Frozen Shoulder, Part 2

by Baxter

Anatomical Studies of the Shoulder by Leonardo da Vinci

For those of you out there who might have missed Nina’s original post on frozen shoulder from a while back (see Yoga and Menopause: Frozen Shoulder), I’d highly recommend it. And while Nina rightly points out a correlation between menopause and adhesive capsulitis (that’s its fancy name), it turns out that men fall victim to this conditions as well. In fact, I developed a case of it in my left shoulder over the fall and early winter months of 2015-16!

Some interesting statistics on and features of frozen shoulder: 

• It usually affects those over 40 years of age, with the peak period being between 40-70 year of age. 
• 70% of cases are women and 30 percent are men. 
• The jury is still out on what causes frozen shoulder. Although there is a connection between menopausal changes in women and the development of frozen shoulder, the other leading contenders are that it is an inflammation problem, an autoimmune problem, or simply a stiffening of the joint capsule problem (a process called fibrosis). 
• Since it does not always show up in isolation, it can be accompanied by other causes of shoulder pain, such as bursitis or rotator cuff injuries, making diagnosis and treatment tricky. 
• According to the Mayo Clinic, you are at higher risk of getting it if you have diabetes, heart disease, Parkinson’s disease, thyroid conditions, or a recent trauma that immobilizes your arm such a fracture or stroke.

When I started getting pain and limited range of motion in my left shoulder and arm last fall, I was not sure what was going on. It came on gradually and I did not have any of the risk factors I had read about, but I had tweaked my shoulder 15 years ago while climbing and had some chronic stiffness that my yoga usually worked out nicely. And then there were two events in September. First, I was swinging on a low trapeze bar for about two minutes, after which I noticed that my shoulder was not so happy with me. And, second, two weeks later I took a trip to an indoor sky-diving place, where a total of four minutes in the wind tunnel with the arms in bird-wing position made my shoulder even more unhappy. I recently came across research that connects direct or indirect trauma to the shoulder joint as a common cause of secondary frozen shoulder, which could explain my case.

When I finally got into to see the orthopedic specialist in late January of this year, initially I was offered a couple of steroid injections to cover both rotator cuff injury and frozen shoulder. At that point I asked for an MRI, since my physical exam could not confirm either diagnosis (it’s good to keep in mind that history and exam don’t always tell you what is going on for sure). And the MRI showed a healthy rotator cuff and definite frozen shoulder, so I only really needed one injection! That very same day, I got into to see an amazing physical therapist, who gave me a set of exercises to begin immediately. From a Yoga for Healthy Aging perspective, I was delighted to discover that some of the exercises were dynamic movements (similar to Arms Overhead Pose), done in sets of 10 repetitions, and others were static movements, held between 2-5 minutes. When I asked about the longer holds, my physical therapist mentioned that the joint capsule, made up of thick connective tissue, requires longer holds to loosen, similar to the timing we’ve discussed for stretching fascia here on the blog.

Now, I had read the studies that the average time for recovery of range of motion was 1-2 years and that really did not fit into my plans, so I asked the physical therapist if he had ever had a patient who recovered faster. He said, yes, one person who had actually taken his advice to do the physical therapist exercises hourly during the day had seen a rapid recovery in just a few weeks! (He pointed out that most patients only do them infrequently.) That was all the incentive I needed, and I started my practice immediately that day. After all, abhyasa (yogic practice) is not all that different (see Practice)!

One of the challenges of rehabbing frozen shoulder is that you actually have to move into far enough into stretch that it is painful. This is in contrast to physical therapy for rotator cuff injuries, where you would not go to the point of pain. I found that my ability to focus on my breath while holding painful stretches for 2-5 minutes was invaluable in staying the course without over triggering my sympathetic nervous system. And although I did not do them every hour, I often got 3-4 sessions in every day for the next few months. By April, my pain-free range of motion in that left shoulder was back to normal, and my physical therapist bid me farewell, with the important reminder to keep an eye on my right shoulder, as 25% of those with frozen shoulder will get a case of it showing up in the opposite shoulder in the 2 years that follow (Nina had this happen).

