Frozen Shoulder Rehab

The physiological path to unfreezing frozen shoulder

Intro

Frozen shoulder is a condition in which the shoulder abruptly stops normal movements and replaces this needed function with disabling pain.  Doctors and physical therapists team up to pry the shoulder open and get the arm to move.  The shoulder stays stubborn and the options become dismal.  Options include…

  • expensive option of surgery with long post-op healing time
  • ultrasound and painful stretching by a PTA several times a week
  • a lifetime of muscle relaxers and pain meds
  • learning to deal with the anxiety/pain and wait it out
  • or………

to recognize that the shoulder is proactively protecting itself from dislocation. Treatment is effective if its focus supports a protocol, that restores the shoulders sense of security to allow for its amazing agility.

The shoulder is an intrinsically very mobile joint that has this quality to optimize freedom of movement. When any joint becomes too unstable and over stressed, it automatically recruits surrounding muscles to stabilize and stiffen its path.  As body work practitioners, we need to reinforce the bodies effort to heal vs fight against it, re-establish its integrity and delve into the more global source of dysfunction. Through my extensive experience with working with this physiological approach, frozen shoulder unfreezes almost instantly.

What exactly is frozen shoulder

  • Mechanics – the shoulder is a ball and socket joint. Meaning – if you reach your arm up – the shoulder joint goes down.  This is consistent throughout any movement of this joint.  It is a physiological magnificent relationship of the glenoid Fossa and the head of the humorous (GH joint), both facing upward when arms are at rest and by sides.   With every movement, the 2 parts of this joint stay in perfect opposition, as they glide, spin and rotate.

The perfection, agility and efficiency of the shoulder –  has more to do with other structures other than the actual shoulder joint (Glenoid Humoral joint – GH).   The complex combination of joint articulations of the sternal costal, intercostals, sternal acromial, scapula, 1st rib and spine, move fantastically in tandem, to allow the humeral head to perch perfectly in the glenoid fossa.  Shoulder mobility also depends on the fluidity of the fascial connections of skin, muscles, connective tissues and organs, all the way down to the feet.  Importantly, is the deep diaphragmatic breath, that disallows the upper frame from collapsing forward.  Lastly, there are those little power house rotator cuff muscles that keep the “humoral wrecking ball” moving in a small controlled range, as to not break through its sleeve.

  • Catalysts of dysfunction

could be any dysfunction of the structures mentioned above, but almost always presents as the dumb “injury” or “accident” that the patient can’t forgive themselves for.  The patient doesn’t yet realize that this unbearable condition is usually stemmed from a more global and chronic dysfunction, that can easily be understood and rectified.  The classic presentation is “I don’t know why I reached so far under my couch, just to get my dog his bone. Now I can’t move my shoulder.”

Basically, the problem is always an overused, unstable shoulder that is in a downward position.  All those joints that operate to keep the shoulder joint on the up and up (both the glenoid and head of humerus facing upward), are now, out of commission. The rotator cuff muscles, that should only have to function as kinematic guides of the humeral head, have finally been overpowered.  The only protective forces remaining in this “rogue wrecking ball event”, are the muscle guarders; insertion of Lats, pecs and subscapularis.  The biceps also tighten, pulling down on the clavicle and acromion.  This latter pattern comes partly just from people keeping their arm bent for protection but can originally come from the bicep kept in constant shortness (example – computer use).

The muscle guarders keep the shoulder from moving and honestly do a great job at keeping the arm attached to the shoulder but…..  it is poorly understood that they also pull the glenoid fossa and the humeral head into a downward facing position.  On top of that, they approximate the two ends of the shoulder joint too close for them to dance together with ease.  They grind against eachother and cause pain. When you try unsuccessfully to reach your arm up, it is usually because these “bad ass” muscles are doing a great job of keeping your arm on you shoulder.

