
I see many women in their 40s and 50s who come in for frozen shoulder massage therapy who are also curious about a broader holistic approach.
Women form the vast majority of frozen shoulder patients in the world.[1]
Primary (idiopathic) Frozen shoulder is so common in women in their 40s and 50s that in some Asian countries it is called ‘Fifties shoulder’.
Conventionally treated with some combination of analgesics or injections for pain relief, home exercises, manual therapies like physiotherapy and massage, severe cases of Frozen shoulder are (less commonly) treated by surgery or manipulation under anesthetics.
Interest in the connection between estrogen levels and frozen shoulder has been growing[2] and a few studies have explored this connection.[3]
Of course, more and diverse research is needed especially from the point of view of providing whole- person solutions.
Although it is not a symptom of perimenopause or menopause, here is how frozen shoulder can be a result of hormonal fluctuations and decreasing estrogen levels
Anti-inflammatory effects and Collagen metabolism: Estrogen has anti-inflammatory effects. It plays an important role in collagen metabolism of connective tissue. Fluctuations in estrogen dysregulate collagen metabolism affecting the structure and function of the shoulder joint.
Impact on Joints and connective tissue health: Estrogen receptors are present in diverse tissues of the body including the connective tissue of the shoulder joint. Estrogen helps maintain the elasticity and strength of these tissues; So a decrease in levels may affect the quality and function of these tissues leading to stiffness and reduced flexibility.
Bone health: Decreasing estrogen levels is linked to bone loss. Changes in bone density around the shoulder joint affect function& stability potentially contributing to frozen shoulder.
What causes Frozen shoulder?
As manual therapists, we learn that frozen shoulder is caused by inflammation of the tissues surrounding the joint capsule and thickening of the capsule which leads to adhesion, pain and restricted movement. Tendinopathy in the joint, partial tears in the tendons can also cause this inflammation and fibrosis.

Why does this happen?
The Ayurvedic view is that there is a metabolic component underlying the structural changes in the joint capsule. Additionally, there are longstanding dosha imbalances that create the right conditions for frozen shoulder to develop
Some of the factors at play
Dosha imbalances- Frozen Shoulder is seen primarily as a Vata disorder in a kapha area of the body.
Vata is the dosha that is responsible for controlling all the neurological and neuromuscular actions in the body.
[Some forms of Vata aggravation manifest as depletion, degeneration, dryness, roughness poor circulation etc. in the various tissues of the body, which secondarily sends other doshas into imbalance].
The main factor in frozen shoulder is Vata aggravation concurrent with asthi dhatu kshaya (degeneration or reduced quality of bone tissue ) in the shoulder joint.
Vata dosha has an inverse relationship to bone tissue. When vata gets highly aggravated, it depletes bones.
High vata in this region also reduces healthy shleshaka kapha (the sub-type of kapha responsible for joint lubrication) in the shoulder joint.
Agni, Ama and Metabolism- When the agni (metabolic strength) in the various dhatus (tissue layers) is not optimal, the body does not do an good l job of digesting fats and sugars in the blood. This creates chronic inflammation everywhere. When a weak spot in the shoulder area develops due to longstanding vata aggravation, this inflammation find it easiest to lodge there, grow and create dysfunction.
Additional Risk factors-
In Ayurvedic practice, it is thought that people with a family history or pre-existing metabolic conditions like diabetes, hyper/ hypothyroidism are more at risk for developing frozen shoulder.
Ayurveda, Estrogen levels and Joint issues-
The hormones estrogen and progesterone are seen as serving vital kapha and pitta functions.
Estrogen is a part of healthy kapha, fulfilling the functions of cohesion, stability, growth and nurturing and nourishing all the tissues.
As we age, vata dosha naturally increases in the body. Healthy levels of kapha and ojas (subtle, super-refined form of kapha) are a natural buffer to the erratic, dry and depleting nature of vata. As ojas decreases during menopause, the body has less of a buffer against the erratic nature of vata aggravation (and in many cases also heightened pitta).
High vata obstructs microcirculation in skeletal muscle and connective tissue, dries tissues, depletes bone, affects digestion and overall nutrition, and in some cases may cause osteoporosis.
So Ayurveda places a lot of emphasis on maintaining healthy ojas, by maintaining healthy kapha, as we age.
What ‘Healthy kapha’ looks like, is different for each person and mustn’t be mistaken as simply increasing estrogen.
In-depth work is possible when you work one-on-one with a qualified Ayurvedic practitioner.
Everybody is different and so it is not helpful to make generalizations, especially around herbal suggestions.
