One day you reach up to comb your hair or slip an arm in your favorite jacket and you feel a pull. At first you think nothing of it. Then you notice that washing your hair makes your shoulder feel stiff and achy. You start to lose the ability to lift your arm at all. You can no longer lay on that shoulder in bed. If these symptoms sound familiar, you may have adhesive capsulitis – more commonly known as frozen shoulder. Women with Hashimoto’s thyroiditis or a low functioning thyroid have a higher probability of experiencing frozen shoulder symptoms. The rehab for frozen shoulder is a long, painful process, but you can learn how to avoid it. If it does strike, doing the right exercises is essential to speed up the healing process.
There are four main muscles that make up the shoulder complex and many more muscles that help stabilize and move the ball in the socket joint. All of the bones, tendons, and ligaments are wrapped in a capsule of connective tissue. Frozen shoulder occurs when the capsule becomes inflamed, thickens, and creates contracture, leading to less range of motion of the joint. It’s a vicious cycle because less shoulder range leads to more contracture and more contracture leads to less range.
Having an endocrine condition like hypothyroidism or Hashimoto’s is a risk factor for frozen shoulder. The link between the two conditions is not entirely clear, but research has revealed some possible connections.
A 2017 study evaluated 401 shoulders from 93 frozen shoulder patients and 151 controls. The prevalence of hypothyroidism was significantly higher in the frozen shoulder group. The results suggest that higher serum TSH levels are associated with bilateral and severe cases of frozen shoulder.
Who is at risk for Frozen Shoulder:
- Women (70% of cases are women)
- Over the age of 40
- Previous shoulder injury, shoulder surgery, or shoulder trauma
- Previous surgery that immobilizes your shoulder, such as breast surgery or open heart surgery
- Hormonal changes, such as perimenopause and menopause
- Cervical disc disease
- A history of diabetes
The Three Stages of Frozen Shoulder
Dr. B. Reeves first divided the clinical presentation of frozen shoulder into three stages in 1975, when he studied 49 cases over a 10-year period. The American Academy of Orthopaedic Surgeons now describes the three stages of frozen shoulder as:
1. Freezing, or painful stage: Shoulder pain increases gradually, making shoulder motion harder, and the pain worsens at night. This stage can last from 6 weeks to 9 months.
2. Frozen, or transitional stage: Pain may decrease but the shoulder joint remains stiff. This stage can last from 4 to 6 months, and movement may be restricted.
3. Thawing: Movement gets easier and may eventually return to normal. Pain may decrease but can recur. This may last between12 months and 4 years.
The Effects of the Thyroid on Frozen Shoulder
It is known that women with an underactive thyroid have a harder time maintaining their muscle mass and some can have muscle weakness in their arms and legs called hypothyroid myopathy. The muscle weakness and low muscle mass can contribute to frozen shoulder. This is probably due to a lack of support and decreased muscular stability of the shoulder.
Symptoms will often include:
- Muscle pain, aches and cramps that move around the body
- Joint pain and stiffness
- Weak grip strength
- Difficulty raising arms above the head
Women often experience a sudden frozen shoulder onset from minimal activity. It is known with an under active thyroid that type 2A muscle fibers (known as fast twitch fibers) turn into slow twitch Type 1 muscle fibers. Type 1 fibers are known as postural muscles and are considered a lower quality of muscle tissue. This could also be why women with an under active thyroid and with lower quality muscle tissue can experience frozen shoulder with minimal activity.
My thoughts on traditional treatment of Frozen Shoulder
1. NSAIDS like ibuprofen to reduce pain, swelling, and inflammation.
– While this can help relieve the pain, this is a Band-Aid solution and doesn’t address the underlying root cause of a frozen shoulder.
2. Corticosteroid injection, a strong anti-inflammatory to reduce inflammation at the local injection site.
– While this can reduce inflammation locally, this is not a local problem especially with an underactive thyroid.
3. Physical Therapy to restore shoulder movement, mobility, and strengthen the shoulder.
– I believe physical rehabilitation is essential to recovery from frozen shoulder and healing properly, but often traditional exercises don’t address weakness or movement root causes head-to-toe in the body. In addition, the physical therapy must go hand-in-hand with functional medicine to help regulate the thyroid and heal the connective tissue faster.
4. Manipulation under anesthesia. The doctor forcefully moves the shoulder joint to stretch the capsule while the patient is asleep.
– I’ve seen many patients with this procedure get their range of motion back initially, but a few months later, contract back to the original limited range.
