December 7, 2010
How to release a frozen shoulder
Frozen shoulder (also called adhesive capsulitis) is a common disorder that causes pain, stiffness, and loss of normal range of motion in the shoulder. The resulting disability can be serious, and the condition tends to get worse with time if it’s not treated. It affects mainly people ages 40 to 60 — women more often than men.
We don’t fully understand the causes, but an inflammatory process is probably involved. Sometimes freezing occurs because the shoulder has been immobilized for a long time by injury, surgery, or illness. In many cases the cause is obscure. Fortunately, the shoulder can usually be unfrozen, though full recovery takes time — and lots of self-help.
The shoulder has a wider and more varied range of motion than any other part of the body. It pivots mainly on a ball-and-socket arrangement called the glenohumeral joint, which joins the top of the humerus (upper arm bone) to a scooped-out part of the scapula (shoulder blade) called the glenoid cavity.
How does the shoulder become frozen?
The process usually begins with an injury (such as a fracture) or inflammation of the soft tissues, such as bursitis or tendinitis of the rotator cuff. Inflammation causes pain that is worse with movement and limits the shoulder’s range of motion.
When the shoulder becomes immobilized in this way, the connective tissue surrounding the glenohumeral joint — the joint capsule — thickens and contracts, losing its normal capacity to stretch. Trying to avoid the pain caused by moving the shoulder leads to further contraction of the capsule. The humerus has less space to move in, and the joint may lose its lubricating synovial fluid. In advanced cases, bands of scar tissue (adhesions) form between the joint capsule and the head of the humerus.
A frozen shoulder may take two to nine months to develop. Although the pain may slowly improve, stiffness continues, and range of motion remains limited.
Who gets frozen shoulder?
The risk is increased when you don’t receive exercise therapy after tendinitis or an injury, and when you wear a sling for more than a few days without intermittent stretching. About 10% of people with rotator cuff disorders develop frozen shoulder. Enforced immobility resulting from a stroke, heart condition, or surgery may also result in a frozen shoulder. Other conditions that raise the risk are thyroid disorders, Parkinson’s disease, and diabetes (frozen shoulder affects 10% to 20% of people with diabetes).
What to do
If you think you have a frozen shoulder or are developing one, see your clinician or a shoulder expert for a physical exam. To assess your shoulder’s range of motion, the clinician will ask you to perform various movements with your arm, such as reaching across your chest to touch the opposite shoulder or down your back to touch the opposite shoulder blade (the Apley scratch test). She or he may take x-rays to make sure there’s no other underlying problem, such as arthritic changes or a dislocation. An MRI may be ordered to check for a rotator cuff tear.
Treatment is focused on relieving pain and restoring the shoulder’s normal range of motion. Your clinician may recommend an anti-inflammatory medication such as aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve, Anaprox). An ice pack or bag of frozen vegetables applied to the shoulder for 10 to 15 minutes several times a day can also help with pain. You may be given a corticosteroid injection into the shoulder joint or soft tissues. But the cornerstone of treatment is physical therapy, concentrating first on exercises that stretch the joint capsule, and later, on strengthening exercises. A physical therapist can show you how far to push yourself and can teach you the appropriate exercises. Once you’ve learned your limitations, you can practice most of your exercises on your own at home.
As you work to stretch the shoulder capsule, you should avoid any activities that require overhead reaching, lifting, or anything else that aggravates your pain. If you diligently follow your regimen of shoulder exercises, it’s likely that you’ll be able to resume your usual level of activity (more than 90% of people improve with these nonsurgical measures). But full recovery takes time — from several months to two or three years. If you don’t improve steadily or if you reach a plateau, go back to your clinician or consult a shoulder expert. Rarely, recalcitrant cases require surgery.
Am I exercising too much?
Q. I am 80 years old. Forty years ago I had a heart attack. I stopped smoking but remained very active. My blood pressure, with the help of medications, is around 125/70. I now walk 2 to 3 miles a day, work out with weights three times a week, and walk up and down 25 flights of stairs twice a week. My physician thinks I am pushing too hard and has urged me to take it easier. Is he right?
A. I congratulate you on being so vigorous and giving your blood pressure and overall health so much attention. You are living proof that you can survive a heart attack and do extremely well for many decades. The medications and lifestyle changes you have made add up to a big reduction in your cardiovascular risk.
Your blood pressure is close to perfect, and I can only assume that your cholesterol and blood sugar are also in good shape. Obviously, stopping smoking in 1970 was a great idea.
The question of how much exercise is too much is a challenging one. Although some cardiovascular risk indicators like HDL, the so-called good cholesterol, continue to improve with extreme forms of exercise like marathon running, the risk of injury also increases. It’s safe to say that moderate exercise every day is far better for you than intense exercise followed by long periods of inactivity due to injury.
My advice is to continue what you are doing: mix it up, combining different weight-bearing activities (like walking) with weight training. Such cross-training reduces the risk of injury from repetitive stresses on specific joints and muscles. Resistance exercises like upper-extremity weight training were once thought to be bad for the heart, but experts now believe that moderate weight training is good all around — it exercises the heart and lowers blood pressure, too.
As you grow older, the “no pain, no gain” adage shouldn’t be your motivation. Instead, avoid injury so you can keep on being active. Even gardening is great — and much better than being in a full-leg cast.
— Richard Lee, M.D.
Associate editor, Harvard Heart Letter