Vivian Grisogono

Shoulder query

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Tendon tear or frozen shoulder?
Q. It has been a long time, hope you remember me from squash/Ealing sports. I understand you are now in Croatia, I am in Arizona
    I need advice please. About a month ago I was playing squash and fell on my left knee and left shoulder, no problem. Then about a week ago I went into the wall, still no problem except for a slight initial ouch. Anyway on the Saturday I played squash and badminton and felt fine. Later that evening my left shoulder was really aching and ever since had got progressively worse. I went to see a therapist and she wants me to see a orthopedic doctor as she is pretty sure I have a tear and will require surgery. Am currently waiting for an appointment.
    At one stage I could lift it on to a wall with the help of my right arm (past about 50 degrees) and climb the wall using my fingers, but cannot do that anymore.
    Do you have any suggestions on what I can do to relieve it? In the meantime. I have gone from a pain level of 8-9 ( 10 being highest) to a less than 2, but nights kill me as it gets stuck. Basically I cannot raise my left arm at all, I manage about an hour’s sleep and then spend the next hour trying to find a comfortable position. I find putting a pillow under the arm helps but not much.
    You have always been great at putting me back together, what gets me is that it is my left arm when I am right handed. Any advice would be greatly welcome I just want to be able to get some movement back.
Female, 44, USA

A. Of course I remember you! and I'm very glad to hear from you.
    The injury you describe doesn't sound typical of rotator cuff tear, although that's not to say it definitely can't be that. The sequence of events in your injuries and the subsequent progressive pain, movement limitation and especially the pain at night all suggest more strongly that the problem stems from the shoulder girdle region, the area which joins the shoulder to the shoulder blade and then the spine. Quite often a seemingly minor injury to the shoulder leads to increasing stiffness and pain in the way you describe. The reason is that one tends to protect the shoulder after the initial injury, especially in the non-dominant arm which is used less for normal activities. Because the shoulder is totally dependent on its muscles and tendons for both its stability and its mobility, the protection phase sets up a situation where the normal movement of the joint is significantly disrupted. So normal movements become more painful, therefore more inhibited, and the joint itself stiffens up because it is not being mobilized in the usual way. The shoulder girdle is automatically implicated in this process, and then the pain can become very severe, as many complex nerve systems are involved.
    Hormones can be another factor in this kind of pain: for instance, in middle age, when females go through hormonal changes, the area around the shoulder blade can become subject to sudden phases of apparently arbitrary stiffness, even in the absence of injury. This can also happen through the influence of hormone replacement therapy and some other medicines.
    If hormone imbalance might be a factor, it would be wise to have yourself checked by your doctor, especially to ensure that all is well with your diet, your mineral and vitamin balance, your thyroid function, and any medicines or supplements you might be taking.
    The simple things you can do for yourself in this situation are to try to improve the circulation to the whole area (1), stabilize the shoulder girdle region (2), and gently restart mobilizing the shoulder (3).
    1. To help the circulation , warm baths and gentle massage with arnica cream round the upper back, neck and shoulder blade areas can help. It's difficult to massage this area for yourself, but you can try lying on your back with a tennis ball under you, between the shoulder blade and the spine, and rub your back gently over the ball.
    Of course, you should drink plain water throughout the day, little and often from morning onwards.
    2. For the shoulder girdle region, the primary exercise is to lie on your stomach with your hands alongside you, lift your head and shoulders a little way upwards, and gently bring your shoulder blades together  The second exercise is to sit or stand in front of a mirror, bend your elbow to a right angle, and gently lift your arm away from your body, making sure (in the mirror) that your shoulder stays level, so you don't use your neck muscles (link, exercise 1) . Only lift as far as is comfortable. As a possible third exercise, if it does not cause pain, you can try sitting on a bench or wide chair, place your hands flat down on the bench beside your hips, and gently press on your hands, as though you were trying to lift yourself up. Don't lift yourself right up, at least not at first, but just press on your hands to the point where you feel no significant pain.
    3. A gentle way to restart shoulder mobilizing is to lie on your back, clasp your hands together, and gently lift your hands upwards as far as you can without causing pain, keeping your elbows straight (link exercise 2) . Don't force the movement, but rock your arms upwards and back a few times at a time, fairly quickly.
    It sounds like early days to be considering the possibility of surgery. In any event, you should be doing these basic rehabilitation techniques: either they will prove to be the first step towards recovery through rehabilitation alone, or they will serve as preparation for the surgery, so that your recovery from any intervention will be more complete.

