By Dr. Jerry Yoo, DPT, CSCS | NL Physio
“Mary” walked into my office holding her right arm close to her side and guarded. She hadn't come in for her shoulder. She was back for a check-up on an old knee injury we'd worked through together the year before, and almost as an afterthought, she mentioned she'd been having trouble with overhead presses and even just reaching the middle shelf of her cupboard. Washing her own back in the shower and dressing had gotten hard too. She figured she'd slept on it wrong, but it had been over 6 weeks and wasn't getting better on its own.
She hadn't slept on it wrong. Mary had frozen shoulder, and she had no idea because like many of our clients, Mary was good at compensating for her shoulder limitations…until she couldn't…and Mary just didn't want to stop working out- until her shoulder really got in the way.
That's the thing about this condition. It’s often a slow progression. Nobody feels a pop or a tear and thinks "there it is." It creeps in over weeks, sometimes months, and by the time someone finally says something about it, they've already stopped doing a dozen everyday things without noticing it.
Mary hadn't connected any of it and again, this has often been the case for most of our frozen shoulder clients. She just thought her shoulder was a little “stuck” or strained, even after having to modify exercises at the gym. Who could fault her for not wanting to stop??
Remember, compensations compound when we ignore them.
Frozen shoulder might be the clearest example of it I see in the clinic.
Frozen shoulder typically moves through three overlapping phases. First comes the freezing stage, where pain shows up gradually and tends to be worse at night, this can last anywhere from two to nine months.
Then comes the frozen stage, where pain actually starts to ease but stiffness takes over, often for another four to twelve months.
Eventually most people reach a thawing stage where motion slowly comes back, though a meaningful percentage of people never fully get there and some still have symptoms years later.
Mary was caught early enough that we never let her sit in that middle stage for long.
Here's what treatment looked like for her. We started with shockwave therapy to the posterior shoulder and the subscapularis, one of the four rotator cuff muscles and often the one that gets ignored in a shoulder that's lost internal rotation. Alongside that, we did what I call “cautiously aggressive” range of motion work. Gentle pendulum swings don’t move the needle and full-force stretching makes things worse. Somewhere in between, I pushed with intention and pulled back with judgment depending on how her tissue responded that day.
I also had her get a cortisone injection. BUT, and this part matters, the injection was never meant to stand alone, it was one piece of a combined plan.
You see, cortisone by itself often doesn't result in sustainable gains once a joint has already started to stiffen.
I've had more than a few women walk into our office after getting an injection for frozen shoulder without physical therapy recommended, confused about why they still can't reach behind their back three weeks later. The injection can calm the inflammatory piece, but cortisone does nothing for the biomechanics.
Medicine without corrective exercise or guided movement is fruitless, because medicine doesn't change biomechanics.
Long story short, the combination is what expedited Mary's results. Shockwave, electro dry needling, targeted mobility work, and an injection used at the right moment, in the right sequence.
Shockwave deserves the quick limelight here because I have personally found it to be a critical tool for getting faster results with frozen shoulder in particular.
Across the research comparing nonsurgical treatments for frozen shoulder, shockwave therapy has ranked among the more effective options for restoring function.
It's shown particular value in patients managing diabetes, where corticosteroids can complicate blood sugar control; diabetes and metabolic issues show up disproportionately often in the frozen shoulder patients. One more reason why nutrition and exercise can be medically beneficial!
There was one more piece to Mary's case, and it's the piece most PTs never get to. During her visit, I asked if she'd had her hormones checked. She hadn't. I referred her back to her physician, and it turned out her estrogen was quite low. She started hormone replacement therapy, and not only did her shoulder respond faster once she did, she told me it helped other parts of her physical health too, sleep, energy, and recovery from her workouts. She's a fit, active woman in her fifties who trains hard, and she noticed the difference across the board.
