Reading: Frozen Shoulder? Odd Aches and Pains?

Frozen shoulder, body pain, and arthritis are not the symptoms that typically come to mind when we think about menopause, but according to orthopedist and longevity doctor Vonda Wright, MD, they are inextricably linked to the decline in estrogen that occurs in midlife women. 

Dr. Wright notes that 80% of women will be affected by the “musculoskeletal syndrome of menopause,” a term she coined to encompass the myriad ways that loss of estrogen adversely affects our bones, muscles, and joints. But “we do not have to live in menopause misery,” she says. 

She has practiced as an orthopedic surgeon for more than 20 years — also specializing in sports medicine — and has conducted pioneering research into mobility and musculoskeletal aging. Now, she has made it her mission to educate women about how to stay strong and mobile throughout midlife and beyond. Because women lose an average of 3% of muscle mass per year after age 50, Dr. Wright stresses the importance of investing every day in one’s strength and mobility: “I want you to build muscle, I want you to build bone, I want you to feed that muscle,” she tells her 1 million Instagram followers with an almost evangelical zeal. 

CoveyClub recently caught up with Dr. Wright to learn more about the “musculoskeletal syndrome of menopause” — and how to combat it. 

(Interview has been edited for length.)

CoveyClub: How did you, as an orthopedic surgeon, become part of what I’ve heard you call the “menoposse” — a group of healthcare experts “out to defend the rights of women in midlife”? 

Dr. Wright: When we talk about women’s health, we traditionally think of it, frankly, as everything below the bikini line having to do with fertility. We should be talking about the health of a woman across her health span, because health is from the top of our heads, our brain function, all the way to the bottom of our toes. And so, as I went through my own menopause, I started doing deep dives about what was going on. 

How come I don’t feel like myself? I’m an athlete, I’m used to having total control over what my arms and legs do, but I couldn’t get out of bed. It was so painful. I went from true misery — that, like many women, I didn’t talk about, I just tried to figure it out myself — to really feeling like I’ve mastered a lot of what’s going on in midlife. 

Every tissue in the musculoskeletal system has estrogen receptors, and as estrogen walks out the door and never looks back, why wouldn’t our musculoskeletal system hurt? [But] if a woman goes to a doctor and says, “My whole body hurts, my knee hurts, my shoulder’s frozen, I feel inflamed…” pretty soon — because of the way healthcare is reimbursed, and we have 15 minutes with each person — that poor doctor is going to glaze over and say, “Choose something.”

When you arrive saying, “I’m in midlife, I do not make estrogen anymore, and I have the ‘musculoskeletal syndrome of menopause,’ and here is how it’s manifesting in me,” that’s a better package. 

I’m the only orthopedic surgeon talking about this; 97% of all of my colleagues are men … they were born without the benefits of ovaries. I can’t expect them to understand until I educate them or their wives say, “Have you heard this crazy orthopod talking about this?” 

CoveyClub: We all know to expect hot flashes, night sweats, disrupted sleep, and maybe decreased libido during the menopausal transition, but most of us have not heard of the “musculoskeletal syndrome of menopause.” If, as you say, 80% of women will experience symptoms of this syndrome, why aren’t more people talking about it? 

Dr. Wright: Well, I can reverse that question and ask the legitimate question: Why don’t more women even know what perimenopause is? I mean, I had 30 people in my clinic yesterday, and several of them, they came to me for various musculoskeletal things, and I asked the question, have you ever heard of perimenopause? And they hadn’t. So, wow. That goes along with the fact that only 7% of women in this country are prescribed hormones, so I don’t think that it’s isolated to not knowing about how it manifests in the musculoskeletal system. I think the musculoskeletal system is even more behind than every other symptom that’s going on. 

CoveyClub: So what exactly is the “musculoskeletal syndrome of menopause?” And what are the most common symptoms? 

Dr. Wright: Women come to me with a variety of things, but they always summarize it for me like this: ‘I don’t know what’s going on. I think I’m falling apart. And sometimes I think I’m going crazy, because no one can explain it to me.’ And as we’re talking about it and putting the pieces together, I say, ‘You are not going crazy. You are perimenopausal, and your estrogen is walking out the door.’ 