Q2. Thanks for getting back so quickly.
    I hope I told you everything correctly. The pain does go down the left arm mainly to the top of the biceps. I can pull the arm straight back to about 60 degrees but I would say less than 10 degrees in front. I can bend the elbow and move the arm sideways.
    I don't think the hormones come into it (although I am a month short of 44) and I don't take supplements. I try to eat healthily but....I am taking Aleve - don't know if it’s doing any good - and icing.
    The rehab place here I use (wish you were here) did find a very tender area in my back under the left shoulder blade.
    I will try these exercises. The first one with tennis ball should work. Funnily enough I had found soaking in a hot bath really helped and asked if it was worth going in the hot tub where there was more manoeuvring room. My physio was not keen on that. Exercise 2 is hard. Exercise 3 have not tried but think I can manage.
    Thanks for your help and I will keep you posted

. If the "body lift" exercise (number 2) is hard, just try to initiate it once or twice a day, without undue pressure, and see how it goes over time. But if you feel even that increases your pain, leave it out for now.
    As you've find the warm bath helps (it shouldn't be too hot though), the hot tub may well be useful for gaining movement. But don't do too much, as you will seize up afterwards. Proceed cautiously, so that you can do a little bit more each time.
    I don’t know what Aleve is, but if it’s something you swallow, be careful. I feel painkillers and anti-inflammatories are not advisable in this situation, as they tend to mess up your digestion, and rarely touch this kind of pain or influence recovery anyway. I suspect if you stop taking them you'll find it will make no difference. What will stop the pain is getting movement back little by little, especially into the shoulder blade joint complex.
    Icing the shoulder itself is unlikely to do much, if the root cause is, as I suspect, in the shoulder girdle, behind the shoulder blade. That tender spot the physio found is the place where massage would certainly help to reduce any spasm.
    The fact that the pain travels down the arm, and that you can take the arm backwards is another sign that the problem is not in the shoulder itself, but stems from the shoulder girdle - spine connexions. If the biceps is sore but you can still stretch it backwards, the chances are the nerves are involved as much as, or more than the tendon itself.
    At night, it might help if you lie on your right side and support your left arm on a pillow or two in front of you, with the arm pulled slightly forwards. If it isn’t comfortable for sleeping, do this movement as an exercise: lie on your right side, put your left arm on the pillow(s), with your hand as far in front of you as is comfortable; gently slide your hand forwards, away from the body, then back again, keeping your trunk as still as possible, to get the shoulder blade moving. As your movement patterns improve, you'll be able to place the hand more at a right angle from the body, whereas it's likely to be only slightly forward at first.
    Deep breathing can also help, as it helps your circulation, and eases tension and spasm in the muscles.
    Another basic and invaluable exercise is to stand with your right side by a table or similar height support; bend forward from the hips so that your upper body is more or less horizontal and put your right hand on the table or support for stability; swing your left arm backwards and forwards gently, and then across the body and out to the side, keeping your trunk steady, about 10-20 times each way, always within the limits of pain.
    Most importantly, although the pain has been very severe, you mustn't worry. This kind of problem is relatively common, and in my experience always recovers, especially if treatment is gentle, and rehabilitation exercises are done very carefully and progressively, never forcing the pace.
    Hopefully, the guidelines I've set out will get you going. You'll see, once you cross the barrier of creating a little functional movement in the shoulder girdle complex, the whole situation eases.

Q3. Thanks for that, you make me feel much better.
    Sleeping on my right side does not help, I have found a pillow/towel under the left arm helps a bit and then I have to lie on my back. What happens is I wake up about an hour or 2 later with the arm (biceps) area very stiff. That’s the situation right now.
    Aleve is an anti-inflammatory, Americans are real pill poppers and I never have been but it does seem to help temporarily.
    As far as the original exercises go, the one lying down and bringing my shoulders up I can do, hard work getting into position but doable. Arm abduction: I can only get the left arm up about 30 degrees. Lifting the arm up lying on my back, not a hope.
    The 2 extra you gave me when I get down horizontally the arm kills me, as for the side lying no can do, can move it a little backwards.
You did not give me this but I can stand straight arms down my side and swing pendulum style about 30-40 degrees. No problems with right arm.
    I have an appointment with an orthopedic doctor Wednesday and hopefully he will confirm your thoughts.
    How long do you think this lasts? It has been a week in which it has got worse. I am really struggling to move the left arm and the biceps area is a tight pain.

