THAWING A FROZEN SHOULDER
By Julie Gudmestad
Published in Yoga Journal
With slow and careful guidance, you can help a student (or yourself) work through one of adulthood's common injuries.
Chances are good that at least once in your yoga teaching career, you'll encounter a student with a frozen shoulder. In fact, chances are even better that you'll encounter many more than one, since so many of the so-called baby boomers, now middle-aged, are practicing yoga. Your student with this condition will report a stiff and painful shoulder and will probably be unable to do, or will at least have difficulty with, certain poses: those with the arms overhead, held out to the sides in standing poses, or bearing weight in Sun Salutations. Given this much pain and limitation, your student should already have seen a health care provider, and the knowledge gained from that evaluation and diagnosis will help you help your student continue to practice yoga.
Ironically, a diagnosis of frozen shoulder actually describes a hot, painful, and inflamed joint, which is technically called adhesive capsulitis. Breaking down the words can help you understand the condition: -itis means inflamed, so you know that the fibrous capsule that surrounds the shoulder joint is swollen, hot, and painful. Adhesive refers to adhesions, which is scar tissue that forms between the folds of the capsule. If you stitched the folds of a tablecloth, you wouldn't be able to open the cloth up to its full size. Similarly, with adhesive capsulitis, the adhesions won't allow the joint capsule to open fully. The tightened capsule limits the full movement of the shoulder into flexion, abduction, and rotation.
Causes and Effects
A frozen shoulder may occur due to a health problem that causes general immobilization—after an abdominal surgery, say, or during immobilization of the shoulder itself due to guarding and pain after an injury. The lack of movement, plus any inflammation due to injury, allows the adhesions to form between the folds of the joint capsule. Not uncommonly, a frozen shoulder may set in with no known cause, although the condition is common in women between the ages of 40 and 60, so hormonal changes may be a factor. Whether there was a previous shoulder injury or not, the frozen shoulder itself is quite painful, which makes shoulder movement difficult, causes more adhesions to form, and thus the condition becomes a vicious circle that can go on for months.
Fortunately, there are ways to break out of this circle. Unfortunately, the process of healing is slow even under the best of circumstances. Many physicians prescribe anti-inflammatory medications, but ice or acupuncture can also help relieve pain and inflammation. Healing can also be hastened by massage and ultrasound. Yoga, of course, is a wonderful tool to help restore the shoulder's strength, flexibility, and function—but only if it's performed thoughtfully and with patience for the long haul.
First, as you or your student look at building or rebuilding a yoga practice after an injury, it's important to be honest and present with how you deal with pain. It's rarely appropriate, while working with an injured joint, to "push through the pain" unless you are under the guidance of a trained professional. Instead, work at the point where you have significant sensation of stretch, or even discomfort—if you don't push a little into the scary place, you won't make any progress—but not so far into discomfort that you generate resistance in your body or mind. Holding the breath is a sure sign of resistance, as is the tightening and guarding of muscles trying to protect themselves from injury during an overaggressive stretch.
Before you begin stretching, it's a good idea to warm up your body, and your shoulder muscles in particular. Bearing light weight on the arms will not only warm up your shoulders but will also begin some strengthening. What's more, the isometric strengthening (the muscle is working but not changing length) in yoga poses is ideal.
Start with the easiest position, which is on hands and knees. Then lift each arm forward and up a little off the floor, one arm at a time. Just make sure that you keep lifting your torso up out of your shoulders so there's no valley between the shoulder blades. If you can be on hands and knees and lift each arm without pain, you're ready to progress to transitions from Downward-Facing Dog to Plank Pose and back. Though you (or your student) may be apprehensive about trying this, most frozen shoulders actually like mild weight bearing, especially if you do an easier variation, such as Downward-Facing Dog with hands on a chair seat.
Stretches to Restore Motion
With the muscles warm and lightly worked, it's a good time to do some stretching to restore the shoulder's lost range of motion. A typical frozen shoulder can only flex (bring the arm forward and up) to just above horizontal, and abduct (bring the arm out to the side and up) to just below horizontal. Normal range allows the arm to come all the way up to the ear in flexion or abduction. To restore the normal range, you must work carefully, with patience and persistence: Remember, pushing into pain is likely to generate muscle guarding at the time, and a more inflamed, painful shoulder afterward. Will you want to come back tomorrow and do these same stretches again when your shoulder is still very sore from the day before? Probably not, so do your stretches in a comfortable position, lying on your back on the floor. Support your arm in a position where you feel the stretch bordering on mild discomfort, but you can still breathe and relax into the stretch. Learning to relax the shoulder muscles in an open, lengthened position helps your body unlearn the guarding, tightening response that automatically accompanies pain.
While lying on your back, improve shoulder flexion by first stretching your arm up toward the ceiling with the shoulder externally rotated (if both arms are stretching up, the palms should be facing each other). If the shoulder is very sore and tender, use the other hand to help lift the weight of the arm and stretch it up. Then gradually take the arm over your head and toward the floor on the other side, thumb pointing down. When you reach the point of stretch with mild discomfort, stop. Have a friend or helper bring a prop (whether it's a chair seat, block, or folded blanket) to support the arm at just that height. Then at that point of stretch, but not pain, let go of the weight of the arm so the prop supports it fully. Breathe and relax for two minutes or more. Do this stretch at least once a day.
To improve abduction, open your arms out to the sides with palms up, while still lying on your back. Again, use support for the arm at just the right point of stretch sensation. When the arm is at about 90 degrees of abduction, you can also work on external rotation of the shoulder by bending the elbows to 90 degrees and releasing the forearm and back of the hand toward the floor behind you, with the palm up (the hand will be at the same level as your ear). Because this is usually the most difficult movement to restore, use plenty of height in your supporting props, and plan on slow progress.
Over time, yoga can help you, or your student, restore full, pain-free range of motion and function to your frozen shoulder. Think of it as an opportunity to practice the meditative aspect of asana practice and to be completely present in the moment, without glossing over or pushing through the painful, difficult moments of shoulder rehab. There is integrity in being present with things just as they are, whether the difficulty is a painful shoulder or a painful time in your life. Learn to breathe and let go, and things will begin to change.
THAWING A FROZEN SHOULDER