  • Functional limitations involved in the frozen shoulder are basically no easy movement in any direction. There are some positions that are particularly “no goes” and very painful to try to perform
    • with reaching arm to side and up (abduction),
    • arm to side with bent elbow bent and hand up (flexion and external rotation)
    • reaching arm up back (extention and internal rotation)

Interestingly to note that Frozen shoulder is often associated with women who are peri-menopausal.  No explanation is provided, only the correlation of this added difficult possibility to this life event.  I have seen many patients with this “double curse”.  I have found that providing visceral support for the liver dealing with increased hormonal changes, has been a very important component improving function;

Duration and outcome of frozen shoulder is often bleak and seemingly endless. I have heard patients tell me of their doctors prognosis of 1-2 years of pain and limitation.  Current treatment protocols stated previously, involving drugs and/or surgery, are expensive and often ineffective.  The current standards for frozen shoulder rehabilitation negate the basic rules of anatomy, physiology and kinematics.  More knowledge of which, can easily free patients of this unstable mess.

Steps to begin rehab involve the same steps that you would take in any emergency situation.

  • Secure the wrecking ball (humeral head). Best for the shoulder to be supported in an up and posterior position.  Both sides of the GH need to face up to improve security and diminish muscle guarding.  This can be done with a good tape job from the outside of the upper shoulder and pulling tape towards the neck.  Wrapping a scarf around your bent elbow and opposite shoulder is also helpful.
  • Treat the whole shoulder complex. Get all the surrounding joints of the spine, ribs, clavicle, scapula and sternum to move well and way more.
  • Open up all fascial and diaphragmatic restrictions.
  • Calm and reorganize the muscle guarders. Trying to get the muscle guarders to chill out and stretch, damages the shoulder integrity. We need to get them on board, but from a different angle.  Gentle resistance exercises that encourage outer range movements in the exact direction of the muscle fibers, allows them to calm down slowly.  Those muscles will then begin to function as proponents of movement vs. trauma induced contractors.

Also of importance:

Moving the body, even when one part is forced to be still, still helps that one little part.

A good deep breath can actually make a world of difference. Exercise choices that help the whole body and not just focused on “making the biceps big”, protect us from all kind of injuries.  The basic incentive of increasing blood flow, can do wonders for inflammation reduction, collagen restoration and tension unwinding.

General exercise proscription follows the biomechanics of good shoulder movement.

  • Movement that is similar to African dance movement where the ribs, spine and whole shoulder complex is recruited.
  • Modified pushup exercises to recruit the serratus anterior muscle that helps the GH to face up on both sides. The serratus Anterior muscle does this by putting the scapula in an upward position (base moves lateral, superior spine moves medial).
  • The muscle guarders get light resistant exercises that start in a small range of motion and slowly increases. Im suggesting 30-60+ reps, several sessions a day.
  • Awareness exercises of diaphragmatic breathing
  • Postural exercises that are “functional” (meaning dynamic). Many of us have been taught that the military posture is good posture.  If you try to be in this position with your shoulders back and down and try reaching your arms up, you will notice how limited your range is.  Now try the approach of opening and freeing up your ribs, spine and scapula, lifting your shoulders slightly up and back.  When you reach your arms up, its  much easier.  Shoulders up and back not down and back, help the shoulders be in that up/up position?  YES! Try repetitively doing this and include a deep breath where your diaphragm moves down in the opposite direction of the shoulders.  You might feel a good fascial stretch b/t diaphragm and shoulder touch on the negative, there is a list of things that are often included in rehab that can severely work against shoulder rehab.
  • Don’t try to stretch in pain. You will only retraumatize the shoulder joint and tighten the  muscle guarders.
  • Don’t try to “build up” rotator cuff muscles. They are not jocks and are fine coming back to work when muscle guarding, fascial restrictions and posture/biomechanics have been improved.
  • Don’t work the “muscle guarders” in an inner range or at a high intensity since are downward rotators of the shoulders (pec, lats).
  • Don’t pull shoulders down, as a way of having “good” posture.

Your frozen shoulder is an opportunity for sorts of good changes

  • Improved diaphragmatic breathing
  • Good posture that feels good and life giving
  • Recognition of the shoulders complex synchronicity in performing basic tasks
  • Education on exercises and exercise approach that keep you healthy in many many ways
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