A3. You sound very frustrated, not to say fed up, which is understandable, but not helpful to recovery.
    The first priority is to believe that your problem can and will get better through doing the right exercises. Your shoulder sounds well frozen, but that is a neuromuscular problem, and it always resolves (in my experience) with exercise. Acupuncture can help to get the blood flow and nerves working better. Your doctor may offer to inject it or manipulate it, and you will have to decide what you want to do if he does.
    Have you tried moving the arm in the bath? Or doing the exercises immediately after having a bath?
    I can't understand the problem with the abduction exercise - you said you could bend the elbow and lift the arm sideways, and that's the movement to work on.
    If the forward leaning pendular exercise is too painful right now, leave it out for the moment, and come back to it when you feel more confident. The standing pendular exercise you're already doing is a start. Ditto the self-assisted elevation exercise.
    You should persevere with the side-lying exercise: just get into position, take the arm back a little way, as you say you can, and then gently ease it forward back to the starting position. Gradually you'll find you get a little more forward movement.
    It's important to understand in this situation that although the pain is severe, it's not a sign that things are broken or are about t break. It's because your nerves are reacting abnormally to pressure, which is mainly caused by soft tissue stiffness and faulty patterns of movement. The secret of regaining movement is to work within bearable limits, restricted as that is. Keep in mind that as you gradually regain movement, the pain will recede. The more you keep still, the greater the pain.
    You have to be patient, this is a slow steady process. Good luck, and good courage!

Q4. Yes one guy who looked at it said to me something about, I may be describing it wrong, but the long ligament that attaches the shoulder to the biceps had popped out. He did some manipulation and by the end of it with difficulty he had me climbing the wall with my left arm. He felt part of the problem was mental as opposed to totally physical.
    I am going to go to my club today to use the Jacuzzi as I have definitely found out that I have more movement in the water, bath tub too small to really get a feel.
    I had a better night’s sleep, only woke up 3 times with the pain either being by the biceps or the front of the shoulder. At the moment I feel it a little at both.
    Must say shame you are not here, you would have had me back on my feet within days and I am sure you could have all the clients you want

. I'm sorry I'm not there to help you in person, but even so it would be a process of gradually getting movement back.
    This is definitely not in the mind, although of course frustration and impatience make recovery harder, as I mentioned. The frozen shoulder is a nerve syndrome which follows injury to the shoulder and its tendons. As you guard the shoulder, it gets progressively weaker and stiffer, and the nervous system no longer operates correctly, leading to total "lock-down".
    The key area is round the shoulder blade, and that's what needs easing out. In the bath tub, you could still be trying the movement using both hands together to lift forwards a little way. Even when the bath is small, the warm water helps the circulation and makes movement easier.
    Good that you slept better last night, that makes it easier to concentrate on what needs to be done in a more positive frame of mind.

Q5. Some good news I have an appointment this afternoon with a doctor, on Google he sounds good.
    I do feel things are alleviating, it is hard doing the exercises as I am on my own and scared to do more damage. I have been wetting a towel and then heating several times a day and that has really helped, which is why I think things feel better.
    Looked up frozen shoulder on Wikipedia . I think I am on stage 2, which I have to be optimistic about.
    I will e-mail you later with the doctor’s findings

. It's always a bit misleading trying to get information from the internet about medical conditions: it’s limited by having to make things simple, and sometimes by the writer’s lack of knowledge and experience.
    Some medics take the view that frozen shoulder needs a dramatic intervention (manipulation under anaesthetic, injection or -God forbid- operation), others that one should do nothing at all, as it will ease spontaneously within 1-2 years.
    The rehab process is more positive; simply put, the right exercises will lead to the quickest possible recovery. By encouraging yourself to do gentle movements, you free up the systems and make the shoulder and shoulder girdle work again. If you activate everything gently, within reasonable pain limits, you cannot do any damage.     Remember, the pain you're feeling is not caused by tissue damage (eg broken bone or torn ligament, even if there was a ligament tear at the beginning). The condition is functional, caused by a breakdown of function. So restoring function bit by bit is the cure.
    I hope the meeting with the doctor is positive, and I'll look forward to hearing the result.

Q6. You were spot on, he diagnosed frozen shoulder. Took x-rays and confirmed no signs of anything, gave me you guessed it a quart ozone shot.
    Says it will take 3-4 days to kick in properly, and to start rehab next week. Wants me to ice, not heat, as much as possible due to the inflammation, which is pretty bad, you just need to touch me and I hurt.
    He reckons I could be as good as new if lucky in as little as 4-6 weeks, 3 months if not. I go back to him in 5 weeks for re-evaluation
In the meantime I will try to do your exercises as well
    Thanks for all you help, of course if you were here I would probably be half way better and not needed the shot!

