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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Friday Q&A: Painful Shoulder

Q: I have developed a very painful shoulder issue.  I finally stopped doing shoulder stand, down/up dog, and head stand.  I instead switched to "western" solutions, rehab. I am finding that doing Yoga that is not modified for older bodies is dangerous.  Is there a form of Yoga that does not require us to drink the Kool-Aid?

A: To answer this question more fully and accurately it would be helpful to know exactly what type of “painful shoulder issue” you have developed (diagnosis) as well as what your current “western rehab program” is like now.

As a Physical Therapist, when someone in pain comes to see me, I know it is important to try to pinpoint the MAIN area of dysfunction as well as the SECONDARY areas of discomfort. Sometimes the place that hurts the most isn’t the cause of the pain (like painful shoulder) but the pain may be coming from another area of your body. It is very common for neck pain to cause shoulder pain, poor postural habits definitely can cause and exacerbate shoulder pain. Non-ergonomic work stations and driving can also absolutely contribute to painful shoulder as well as recreational activities that you may do, such as rowing for crew, a lot of overhead home repairs, sleep positions and a bed that may be ready for replacement, significant pruning of trees in your garden, backpacking—I think you get the picture.

Usually yoga does not cause pain, but yoga done with structural instabilities and imbalances can exacerbate weak areas and make pain "appear" so we blame yoga for the problem. But the problem is bigger than yoga. My opinion as a yoga teacher and PT is that the teacher doesn’t fit the student to the asana; the asana is there for the student to explore and to find their own release and expansion. In an interview on the Yoga Dork blog Power Your Yoga: Creating Space for Exploring the Present Judith Lasater discusses this very point very eloquently. If you are an experienced student and you know that certain poses cause you difficulties, it is your responsibility to talk to the teacher before class and explain that you have this shoulder problem and if you need to modify a pose it is because you are trying to protect yourself from injury. If the teacher is not agreeable to this plan, then my advice is that you stop practicing with this particular teacher. Now if you are new to yoga and do not feel that you have the experience to modify poses in your class independently, you can ask whether it is possible for you to meet privately so the teacher can teach you ways to modify poses that cause you discomfort or pain.

I always tell my students that I would rather be interrupted in a class to assist a student with a modification than to have that student silently suffering—often their particular issue may also be felt by other students. But some people are too shy to speak up even though the class culture encourages this. (All yoga classes become their own mini ecosystems and there is an exchange and dialogue—not necessarily through words—continuously between students and teachers.)

There are certain rigidities in different styles of yoga that may be less amenable to students who are not all following the same instructions in class. In this instance it might be important for you to stop and reassess why you are studying this particular type of yoga or with this particular teacher. Sometimes it's not the style of yoga but the particular teacher that you may not resonate with. Again, no one can force you to do a pose that is painful or unsafe for you to do.

I would also recommend that you give the rehab professionals that you are working with pictures of the asanas that are currently difficult for you. They can then break down the poses biomechanically to target specific areas of tightness and weakness that are preventing healthy integrated biomechanics in the performance of the asana. 

The poses that you listed as having difficulty with (dog pose, up dog, shoulder stand, headstand) all involve significant weight bearing through the arms, cervical and thoracic spine. Downward-Facing Dog pose has many modifications that you can substitute for the “traditional” pose. For example, if your difficulty with Downward-Facing Dog pose is shoulder range of motion, then it might be better to go back to working with the preparatory position: on all fours, with appropriate shoulder stabilization, torso stabilization, cervical and thoracic neutral positioning and supportive abdominals BEFORE you push up into dog pose. If you are deficient in shoulder range of motion, you might want to practice Half Dog pose at the Wall (or with a table top) to work into stability at 90 degrees shoulder flexion first. Then return to the floor with preparatory Dog, progress to knees off the floor with rocking and then slowly work back into Dog pose using a chair first then returning to the floor. (This progression is difficult to explain without me actually seeing you and watching how you move.)

As to Shoulderstand, a lovely variation is chair Shoulderstand, which takes almost all the weight off the shoulders, and with a bolster under the shoulders, the head and neck are much less weighted. Headstand is a different problem because even with using a Headstander prop or two chairs to unweight your head and cervical spine, this pose puts a lot of weight into your shoulders. So if the problem is truly from your shoulder, I would recommend that you do not do Headstand until you are pain free or, if the studio where you practice has wall ropes, perhaps you can have your teacher instruct you on how to do the inversion without bearing with through your head or shoulders.

Good luck in your explorations!

—Shari

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