The Coldest of Shoulders
Understanding and Not Understanding Adhesive Capsulitis
Marilyn first noticed the right shoulder pain when she was sleeping on her right side. Over the next month, the pain became more frequent and more intense. Her shoulder ached in the morning and after any repetitive activity. Marilyn tried medications and ice, but the pain persisted. After eight weeks, the pain decreased, but her shoulder movement had become restricted. Her shoulder became so tight that she developed difficulty with activities of daily living such as fixing her hair, dressing, and bathing. Marilyn had developed a “frozen shoulder” and the frustrating thing was that she had no idea why it had happened.
No one fully understands why a frozen shoulder develops. For some reason, the envelope of tissue that surrounds the glenohumeral joint–the joint capsule, shortens and develops thickened adhesions or scar tissue. The medical term is “Adhesive Capsulitis”. This tissue restriction limits the ability of the humeral head (upper arm bone) to rotate and glide properly so your shoulder becomes tight and painful.
Most of the time, a frozen shoulder occurs with no associated injury or activity. Frozen shoulder most commonly affects patients between the ages of 40 and 60 years old. It is far more common in women than men. Individuals with diabetes are at far greater risk. If you have undergone a surgery or sustained a trauma to the shoulder, you can develop a frozen shoulder. This is especially true if you have held the joint immobile for a period of time. Several studies have linked Parkinson’s disease, thyroid problems, and heart disease to a greater incidence of frozen shoulder. Patients that develop a frozen shoulder are more prone to getting it in the opposite shoulder. Despite all of this knowledge, we continue to see many frozen shoulder patients that have none of these predisposing factors.
I would add another condition to the commonly mentioned predisposing risk factors for frozen shoulder. In my career as a physical therapist, it has been a rarity to find a frozen shoulder patient who was strong. From grip strength in the hand to the muscles that hold the shoulder blade on the rib cage, these patients are usually weaker than their same age and sex peers. The strength in the unaffected arm is often as limited as the arm with the frozen shoulder. My belief is that the most common risk factor for developing a frozen shoulder is upper body weakness. The glenohumeral joint is a fairly unstable joint that relies on the integrity of the muscles to kept it free from trauma. If the shoulder muscles are unable to properly control the joint, then excessive stress is transmitted to the joint capsule and an inflammatory response ensues that scars and tightens the capsule.
Physical therapy for a frozen shoulder consists of manual therapy to stretch out the shortened joint capsule and a program of exercise to restores shoulder range of motion, coordination, and strength. Most of the time, we get the patient when the shoulder is at its tightest point and recovery takes six to ten weeks. As with so many conditions, the patients that get to therapy earlier or before the shoulder is fully frozen do better with therapy.
In many ways, Marilyn is the typical frozen shoulder patient. She is the correct, age, sex, and fitness level. Further medical work up revealed that she was prediabetic and in need of some ongoing medical attention. Marilyn was a model physical therapy patient and her shoulder function was restored with six weeks of physical therapy.
Michael S. O’Hara, PT, OCS, CSCS
Keep your shoulders and spine happy and strong by following Mike O’Hara’s advice in “Pushing Up Performance”. Video explanation and performance of pushups and their variations included. Jeff Tirrell discusses the proper performance of pull ups in his article. “Movement You Should Master”. Is your mobility limited? Try massage sticks or foam rollers with the information provided in “Pain, Pressure, and Pliability”.
I get flak from some of my fellow gym rats because I do not believe in muscle isolation exercises. While I do not think it will harm most young and recovery-resilient trainees to perform fifteen sets of shoulder lateral raises or five different styles of bicep curls, I do find that format of training less than optimal. Older gym goers (30+ years) will see better results and fewer injuries if they stay far away from incline curls and the seated knee extension machine. Father time and experience has taught me that, excluding the bodybuilder who trains solely for hypertrophy, most of us will be more successful by becoming proficient in multi-joint exercises.
That being said, there are a few isolation-type exercises that I regularly use with fitness and rehabilitation clients. These isolation exercises are designed to improve posture, restore proper joint mechanics, enhance neural response, and reduce the risk of injury. These activities will not put a “peak on your bicep” or give you “massive quads,” but they will make you less likely to develop shoulder and lower back pain.
Band No Money Drill
Most people have weak shoulder external rotator muscles and a rounded over shoulder girdle posture. This is never a good combination if you are going to perform any type of upper extremity strength training. The band no money drill helps remedy both of these problems.
Stand tall with the chest proud and the head pulled back. Hold the band with the palms to the sky, elbows bent at 90 degrees held at the side-the palm up and no money in your hand position. Concentrate your efforts on the muscles between your shoulder blades as you pull the band apart and bring the hands out to the side. The tempo of the exercise should be controlled– two counts to pull the band apart and two counts to return to the starting position. Choose a resistance band that is fairly easy and focus on making the motion smooth. Perform two or three sets of ten repetitions.
Four Point Band Gluteal Activation
The gluteus medius is the muscle responsible for preventing unwanted rotation and inward collapse at the knee. It also helps stabilize the pelvis and keeps damaging stress off the lumbar spine. The four point gluteal activation drill activates the gluteus medius.
Place a mini band around both legs just above the knees. Position on all fours–hands directly under the shoulders and knees under the hips. Keep the spine stationary and lift the right leg up and out to the side so that the hip abducts approximately 30 degrees. Hold for twenty to thirty seconds and then repeat on the other side. Perform two times on each side.
Belly On Ball “Ys”
Postural Stress Disorder (PSD) is the new name given to the multiple pain problems associated with a flexed-over thoracic spine, forward head, and rounded shoulder posture. Your fitness program should help you combat the damaging forces created by prolonged sitting. The belly on ball Y exercise helps train away the postural flaws that create the symptoms of PSD.
Position yourself facedown over the top of a physioball. You need a fairly firm ball that does not flatten out when placed under load. Keep your spine stable and the chest off the ball. Lengthen the neck and thoracic spine-they should not move at all during the exercise. Keep the gluteal muscles tight and legs extended. Start with the arm in front of the shoulders on either side of the ball. The shoulders should be externally rotated in a thumbs up position. Raise the arms overhead like a football official signaling touchdown. This will create a Y shape with your torso and arms. Hold the arms overhead for three counts and then lower back down in a controlled fashion. Perform two sets of ten repetitions. As you get stronger try adding resistance with some dumbbells.
Single Leg Hip Lifts
Gluteal amnesia is at epidemic levels in gyms and fitness centers across America. A loss of gluteal muscle activity is the primary driver of lower back, knee, and hip pain. Prolonged sitting, elliptical training, and a general lack of any type of sprinting has created a large group of people who are unable to efficiently fire their gluteal muscles.
The single leg hip lift facilitates a better neural connection to the gluteals and can help reduce the occurrence of anterior hip pain. Lay supine with the knees bent and feet flat on the floor. Lift the right leg off the floor and hold onto the front of the right lower leg with both hands. Use the left leg to perform a single leg bridge. Focus on contracting the left gluteal muscles in an attempt to reach full left hip extension. Hold at the top of the bridge for three seconds. Perform two or three sets of five to ten lifts on each leg.
To view video demonstration of Mike’s choice isolation exercises, click on the link below:
-Mike O’Hara, PT, OCS, CSCS