5. Surgery to cut through and release the capsule.
– While a last resort, this option seems counter-intuitive since a frozen shoulder can be from scar tissue and surgery creates more scar tissue. I’ve seen this procedure successful in helping patients regain shoulder range of motion but down the road the other shoulder freezes because the thyroid was not addressed properly.
In my experience, most women with Hashimoto’s and a frozen shoulder who only do traditional rehab can expect 1-2 years of physical therapy. But if women are treating the shoulder from a biomechanical perspective with physical therapy and seeing a functional medicine doctor to help heal their thyroid from the inside, they often have a quicker recovery time.
Prevention of Frozen Shoulder Living with Hashimoto’s
Frozen shoulder is usually a diagnosis of exclusion. But prevention is the best tool to avoid the condition.
If you are hunching over for an extended period of time, your shoulders roll forward and your chin juts forward. This puts more pressure on the neck and creates muscle imbalance. The upper traps and pectoral muscles tighten and the muscles that hold up the neck, the deep neck flexors and shoulder stabilizing muscles will weaken. This imbalance is called upper cross syndrome and can create tension on the shoulder capsule.
Stressed out chest breathing will overuse the muscles in the neck and the pectoral muscles. Overusing these muscles can pull the shoulders forward, leading to an imbalance of tension on the shoulder capsule and frozen shoulder symptoms.
3. Strengthen your core
There are fascial connections between the muscles that stabilize the shoulder and our core muscles. Almost every woman I see with frozen shoulders also has a weak core. Four of my favorite core strengthening exercises are 90-90 knees, beast plank, beast to bear, and hard-style plank.
4. Active Release Technique
This is the gold standard in soft tissue massage, and helps release scar tissue and adhesions in the shoulder capsule. Here’s a provider list on the Active Release website. I firmly believe ART practitioners have a better grasp of anatomy, a better touch, and are clinically more proficient than practitioners without ART certification.
Pressing weight overhead “greases the groove” of the shoulder. It helps synch the core, glutes, and shoulder complex so they are all “talking” to one another. I like to start with a floor press because I can work on getting “stacked” and using the sensory feedback from the floor to not let my low back overarch. I eventually like to work my way into an overhead kettlebell press.
Why the kettlebell, can I just use a dumbbell? You can but the offset distribution of weight helps grease that shoulder joint groove. Three things I look for when I teach women with Hashimoto’s to press overhead: Is their core stacked, is their wrist neutral, and is their back swayed?
6. Massage Old Scars
Old scars like gallbladder surgery, appendectomies or breast scars affect our muscle memory. Even if these scars are a decade old, they create a subconscious tightness and affect how we move our body. I have found that old, tight gall bladder surgery scars affect the shoulder on that same side of the body. Gently massage around the scar with magnesium oil to soften the scar tissue and help create more freedom of movement in that area.
7. Getting your thyroid checked.
Short and sweet. Make sure everything is checking out if you haven’t already. If just TSH is getting tested, ask your provider to dig a little deeper.
Exercises to Help Frozen Shoulder
Frozen shoulder rehab is a long road and if you are in the thick of it start slow with these exercises. These rehabilitation exercises for frozen shoulder may feel basic but when you are in the freezing stage, these are all you need. No need to push it too hard in this stage to avoid more contracture and more pain.
- Pendulum swings aka Codman arm circles
Bend forward at hips in a lunge stance and gently hanging your arm forward and draw small circles with your arm. Start the circles clockwise and counter clockwise, make then small first then larger. This helps loosen the tissue and contracture in the shoulder joint. Once you feel there is more range of motion, feel free to grab a five pound weight and add weight to the arm circles.
- Table slides
Gently slide the arm along a table or countertop to increase the flexion in the shoulder. Start slow and try not to lift your shoulder up to your ear.
- Wall Walks
Similar to table slides but not stand facing a wall and walk your finger tips up the wall. Again go slow and try not to hike your shoulder up to your ear.
Rocking opens up the shoulder and gets the core and shoulder stabilizing muscles to talk to one another.
You don’t have to live with frozen shoulder ladies, there is a better way! If you want to learn more rehab exercises to relieve muscle aches and joint pain that come with Hashimto’s, join online at Thyroid Strong. If you want to learn how to get resilient and have the confidence to not worry if you’ll injury yourself doing something small and what may feel silly, join Thyroid Strong. If you want to learn more about what blood work to ask from your doctor, join Thyroid Strong, we have a private Facebook group with FB Lives with Functional Medicine doctors that educates on this topic.
In Good Health,
Dr Emily Kiberd