And here’s what it causes in your body from a musculoskeletal syndrome effect:

It causes total body pain, which is called arthralgia and 80% of all women will experience that, and 25% will be devastated by it. We know that men before 50 have much more arthritis than women, [but] after 50, women rapidly progress in arthritis, and that’s because estrogen is critical for the health of the cartilage matrix.

We know we lose muscle mass with aging — it’s called sarcopenia — but without estrogen, we lose it more rapidly. 

We know women lose bone density because estrogen is critical in the balance of reabsorbing and laying down bone. Our tendons and ligaments are [also] dependent on estrogen for their health, so we get a lot more tendinitis problems.

Probably the number one thing women show up in my office with, besides total body pain, is a frozen shoulder, out of nowhere. Their shoulder just stops moving, and that’s due to the inflammation that comes when estrogen walks out the door. 

CoveyClub: I was surprised to hear that frozen shoulder was connected to menopause — why is this such a common problem among midlife women?

Dr. Wright: Estrogen is a powerful anti-inflammatory. It acts directly on the immune system through a complex molecule called the “inflammasome,” and without estrogen doing its job to lower inflammation, the body is essentially, in layman’s terms, hot and red inside. The shoulder capsule, which is the inside portion of the shoulder, seems to be very sensitive to that. So the first thing that happens when your whole body becomes inflamed is the shoulder capsule becomes inflamed and it becomes painful. So what’s our response to pain? Well, let’s protect it. Let’s not move that painful part. Very rapidly, the shoulder becomes stiff. It’s not just painful, but the capsule physically contracts, so you can’t move your shoulder. 

CoveyClub: And why does the decrease in estrogen lead to problems with our muscles, bones, and joints in general?

Dr. Wright: One of the ways our body works is [that] cells have receptors sitting on them like little baskets, and they sit there empty. Only when their stimulus — [in this case] estrogen — sits in the estrogen basket is there a change in the receptor, which leads to all the good things that estrogen does in a cell. So, if the basket sits empty, none of the downstream things — bone-building, muscle building, anti-inflammation — nothing that’s supposed to happen when you have estrogen, happens. 

“Every tissue in the musculoskeletal system has estrogen receptors, and as estrogen walks out the door and never looks back, why wouldn’t our musculoskeletal system hurt?”

CoveyClub: You mentioned before that women are more likely than men to have osteoarthritis after age 50 — how is this connected to the decline in estrogen? 

Dr. Wright: Arthritis, by definition, is loss of cartilage. Cartilage is a spongy matrix that sits on the ends of every bone and gives you smoother than ice, frictionless motion. Without estrogen sitting in the estrogen receptors on cartilage, the cartilage matrix breaks down more rapidly. So we’re going along, we’re doing fine. And then all of a sudden, the protective mechanisms that estrogen has on a cartilage matrix no longer happen because there’s no estrogen sitting in the receptors. So the cartilage matrix starts to break down.

CoveyClub: For women who are pre- or perimenopausal, is there a way to prevent osteoarthritis? And once you already have it, is it possible to reverse it — or at least to halt progression and keep pain at bay? 

Dr. Wright: Yes, there are many ways to prevent osteoarthritis. A small portion of it is genetically predisposed. What are some of the other things that lead to rapid onset of osteoarthritis or progression? Being heavy. We know that joints bear 10 times body weight. … so, if we’re carrying an extra 100 pounds, that’s an extra 1,000 pounds of pressure on [a] very delicate cartilage matrix. So is there a way to prevent osteoarthritis? Yes, we need to build more muscle and not carry around a lot of extra weight because that speeds it up.

Can we prevent the progression? Yes, by identifying that we are in perimenopause and making our hormone replacement decision early. I didn’t make my decision until I was already in menopause. I didn’t know enough at the time. So at 52, I started on hormone replacement therapy. If I were to go back to when my perimenopause started, at 47, I would have started then to prevent any muscle loss, to prevent bone loss, to prevent any cartilage wear that I developed. 

CoveyClub: What about women who didn’t go on hormone therapy because they were told they were high risk, and now they’re past the time period — within 10 years of menopause onset — when most guidelines recommend starting HT? Or, what about women who make the decision not to go on HT? Are there other ways to either reverse any of the musculoskeletal decline or prevent progression? 