My takeaways:

1. If stiffness and pain persist in your shoulder, get it checked out by a specialist to get a solid diagnosis.
2. Try to see the best physical therapist you can in your community—it can make a difference.
3. Apply your yogic practice skills and your yoga tools to your rehab. (I was doing all the yoga poses I could do, although with left arm modified, along with my physical therapy exercises, and I believe it helped!).

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Yoga and Menopause: Frozen Shoulders

by Nina

When I was doing research for my post on menopause and headaches (see Yoga for Menopause: Headaches), I was very surprised to learn that the most common complaint that Japanese women have during menopause is not headaches (which is what I previously thought) or hot flashes (the most common complaint in the US) but frozen shoulder. As many of you probably know by now, I experienced two bouts of frozen shoulder during perimenopause/menopause. Although I knew this condition was common among women my age, no one I consulted about the condition really tied it directly to menopause, although there was some speculation that it might be related to hormonal changes. That's because they all said  no one really understands what causes this temporary (though very painful) problem. So it was very interesting for me to learn that in Japan it is considered a problem related to menopause. And because we've been focusing recently on menopause and I'm very, well, experienced, with this particular problem, I decided this would be a good time to write about it. (By the way, men also get frozen shoulders, and all the advice in this post will pertain to them as well.)

So to start, what exactly is frozen shoulder? According to the Mayo Clinic web site:

"Frozen shoulder, also know as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.

Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so it can move more freely.

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months:

Painful Stage: During this stage, pain occurs with any movement of your shoulder, and your shoulder's range of motion starts to become limited.

Frozen Stage: Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.

Thawing Stage: During the thawing stage, the range of motion in your shoulder begins to improve."

I'd like to expand on this a bit. First of all, your range of motion, especially if you're a fairly flexible yoga practitioner like me, is drastically reduced. Basically, at the frozen stage you can barely move your arm, in any direction. Even lying on your back, with your arms resting directly on the floor can be painful because your arm needs to be in a completely neutral Tadasana position to be pain free. And the pain is really pretty bad! Sleeping is difficult unless you prop your arm up on a pillow so it doesn't hurt, and of course if you move your arm around in your sleep, pain may wake you up. Some ordinary household tasks are difficult or impossible because you can't raise your arm or carry heavy objects, like shopping bags. Eventually lack of use makes your arm weak, so when you're over the frozen shoulder, strengthening is important.

It's essential to have an expert diagnose you for frozen shoulder because other shoulder problems, such as a torn muscle, are treated very differently. But the tests for frozen shoulder are very simple and not invasive, because with a torn muscle, someone else can move your arm for you, but with a frozen shoulder, your arm just won't move at all. So your doctor or physical therapist, will simply move your arm for you in various directions.

Once you have a diagnosis, how can yoga help? Well, first yoga provides a lot of good shoulder stretching exercises, which are recommended by the Mayo Clinic. The sequence that Baxter and I developed for tight shoulders (see Featured Sequence: Opening Tight Shoulders) was partly influenced by the routine I developed for myself to stretch my frozen shoulder. Try poses 2 through 7 from this sequence. Of course, when your shoulder is frozen, your arm will not be able to be straight up the wall as in the photos, but even if you have to bend your elbow and creep the frozen arm just partly up the wall, that will still be a good stretch. This is one case where moving into the pain is actually beneficial rather than harmful. And I actually found that stretching left me feeling better afterward, so that helped motivate me to practice through the pain. And, hey, look at me now! (See Living Proof for my testimonial about the effectiveness of shoulder stretches.)