This is very general outline of how I might work with Ayurvedic principles around Menopause.
· Work with the nervous system: Encouraging the shift into parasympathetic states with bodywork, appropriate herbal oils, abhyanga/ shirodhara, yoga nidra, pranayama.
Strengthen and protect Agni
· Increase moisture/ hydration- Adjust diet appropriate to individual , work with the right herbs for each person, build healthy kapha.
· Lower inflammation
· Focus on Rasayana (nourishing, building) therapies, foods and practices
· Build and Maintain bone health
· Rest well, move well, slow down
How I might address Frozen Shoulder with Manual therapy and Ayurveda ( general outline )
· Assess for range of motion, swelling, tenderness, pain, past injuries followed by an overall Ayurvedic assessment.
· What state of freezing, frozen or thawing is the shoulder in? What are the doshas involved?
· Where there is a lot of pain and guarding to begin with, I do not recommend pushing through the pain barrier with exercise or manual techniques.
· I like to start with hands-on techniques that establish safety in the nervous system; do careful work on specific muscles mainly through isometric contractions, respecting the guarding response.
· Alongside this, I like to address the metabolic aspects- agni, ama, inflammation, doshas and sub-doshas which are out of balance through herbs, food and lifestyle adjustments appropriate to each person’s situation, and add home exercises
· Once the intensity of pain goes down, I progress to a variety of manual therapy techniques which introduce frictioning and mobilization to unadhere the joint capsule.
· Having taken ama-reduction, and anti-inflammation measures through food and herbs, it is time to build on the body’s readiness for oil based treatments like abhyanga massage, localized oil streaming (pizhichil/ kayasekam), warm compresses, nasya and steam treatments to further resolve adhesions, address the soft tissue, circulation and nervous system.
With this approach, It’s been great to see not only pain go down, range of motion &muscle strength return, but an overall positive shift in the body-mind.
Footnotes
[1] Mezian K, Coffey R, Chang KV. Frozen Shoulder. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK482162/
[2] Yoon, Seunghyun MD, PhD; Lee, Doo-hyung MD, PhD; Bang, Junyoung MD. Perimenopausal arthralgia in the shoulder. Menopause 25(1):p 98-101, January 2018. | DOI: 10.1097/GME.0000000000000944
[3] Saltzman E, Kennedy J, Ford A, et al. Poster 188: Is Hormone Replacing Therapy Associated with Reduced Risk of Adhesive Capsulitis in Menopausal Women? A Single Center Analysis. Orthopaedic Journal of Sports Medicine. 2023;11(7_suppl3). doi:10.1177/2325967123S00174
Select Additional References:
Alsubheen SA, Nazari G, Bobos P, MacDermid JC, Overend TJ, Faber K. Effectiveness of Nonsurgical Interventions for Managing Adhesive Capsulitis in Patients With Diabetes: A Systematic Review. Arch Phys Med Rehabil. 2019 Feb;100(2):350-365. DOI: 10.1016/j.apmr.2018.08.181. Epub 2018 Sep 28. PMID: 30268804.
Charaka Samhita of Agnivesha, Chikitsa Sthana, In: Sharma PV, ed. 2nd ed., ch. 28, Varanasi: Chaukhamba Orientalia; 2014.
Charaka Samhita of Agnivesha, Sutra Sthana, In: Sharma PV, ed. 2nd ed., ch. 14 & 22, Varanasi: Chaukhamba Orientalia; 2014.
Innes KE, Selfe TK, Taylor AG. Menopause, the metabolic syndrome, and mind-body therapies. Menopause. 2008 Sep-Oct;15(5):1005-13. DOI: 10.1097/01.gme.0b013e318166904e. PMID: 18779682; PMCID: PMC2810543.
Noten S, Meeus M, Stassijns G, Van Glabbeek F, Verborgt O, Struyf F. Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review. Arch Phys Med Rehabil. 2016 May;97(5):815-25. DOI: 10.1016/j.apmr.2015.07.025. Epub 2015 Aug 15. PMID: 26284892.
Pillai S, Krishnakumar K, Soman D, et al. Concept of Apabahuka in the lights of modern science: a review. Int J Res Ayurveda Pharm 2017;8(Suppl 3):39–42. DOI: 10.7897/2277-4343.083166.
Sushruta Samhita of Sushruta, Nidana Sthana, In: Sharma PV, ed. 2nd ed., ch. 1, Varanasi: Chaukhamba Orientalia; 1991.
Welch, Claudia. Balance Your Hormones, Balance Your Life. Da Capo Life Long. Massachusetts. 2011
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