By month three, Mary had >80% of her range of motion back. That might sound like a long timeline, and I get it, most people want a two week turnaround for anything involving their body. BUT frozen shoulder can take anywhere from six to twelve months to resolve on its own, and sometimes EVEN LONGER. Three months, with a lot of function restored, is fast. Mary got back to the things she loves doing with her body, and she was lucky.
She was already a patient of ours from a prior injury, so someone caught what was happening before she'd been compensating for a year. Most people aren't as lucky as Mary was.
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In women over 40, what gets missed almost every time is the hormonal piece. In my own practice, over 90 percent of the frozen shoulder cases I've treated in this age group have shown up alongside significant hormonal shifts tied to perimenopause.
Estrogen appears to have a direct antifibrotic effect on the tissue of the joint capsule itself, meaning declining estrogen may be part of what allows that capsule to thicken and contract in the first place.
Perimenopausal women show meaningfully higher rates of shoulder synovitis than premenopausal women. There's even early, preliminary data suggesting women on hormone therapy may develop frozen shoulder less often than women who aren't.
Researchers have also flagged higher inflammatory and metabolic markers, things like elevated cholesterol and blood sugar patterns, showing up more often in frozen shoulder patients, which fits the broader picture of this being a whole body issue.
This is why I ask every client over 40 who walks through my door, regardless of what they're being seen for, whether they've had their hormones checked. It's become one of the most useful ones I ask.
A recent editorial in one of the major orthopedic journals pointed out that estrogen influences bone density, muscle quality, collagen synthesis, and adhesive capsulitis, and called for a lot more research into the connection between sex hormones and musculoskeletal health.
So why does standard treatment fail so often for this population, specifically for women? Because traditional PT only treats diagnosis 1, the shoulder limitations in this case, and never dives into diagnosis 2, the root cause and hormonal environment that shoulder is sitting in.
You can shockwave, inject, and mobilize a joint all day long, but if the underlying hormonal or metabolic terrain hasn't been addressed, you may be fighting an uphill battle the entire time.
(Side bar- this doesn't mean every woman with shoulder pain needs HRT, and it's not something I prescribe or manage; that's a conversation between the client and her physician. What I can do is notice the pattern, ask the question, and make the right referral at the right time).
I've watched enough of these cases over 25 years to know the pattern by now. The women who come in early, like Mary did, tend to get their range of motion back in a matter of months. The ones who wait a year hoping it resolves on its own often end up fighting a much longer, much harder battle, and by then the compensations have spread well past the shoulder into the neck, elbow, upper back, and the opposite side from overusing it.
This shows up constantly across our New Jersey and North Carolina practices, especially with the women and men we treat who are still super active. Tennis players who can't get their serve overhead anymore…having neck pain. Pickleball players switch to a shorter backswing on their dinks and drives coming in with elbow pain. Golfers whose backswing has shrunk over the past year and now getting hip and knee pain. Women in group fitness classes at OrangeTheory, F45, or CrossFit who've started modifying every overhead movement without ever mentioning it to their coach…until it's late in the game.
If something in your shoulder has steadily stopped working the way it used to, do something about it. Today.
Fast forward, and Mary is back in the gym without limitations, reaching for whatever she wants off the top shelf, and training the way she wants to train. She got there because she didn't wait, and because we looked past the shoulder itself to ask what else might be going on underneath it.
PS-> Don’t let compensations compound. If you've struggled with shoulder pain or noticing limitations in how your shoulder moves, schedule a Shoulder Pain Assessment at our North Jersey or North Carolina location today.
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Medical disclaimer: This content is for educational purposes only and is not medical advice. Consult a qualified healthcare professional before beginning any new exercise program, especially if you have a history
of heart disease, back pain, or other medical conditions.
About the Author
Dr. Jerry Yoo is the Founder of Next Level Physio.
He has worked with runners and lifelong athletes for over 25 years, and is a clinical running research partner with Rutgers University. Dr. Jerry is an expert at helping athletic men and women over 30 who just don't want to stop.
He can be reached directly at Jerry@NLPhysio.com