To continue with your regular yoga practice, you'll need to modify your arm position in standing poses. For example, in Tree pose have your arms in namaste, in Warrior 2 pose have your hands on your hips, and Triangle and Extended Side angle poses, when your frozen arm is on top, just keep it tucked against your side or with your hand on your hip. In seated forward bends, you'll need to support your frozen arm, perhaps on a block, as you won't be able to reach for your feet. In restorative poses, be sure to place a folded blanket under your arms to support them so the frozen arm doesn't fall into a painful position. For poses you just can't do, like inversions or backbends, come up with an alternative. I did Standing Forward Bend and Widespread Standing Forward Bend with my head on a block instead of Headstand and Legs Up the Wall pose instead of Shoulderstand. You won't be able to do most backbends, so try practicing a passive, supported backbend of some kind to maintain mobility in your spine during this period. If you're in class, ask your teacher to help you find appropriate alternatives.

For the stress and pain associated with this condition, practice conscious relaxation in your favorite form (see The Relaxation Response and Yoga). When asana just seemed too hard for me because almost anything made my arm hurt, I experimented with a long version of yoga nidra.

Finally, after your shoulder is back to normal, your arm is going to be very weak from lack of use. Now is the time to do some arm strengthening poses! See Upper Body Strengthening the Easy Way and our featured upper body strengthening poses for ideas.

Of course, it is no fun going through this, but a frozen shoulder is a temporary condition. And with the help of yoga you can regain both flexibility and strength. Hey, I'm even back to doing arm balances!

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Living Proof: Increasing Shoulder Flexibility

by Nina

Photo by Erin Collom

Last week, my friend Erin Collom (thank you, Erin!), a Bay Area yoga teacher, took some photographs of me doing some of my favorite stress management and anti-anxiety poses. It was kind of nerve wracking for me because I’ve never been photographed doing yoga before (I’m typically somewhere behind the camera). But I decided we needed an older woman on the blog, and I was the handiest one around, so....

When I saw this photograph of me doing Downward-Facing Dog, I was actually quite pleased. My alignment looks pretty good! Even my shoulders look good, which I wasn’t expecting. A well-balanced Downward-Facing Dog takes flexibility in both the legs (the hamstrings especially) and the shoulders. Back in the day, before I hit menopause, I had a lot of flexibility in both areas (some of it was natural and some of it was earned through consistent practice of the asanas over a period of years). But the hormonal changes brought on by perimenopause and menopause triggered a condition for me called a “frozen shoulder” that drastically limited my range of motion in my shoulder.

“Frozen shoulder (adhesive capsulitis) is stiffness, pain, and limited range of movement in your shoulder that may follow an injury. The tissues around the joint stiffen, scar tissue forms, and shoulder movements become difficult and painful. The condition usually comes on slowly, then goes away slowly over the course of several months or longer.” — from Web MD

The only quibble I have with that definition is that the “stiffness, pain, and limited range of motion” should be more like “extreme stiffness, constant pain, and drastically reduced range of motion”—yes, it’s that bad.  After getting over the first one, which was on my left side, I managed to get one on the right side as well. But through both of those, as painful as it was, I continued to do non-weight bearing shoulder openers to try to prevent the permanent formation of scar tissue and gain back as much of my former range of motion as possible. (I also did strength building, because the arm and shoulder muscles may become withered as a result of the condition.) And after the condition had cleared up, I continued to work with these shoulder openers because I noticed I still did not have the range of motion I had originally and I could actually feel the presence of lingering scar tissue. While I was not necessarily expecting that I would regain what I had lost, I thought it worth trying, and besides, who doesn’t need to keep stretching our shoulders as we go through the aging process?

This photograph made me realize how much I had accomplished. So I thought I’d share my story in the hopes that it would inspire those of you who have or have had a frozen shoulder as well as anyone with tight shoulders who wants to make some changes.

Tomorrow Baxter will be presenting a sequence for tight shoulders. Some of these poses are ones that he teaches on a regular basis. But others are ones that I suggested to him because I had practiced them on a regular basis while my shoulder was “frozen” and painful as well as after the condition cleared up, always holding them for at least 90 seconds. These included the three different versions of hands up/on the wall and the doorknob version of Cobra. So if tight shoulders are a problem for you maybe give these a try. (See Friday Q&A: Tight Shoulders for information about why people have tights shoulders and how it can be a problem in both asanas and everyday life.) I'm living proof that they actually do work!

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