Frozen Shoulder
What Is Frozen Shoulder (Adhesive Capsulitis)?
Frozen shoulder, known medically as adhesive capsulitis, is a painful loss of shoulder movement caused by inflammation, thickening and contracture of the capsule that surrounds the shoulder joint. As the capsule tightens, the space available inside the joint shrinks and the head of the humerus can no longer rotate freely within it.
What separates frozen shoulder from most other shoulder problems is that both active and passive movement are lost. The patient cannot raise the arm, and when someone else lifts it the movement still stops at the same point. The restriction is usually most obvious in external rotation, so combing your hair, reaching into a back pocket or taking something from a shelf becomes difficult.
It most often affects adults between the ages of 40 and 60 and is seen more frequently in women. One shoulder is usually involved, although the other shoulder may be affected years later. Although symptoms last a long time, the condition follows a self-limiting course in most patients.
Types of adhesive capsulitis:
- Primary adhesive capsulitis: begins spontaneously, with no identifiable underlying cause.
- Secondary adhesive capsulitis: develops after a shoulder injury, a period of prolonged immobilisation, previous shoulder surgery or on the background of an associated systemic condition.
What Causes Frozen Shoulder? Risk Factors
Why the joint capsule becomes inflamed and contracts cannot be explained in every patient. What is well established is that certain conditions clearly increase the risk, and the strongest association is with diabetes.
- Diabetes: markedly increases the risk. In these patients the condition can be more stubborn and both shoulders are more likely to be affected.
- Thyroid disorders, whether the gland is underactive or overactive.
- Prolonged immobilisation of the shoulder: sling use, immobilisation after a fracture, paralysis or extended bed rest.
- Surgery around the shoulder or chest wall, and the periods afterwards when the arm is used very little.
- Conditions in which pain stops the shoulder being used: rotator cuff disease, biceps tendinitis or shoulder impingement syndrome.
- Heart disease, the period after a stroke and Parkinson's disease.
- Conditions with a similar tendency towards connective-tissue thickening, such as Dupuytren's contracture.
Having one of these factors does not mean frozen shoulder will develop. It does mean, however, that a patient with shoulder pain who also has diabetes should not leave the shoulder immobile for long periods.
The Stages of Frozen Shoulder
Adhesive capsulitis typically passes through three stages. How long each stage lasts varies from person to person, and the transition between them is gradual rather than sharp. The treatment plan is shaped by the stage the patient is in.
- Freezing stage (6 weeks – 9 months): pain dominates and steadily increases. Night pain is prominent, the shoulder gradually stiffens and range of motion falls.
- Frozen stage (2 – 6 months): pain settles somewhat, but stiffness is at its greatest. Limitation in daily tasks is felt most keenly during this period.
- Thawing stage (6 months – 2 years): the capsule slowly loosens, pain decreases and range of motion is gradually regained.
Symptoms of Frozen Shoulder
Symptoms usually begin insidiously, without any clear injury. Patients often cannot recall a particular movement that started the pain.
- A dull, deep pain over the outer and upper shoulder that sometimes spreads into the upper arm.
- Night pain and an inability to lie on the affected shoulder; broken sleep is common.
- Marked restriction when lifting the arm out to the side or overhead, and especially when rotating it outwards.
- Difficulty with everyday movements such as putting on a jacket, combing your hair, reaching into a back pocket or fastening a seat belt.
- A sharp, stabbing pain in the shoulder when the arm is moved suddenly.
- A sense of weakness that develops over time because the arm is used so little.
Obvious swelling, bruising, fever or loss of sensation in the shoulder are not typical findings of frozen shoulder. These symptoms suggest a different problem and need separate assessment.
How Frozen Shoulder Differs From Similar Shoulder Problems
Shoulder pain with restricted movement looks similar in many conditions; the most practical distinguishing test is whether passive movement is preserved. With a rotator cuff tear the patient cannot lift the arm alone, but when someone else lifts it the movement is largely completed. In frozen shoulder, passive movement stops at the same point as active movement.
In shoulder impingement syndrome pain appears within a particular arc of movement and complete stiffness is not expected. Shoulder arthritis also causes stiffness, but there the restriction comes from cartilage loss on the joint surface rather than the capsule, and the joint space appears narrowed on X-ray. In pain referred from the neck, shoulder movement is free and the pain radiates down the arm towards the hand.
How Is Frozen Shoulder Diagnosed?
The diagnosis rests largely on the history and physical examination. The assessment covers when symptoms began, whether there is night pain, associated conditions such as diabetes and thyroid disease, and any previous shoulder injury or surgery.
- Active and passive range of motion are measured separately; finding both restricted is the key diagnostic feature.
- External rotation is assessed with the arm at the side; loss of this movement is the most typical finding in frozen shoulder.
- The strength of each rotator cuff muscle is tested individually and the neck is included in the examination.
X-rays are usually normal; their main purpose is to exclude other causes such as arthritis, calcific tendinitis, an old fracture or dislocation. MRI and ultrasound are not needed in every patient; they are requested when a rotator cuff tear, tendon rupture or another intra-articular problem is suspected, or when the expected response to treatment does not occur. Thickening of the joint capsule and the coracohumeral ligament on MRI supports the diagnosis.