Dr. Wright: If a woman is outside the 10-year window, if she evaluates her risks and decides she is not willing to assume the risks, or just doesn’t want to, there are still a myriad of lifestyle things that we can do to support our musculoskeletal system. The primary one, if you do nothing else, is to lift heavy weights, even if we have known osteoporosis.

The LIFTMOR study has shown that under supervision, we can lift heavier weights and build lean muscle mass, which in turn, helps build bone density. So let’s lift weights. 

[Next,] to support that women need to eat more protein. Most women are under-caloried and under-protein-ed because we’ve been taught our whole lives that we have to be tiny, that we have to starve ourselves. So 1 gram of protein per ideal body pound is what I recommend, and so that takes understanding what we’re eating, sometimes supplementing with protein. I get about 130 grams of protein a day. So lifting heavy, smart nutrition, high protein.

And, we need to support our cardiovascular system. I usually recommend that we do three hours a week of base training at a lower heart rate, which can be brisk walking, but twice a week we must sprint. Now, people get a little freaked out by the word sprint. They can’t envision running 100 meters, which is not what I’m asking you to do. Sprinting is simply a heart rate measurement of working hard enough to get your heart rate up to 85% or 90% of your maximum. So for me, it’s sprinting on a treadmill. Other people can do it on a bike or a rowing machine or swimming — anything that gets your heart rate up. When we sprint, we don’t do it for long bouts of time. We do it 30 seconds at a time with complete recovery in between, and we do that twice a week. 

So those are just a few of the lifestyle ways that we can master midlife, plus or minus hormone replacement therapy. 

CoveyClub: When you talk about lifting heavy weights, how do you define “heavy”? 

Dr. Wright: We are all different. My heavy is different than your heavy. So how do we determine that? Well, heavy means lifting what you can lift four reps for four sets. So instead of lifting up weights that you can do 25 times, we lift what we can only do 4-6 times. Is that for every lift we do? No, those are for the complex, multi-joint lifts, the power lifts. So in the upper body, it’s your bench press type move, and it’s your pull up type move. For the lower body, it’s your squat type move and your deadlift type move. For the accessory lifts that support those power lifts — biceps, triceps, lats, delts, row — for those types of lifts we do the amount of weight it will take you to fail after about 8-10 reps. You’ve got to think about, what am I training for? We’re not lifting to get big muscles. We’re not lifting for endurance. We’re lifting for longevity and power, so that we can be independent as we age, so we can open our own pickle jars, so we can get up out of a chair. We’re training for life. 

CoveyClub: How will building lean muscle mass affect the other aspects of the “musculoskeletal syndrome of menopause” — the frozen shoulder, the arthralgia, the decline in bone density? 

Dr. Wright: Last year, I built 8 lbs. of muscle. How does that affect our total bodies? Well, it stimulates bone density. Muscle is connected to the tendon, which pulls on our bones. It causes the biomechanical stimulus to make our bones stronger. Muscle is an incredible metabolic organ. It is incredibly important for insulin sensitivity. So the more muscle we have, the more metabolically healthy we are, the less inflammation we’re going to have, the stronger bones we’re going to have.

Muscle is an incredible metabolic organ, and bone is a master communicator. It is not just a structural phenomenon, but it has multiple paracrine and endocrine functions in the body, communicating with every tissue around it. Sometimes we think of body parts as silos: the muscles over in this county, the bone is over in this county. The fact of the matter is, they’re all part of the same cul-de-sac, and they’re talking all the time.

“Muscle is the Spanx of nature. It’s going to hold everything in.”

CoveyClub: Can working to increase lean muscle mass also help to combat the weight gain and accumulation of fat around the middle of the body that plagues midlife women? 

Dr. Wright: Muscle mass does not cause redistribution of fat — that has to do with hormone shifting. But muscle requires more calories just to sit in one place and be living than fat does. About double the calories. So by building muscle mass, our basal metabolic rate, [meaning] the rate of calories we burn just to live without any exertion, increases. So that’s one advantage. Because muscle is so metabolically important and helps with insulin sensitivity, if we have more muscle, we will accumulate less fat, plus burn more fat, and we will recompose our bodies, right? So, I never talk about weight loss. I don’t actually care what we weigh. What I care about is our percent body fat — between 19% and 28% is healthy for a woman — and how much muscle we have. The more the better.