A6. Well that all sounds positive.
    Probably the best advice I can give you now is to remember that healing and recovery are down to you. Even if I was there to treat you, the important part is what you do for yourself in between. So you need to build up confidence that you can cope with this. You've got all the instructions. The exercises I've suggested cannot do any harm, and if you work at them with patience and optimism, they will help you through this first phase. The cortisone injection may or may not help - it's not a cure in this situation, but a way of helping the shoulder to feel free, so that exercising it is easier. If the injection does help, all well and good, if nothing else you'll gain more confidence. But either way, the exercises are a must.
    The icing also may or may not help at this stage. After all, you've been doing it up to now and it hasn't prevented the present situation. I still recommend exercising in a warm bath or possibly your Jacuzzi, taking care not to overdo the movements, but just aiming at gentle mobilisation.
    Don't think too much about time span. If you do progress quickly, that'll be good, but in my experience this is a slow and gradual process. So you mustn't fall into despair if you're not 100% in 4-6 weeks or even 3 months. it takes as long as it takes. The important thought to keep in mind at all times is that you will be 100% in time, that's definite, and there's no reason why you shouldn't be.

. A bit more positive from my end, I do have more movement, he told me the shot would take 3-4 days to kick in but I definitely have some relief, so without question I will do your exercises and keep at them.
    The bath still feels good so will do that, not the Jacuzzi, and ice it. At this moment I would say I have at least 30% more movement and I am not using the right hand to aid it
    Thanks again and I will keep in touch

A7. Excellent, just take it slowly!

. Just wanted to give you an update: since Tuesday I have had progressively more and more movement , I would say I am now at over 60%. I can lift the arm in front almost over my head , sideways to shoulder level, but than that is one of your exercises I need to work on.
    Today I have pain but I suspect the shot is wearing off (although he said would take 3-4 days to kick in and was instant) and also I probably have done a bit too much, pain not affecting movement though.
    Start rehab Monday so will keep you posted.

Well done, but you must be careful not to jump too far too soon!
You've already started your rehab with your exercises, and they are the important thing to maintain. As you can lift forwards so well, you should be able to use the self-assisted arm raise (lying on your back, hands clasped) to good effect. I hope you will quickly be able to add movements like lats pull-down.
    Don't worry about the pain, but then again don't do things which exacerbate it. Keep within bearable limits, and try to do little and often, rather than a lot in one go.

. I saw the physio yesterday and she has confirmed I have full range of motion now. She massaged my upper back where there was a tender area my shoulder blade, and eased it.
    I still have not regained all the strength but am doing exercises for this. The biceps are a little tight and she massaged, stretched etc... and says I probably have been doing some of the exercises slightly incorrectly putting the strain there instead of using the shoulders more (something like that) so we went back through everything
    I see the doc on the 22nd but the physio told me if I feel good to try and bring forward the appointment. She thinks the way the progress has been, I could be fit again in 2 weeks. She’s shocked at how quickly I recovered considering she saw me at my worst.
    I think I will try to be good rather than rushing back though.
Thanks for all the advice, I think your exercises helped in the speed of the recovery.

. Good, that's the ticket! Strength will come over a space of time, as you build up on the strengthening exercises. The best way to strengthen all the shoulder muscle groups is to use fixed-weight gym equipment (such as Nautilus or similar systems), with very light weights at first, gradually building up week by week. Sessions 2-3 times a week. I hope this will be recommended for you, I'm sure you have a good gym nearby.
    You won't really need anyone else to tell you when you're well, you'll know! The only reason to revisit the doctor is if the shoulder isn't quite right and you’re worried.
    Keep up the good work.

. Thanks Vivian. Yes my squash club is great for the apparatus and I have some light weights at home that I am using. Shoulder feels great, I can actually sleep in any position PAIN FREE.
    Went to get the all clear yesterday. Got it. Mind you he said it was not real frozen shoulder as my recovery was too quick but that I had such inflammation that it gave the feeling. anyway should be okay now but if it swells again he said another shot. I said one a lifetime is enough. Not a believer in that remedy normally but in this instance it was so bad I had it but do not plan on any more
Thanks for all your advice.

This correspondence spanned just under 4 weeks.
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