Non-Surgical Treatment
Treatment progresses in steps, and the large majority of patients recover without surgery. The first aim is to bring the pain under control, and then to restore the flexibility of the capsule gradually.
- Pain management: short-term use of analgesic and anti-inflammatory medication; cold application while pain dominates and heat before exercise once stiffness is the main problem.
- Activity modification: overhead movements that provoke pain are limited, but the shoulder is never left completely immobile.
- Physiotherapy: stretching and range-of-motion exercises performed within the limits of pain form the basis of treatment.
- Home exercise programme: short sessions repeated several times a day work better than a few intensive sessions per week.
- Control of associated conditions: keeping blood sugar well regulated in particular has a favourable effect on the course of recovery.
Forceful stretching well beyond the limits of pain does not improve the condition; it can increase inflammation and pain and reinforce the stiffness. The dose of exercise is adjusted again at every stage.
Exercise and Rehabilitation Programme
The exercise programme is planned around the stage the patient is in. In the freezing stage the aim is to reduce pain and preserve the movement that remains; in the frozen and thawing stages it is to regain the range that has been lost.
- Pendulum exercises: leaning the trunk forwards and letting the arm hang and swing in small circles gently mobilises the joint during the painful period.
- Passive and assisted stretches: forward elevation and external and internal rotation stretched gradually with the help of the healthy arm or a stick.
- Finger walking up a wall and towel stretches: simple home exercises aimed at gaining a little more range in each session.
- Shoulder blade control: scapular squeeze and stabilisation work that keeps the shoulder girdle moving correctly.
- Strengthening: resistance band exercises for the rotator cuff and deltoid to reverse the loss of strength as pain settles.
- Functional use: putting the regained movement to work in daily tasks such as dressing, reaching and carrying.
A mild sensation of tightness that settles quickly during exercise is expected. Pain that carries over to the next day and increases night pain shows the load was too high; in that case the intensity of stretching is reduced.
Injections and Hydrodilatation
When pain is severe enough to prevent the exercise programme being carried out, an intra-articular corticosteroid injection may be considered. Its clearest contribution is in the freezing stage, where pain dominates: by providing relief within a short time it makes physiotherapy possible.
In hydrodilatation (capsular distension), fluid is injected into the joint under imaging guidance to expand the contracted capsule in a controlled way. Injection methods are not a treatment on their own; they are always planned alongside a continuing exercise programme. In patients with diabetes, corticosteroid injection can temporarily raise blood sugar, so careful assessment is needed.
When Is Surgery Needed?
Surgery becomes relevant for only a small proportion of patients with frozen shoulder. It is generally considered when stiffness persists despite several months of regular physiotherapy and injection treatment and clearly limits daily life and the capacity to work.
In arthroscopic capsular release, the joint is entered with a camera and the contracted capsule and the adhesions in the rotator interval are released in a controlled manner. In some patients the procedure is combined with gentle manipulation of the shoulder under anaesthesia. Where manipulation is used on its own, the risk of injury to bone and tendon is taken into account, so the choice of method depends on the patient's bone quality and any associated problems.
Holding on to the range of motion gained is as decisive as the operation itself. Surgery is therefore followed by an intensive physiotherapy programme starting in the first days; without regular work in the early period the likelihood of stiffness returning increases.
Recovery Time and What to Expect
Frozen shoulder requires patience. In patients treated without surgery the whole process usually takes between one and three years, while a clear reduction in pain generally occurs within the first months. The length of this period does not mean treatment is failing; the capsule regains its elasticity slowly by nature.
The main factors influencing the pace of recovery are how long symptoms have been present, the stage at which the diagnosis was made, associated conditions such as diabetes and adherence to the home exercise programme. In patients with diabetes the process can take longer and some permanent restriction of range of motion may remain.
In patients who undergo surgery, most of the range of motion is regained in the first weeks, while full return of strength and endurance takes several months.
Daily Life Advice and Prevention
Frozen shoulder cannot be prevented in every case, but when the conditions that raise the risk are known there are practical measures worth taking.
- After a shoulder injury or operation, start moving the arm as early as your doctor allows; do not keep it in a sling longer than necessary.
- If you have diabetes, keep blood sugar control on track and do not ignore shoulder pain.
- Divide home exercises into several short sessions a day; avoid one long, forceful session.
- Support the shoulder with a pillow under the affected arm at night and avoid lying on that side.
- Move frequently used items from shelves above shoulder height to a reachable level.
- Prepare the tissue with a warm shower or heat pack before exercising; do not stretch without warming up.
When Should You See a Doctor?
Having shoulder pain and stiffness assessed early means treatment can be started at the right stage. Coming in before the loss of movement becomes established makes the process considerably easier to manage.
- Your shoulder pain has lasted for several weeks and your range of motion is steadily decreasing.
- You feel a marked restriction when lifting the arm to the side or overhead, and especially when rotating it outwards.
- Pain breaks your sleep at night and you cannot lie on the affected shoulder.
- You cannot manage everyday movements such as dressing, combing your hair or reaching into a back pocket.
- You have diabetes or thyroid disease and shoulder symptoms have started.
- Stiffness is steadily increasing after a shoulder injury or operation.
To have your shoulder symptoms assessed you can contact Assoc. Prof. Serkan Sürücü, and you can also review the other conditions covered within shoulder surgery.