various TCM physicians in China which are presented below.
Lu Jing Shan of Shan’Xi TCM College (吕景山—山西中医学院)
Mr Lu has a very simple viewpoint which works for him. Chinese medicine states that when the problem is in the upper body, select points on the lower body.
He uses just two points, yanglingquan GB-34 and taichong Liv-3.
This selection is explained as follows. Yanglingquan GB-34 is an earth point as is taichong Liv 3 and they both clear damp. Taichong Liv-3 can supplement the Liver qi and invigorate the Blood and yanglingquan GB-34 treats the sinews. Yanglingquan GB-34 treats the fu and yang, whereas taichong Liv-3 treats the zang and yin. Together this selection can regulate the qi, stop pain, strengthen earth and reduce the wood. The method of treatment is to use a reducing method while asking the patient to move the shoulder whilst the needles are in. After four consecutive treatments there should be a substantial improvement.
Liang Qinghu (梁清湖) of Hongdu TCM hospital in Nanchang city (梁清湖-南昌市洪都中医院)
Mr Liang uses acupuncture and cupping on a special point jiantong xue (肩痛穴)
At the depression between the intersection of collar bone and lateral part of scapula, the tip of the needle to the shoulder joint, manipulate until the whole joint has the feeling of heaviness, numbness, aching. Do not insert the needle perpendicular to the internal side so as not to pierce the lung.
The middle point of triangular muscle, insert this point with the direction to upper part and internal and lateral side, stop manipulation when “de qi” arrives.
Zhang Zheng of the First Renmin Hospital in Suizhou City, Hubei province (张正-湖北省随州市第一人民医院)
Mr Zhang uses jianyu LI-15 with a 1.5 cun needle through to jiquan Ht-1 and a 1.5 cun needle at jianqian xue (肩前穴)and jian hou xue(肩后穴) (extra points). These are as described below.
肩前穴(jianqian xue), 1 cun above the end of anterior axillary fold,
肩后穴(jianhou xue), 1.5 cun above the end of posterior axillary fold.
This is done in addition to quchi LI-11 and hegu LI-4. His method of manipulation is to lift and rotate for 1 minute with strong stimulation, get de qi to go the upper limb and leave for 15 minutes. A special technique is used, where there is shaking of the needle to open the hole and then remove the needle being careful not to close the hole so as to let the evil out. (Please note: More recent acupuncture books and authorities refer to acupuncture points as “holes”, that is acu-holes) Leave hegu LI-4 until last and use strong stimulation and ask the patient to move the shoulder. Zhang advocates giving daily treatments for a week and then 3 days rest followed by another 7 treatments.
Wang Deng Qi of the Guanxi TCM College(王登旗-广西中医学院)
Mr Wang has another quite different approach and also claims good results after just 1-3 treatments with a reduction in pain. He uses xi-cleft points of the arms wenliu LI-7, huizong SJ-7 , yangliao SI-6, kongzui Lu-6 , ximen Pc-4 and yinxi Ht-6. If the pain is more predominant on the back yang surface he uses the yang vessel xi cleft points and if the pain is on the front yin surface he uses the xi cleft points on the yin channels. His method is to use 1 cun 30 gauge needles angling the needles up towards the shoulder at a depth of 0.3-0.7 cun. Manipulate the needles each 5 minutes and with the goal to get the qi to go to the shoulder as well as the wrist. Wang also advocates asking the patient to move the arm and shoulder during the treatment.
The suggested treatment methods of Wang have provided me further variation of treating frozen shoulder. I have added yangliao SI-6 because it is the xi cleft point and being on the Small Intestine channel can help move obstruction of the channel affecting the shoulder. In addition it is in close proximity to zhizheng SI-7 so it is convenient to attach electro-acupuncture wires being close to each other.
To finish off the article, there are a few words from John McDonald from Queensland, Australia Acupuncture and Chinese Medicine Association member. For frozen shoulder I am always referred to Prof Lou Baiceng’s “Ming Dynasty Secret Technique” – xuanzhong GB-39 – which is used with the Hangzhou location in front of the bone. The patient is lying on the unaffected side and they attempt to abduct the arm as far as possible before needle insertion. Then xuanzhong GB-39 is needled and while the practitioner lifts and thrusts whilst the patient continues to flap their arm up and down slowly. It is either miraculous or useless and you know within three or four abductions if you are going anywhere. There is also the tiankou ST-38 technique, done in the same way but some sources say you need to needle with a 75mm needle and go through to chengshan BL-57. My experience has been that if xuanzhong GB-39 works, tiankou ST-38 will work too, but if one doesn’t work neither of them will. There is a variant version of the Song of the Four Dominant Points (Si Gong Xue Ge) called Song of the Eight Dominant Points (Ba Gong Xue Ge) which has a verse “Yanglingquan GB-34 is surely older as a treatment for the shoulder”, but personally I have not tried it. Prof Bai Liangchuan from Anhui lectured in Musculoskeletal Health at University of Western Sydney and he liked to use the opposite hip (eg huantiao GB- 30 for the shoulder as part of what he called “Six Links” (Liu He) Technique [shoulder-hip, elbow-knee, wrist-ankle].
In addition I like to work around the border of the scapula, palpating for ashi points and needling them obliquely going between the scapula and the ribs. The most consistent ashi points are usually jianwaishu SI-14 on the medial top corner of the scapula, gaohuangshu BL-43, yinkou an extra point on the inferior angle, jiantongtian, an extra point on the lateral border of the scapula almost into the axilla and about level with gaohuangshu BL-43 and naoshu SI-10. When the bursa is involved (as it is in a “true” frozen shoulder) then needle naoshu SI-10, jianliao SJ-14, jianyu LI-15 and an ashi point just above the anterior axillary fold. I use lots of moxa stick and occasionally warm needle. I like to needle jianliao SJ-14 and jianyu LI-15 down the deltoid with 75 mm needles in the grooves parallel to the humerus when the arm is adducted (by the side).
In the final analysis, you the practitioner can decide whether to use some of the techniques outlined above. Certainly, it is hoped you have some new options and variations to consider when wishing to supplement using your own methods.
I would like to thank the following practitioners who contributed information via personal communication and were willing to share their experience in treating frozen shoulder.
Phillip Mettrick, David Craddock, Martin Greenleaf, Gavin Hurlimann, Vitalis Skiauteris and John McDonald
Also I would like to acknowledge a special note of thanks to Tom Xu for his translation work.
Any practitioners wishing to comment, contribute, correct or criticize please do so via the comments section below.
Deadman, P and Al-Khafaji, M. (2001) A Manual of Acupuncture. Hove: Journal of Chinese Medicine Publications
Maciocia. G (2006). The Channels of Acupuncture. Philadelphia: Churchill Livingstone
Pirog, J. (1996). The Practical Application of Meridian Style Acupuncture. Berkeley, California: Pacific View Press
O’Connor, J and Bensky, D. (1981) Acupuncture: A Comprehensive Text. Seattle: Eastland Press