The hand that cannot rise above the shoulder: treating frozen shoulder by stage
Female, 55. Symptoms for 5 months, right shoulder, with diabetes (key history).
Woken by night pain three or four times a week, moving from the painful phase into the stiffening phase. Frozen shoulder is a disease of time and of training — if the staging is not made clear, patients tend to abandon the exercises during the stiff phase.
History and prior work-up
Right shoulder pain with restricted movement for 5 months, night pain prominent. Both active and passive range were limited; she could not comb her hair or dress; woken by night pain 3–4 times a week; currently transitioning from the painful phase into the stiffening phase.
Shoulder MRI showed capsular thickening, no rotator cuff tear, no calcific tendinitis; one local corticosteroid injection had been given with short-term relief; physiotherapy intermittent; glycemic control poor (HbA1c 8.2%), thyroid function normal.
Examination and pattern differentiation
The main pattern is wind-cold-damp bi (painful obstruction) with qi stagnation and blood stasis; the long illness adds qi-blood insufficiency and liver-kidney insufficiency. Severe pain with tenderness points to stasis, worsening with cold to wind-cold, aching weakness with atrophy to deficiency.
- Right shoulder flexion 90°, abduction 70°, external rotation 20°, extension limited; tenderness at the bicipital groove and subacromial region; mild deltoid atrophy.
- Tongue pale with a white coat; pulse deep and thready; aversion to cold; poor sleep.
Treatment pathway
- External treatment first: Jianyu LI15, Jianliao TE14, Jianzhen SI9, Naoshu SI10, Tianzong SI11, Bingfeng SI12, Quchi LI11, Waiguan TE5, Tiaokou ST38 (with shoulder movement); acupuncture with needle warming or moxibustion; tuina to release the soft tissue around the capsule, progressing step by step, with no forceful thrusting. Two to three times weekly.
- Herbal decoction as support: for wind-cold-damp, Juanbi Decoction; for blood stasis, Shentong Zhuyu Decoction; for qi-blood deficiency, Huangqi Guizhi Wuwu Decoction or Bazhen Decoction (Eight-Gem) with modifications. Classical reference: Zhang Zhongjing's Jin Gui Yao Lue used Huangqi Guizhi Wuwu Decoction for bi pain from blood deficiency. Dosage is set at the in-person consultation.
- Functional training (core): pendulum swings, wall climbing, towel stretch behind the back, pulley work; 2–3 sessions daily, to the point of a tolerable stretch. The stage sets the intensity: in the painful phase the emphasis is pain relief and gentle movement, in the stiff phase stretching, and in the recovery phase strength work.
- Concurrent management: patients with diabetes must manage blood sugar in parallel — when control is poor, recovery is clearly slower, and this is explained in advance.
Re-evaluation
| Timepoint | Night pain | Flexion | Abduction | External rotation | Training adherence |
|---|---|---|---|---|---|
| Baseline at first visit | 3–4 times/week | 90° | 70° | 20° | Not started |
| Week 4 | 1–2 times/week | 110° | 85° | 30° | 2 sessions/day |
| Week 12 | Occasional | 140° | 110° | 50° | 3 sessions/day |
Follow-up and advice
The goals are framed as 'reduce pain, restore range of motion, restore daily self-care'. The course is usually counted in months, and long-term adherence to the exercises must be made explicit; where acute loss of movement after injury comes with marked weakness, rotator cuff tear is excluded first.