By doing cardiovascular in the way I’ve talked about, by supporting our muscle growth with protein, what we’re capable of is recomposing our body, not simply losing weight. If we’re just focused on what the scale says (‘I’m going to lose 20 pounds’), but we’re not lifting, we’re going to lose half fat, half muscle, and we’re going to end up “skinny fat.” Really, we may weigh less, but we’ll have a higher percentage body fat, which is counterproductive, right?

We should say things like, ‘I want to be more lean,’ not ‘I want to lose more weight.’ Because, you know, a funny thing I like to say is muscle is the Spanx of nature. It’s going to hold everything in. In about a month, your clothes will fit better, even if the scale hasn’t changed. So, we’re building muscle for our metabolic health, for our bone health, to recompose our body, to make us more insulin sensitive, and frankly, it will make our clothes fit better. 

CoveyClub: You’ve mentioned that once you lose cartilage, you can’t regain that cartilage. Once you lose bone, can you regain the bone by doing these exercises? Or, are we just trying to prevent progression? 

Dr. Wright: Yes, yes, yes, and yes. It’s harder to regain bone by just lifestyle changes, by just lifting weights, but if we add estrogen back to that, maybe we add some of the medications temporarily that we know add bone, we can regain bone. Is it as easy as it once was? No, but we can maintain and under some certain circumstances, we can build. This becomes not just a postmenopausal discussion. This is a perimenopausal discussion. It’s a discussion to be had the minute you turn 40, or the minute you turn 35, the minute your ovaries start slowing down.

Because, I would love to prevent bone loss. I also have very young women, 28-year-old women, 30-year-old women, who come to me with fractures because they never laid down enough bone in the first place, because they were taught to be tiny, to not eat a lot of calories. Maybe they were never athletes. Maybe they were athletes and had such dysregulated periods they never had enough estrogen to lay down bone. And so they hit 30, when we’re supposed to be at peak bone density, already osteopenic, so it becomes a lifetime of catching up, right? So this bone message that I’m giving is not just for postmenopausal women. It’s for perimenopausal women. It’s for our millennial daughters, and it’s even for my 17-year-old daughter. We’re all trying not to become the frail old women that I take care of in their 70s, 80s and 90s, laying in a hospital bed before me with a broken hip.

CoveyClub: We’ve talked about exercise. What are the key things that midlife women need to be doing with diet to support the musculoskeletal system?

Dr. Wright: I think words are important, and “diet” has such a negative connotation, because most of us have been on and off diets. So, I talk about smart nutrition. How are we going to fuel all this amazing building we’re doing in midlife? And that’s the way I view food — as fuel. So what are the principles?

Number one: If we want to decrease our inflammation, we cut out simple sugar, no added sugar, no simple carbs, no juice. And frankly, people hate it when I say this, but that includes alcohol, which is full of sugar. Why do we do that? Because we don’t want to hurt all the time. I’m not anti-carb. I am anti–simple sugar. So when we talk about nutrition, that is principle number one: we’re looking for complex carbs and fiber.

Number two: We must fuel our muscle growth. That includes 1 gram of protein per ideal pound a day, and it’s not that hard. We just have to start tracking it. And so that takes, for me, protein supplementation in the form of protein powder. And again, it’s not supposed to be pleasure. Just stick it in a bottle of water and take it down. 

Overall, lots of green leafy vegetables and lean protein of every kind. If we’re going to eat fruit, fruit is dessert. Fruit is sugar. Those are the basic principles of smart nutrition. 

CoveyClub: Is there anything we haven’t touched upon about the “musculoskeletal syndrome of menopause” that you’d like to add?

Dr. Wright: Here’s the message: There is never an age or skill level when your musculoskeletal system will not respond to the good stress you put into it. So, even if you have not moved since high school, even if you were once an athlete, but are now starting from zero, your body will respond and your body will respond rapidly within a month. Probably one of the most hopeful messages: When you reinvest in your musculoskeletal system, it will continue to support you and continue to make you unbreakable.

Dr. Vonda Wright’s new book Unbreakable! How You Can Go Stronger, Live Longer, and Age With Power will be published by Rodale Press in late 2025. Join her waitlist to receive updates and new research. Learn more about Dr. Wright’s accomplishments as a surgeon, researcher, and author here.