Frozen Shoulder (Adhesive Capsulitis)
Frozen shoulder is a condition in which the capsule surrounding the shoulder joint thickens and tightens, so that movement becomes progressively restricted. Its distinguishing feature is this: not only the patient’s own movement but the movement the physician performs is also restricted. This separates it from a rotator cuff tear and from impingement syndrome.
What Happens in the Shoulder?
The capsule around the shoulder joint is normally loose and elastic to allow a wide range of movement. In frozen shoulder an inflammatory process begins in this capsule; it thickens and contracts. The volume within the joint decreases, and the arm can neither be raised nor, in particular, rotated outwards.
Restriction of external rotation is typical: the patient cannot reach behind, comb their hair or get to a back pocket. This restriction is not caused by pain but mechanically, because the capsule does not allow the movement.
Who Is More Affected?
- Diabetes — the most strongly associated condition; the course may be longer
- Thyroid disorders
- A period of immobility of the shoulder (fracture, surgery, prolonged use of a sling)
- The 40–60 age range
- Having had frozen shoulder in the other shoulder
In one group of patients no clear cause is found; this is called primary (idiopathic) frozen shoulder.
Three Phases
Frozen shoulder generally runs in three successive phases. The length of the phases varies markedly from person to person, and for that reason no timeframe is promised on this page.
- Painful (freezing) phase: pain predominates and is particularly marked at night. Movement gradually decreases.
- Frozen (stiff) phase: pain settles somewhat, but restriction of movement is at its most marked. Daily tasks are hardest in this phase.
- Thawing phase: range of movement is regained gradually.
Symptoms
- Progressively increasing pain and stiffness in the shoulder
- Night pain and being unable to lie on the affected side
- Restriction of raising the arm to the side and upwards
- Difficulty reaching behind, combing hair or reaching a back pocket
- Sharp, sudden pain when the movement is forced
Diagnosis
- History: onset of symptoms, history of diabetes and thyroid disease, any period during which the shoulder was immobile.
- Examination: restriction of both active and passive movement is the key finding; loss of external rotation is specifically sought.
- X-ray: generally normal; requested to exclude other causes such as osteoarthritis and calcification.
- MRI: not essential for diagnosis; may be requested if an accompanying rotator cuff problem is suspected.
The differential diagnosis matters: in a rotator cuff tear and in impingement syndrome, passive movement is generally preserved. Related article: Shoulder Pain: Rotator Cuff Tear, Impingement or Frozen Shoulder?
Treatment
Non-surgical treatment
The basis of treatment in frozen shoulder is non-surgical and requires patience. The aim is to manage pain and gradually restore range of movement.
- Pain management — the choice and duration of medication is determined by your physician
- A regular stretching programme — particularly for external rotation and forward elevation
- Physiotherapy; applying heat before stretching may make it easier
- An intra-articular injection in selected cases — particularly in the painful phase, to make starting exercise easier
- Where diabetes is present, attention to blood glucose control
Excessively forceful stretching well beyond the limit of pain is not recommended; it may aggravate the inflammatory process and increase stiffness. The programme should be regular and stay within the limits of pain.
Interventional options
If restriction of movement continues to affect daily life seriously despite a prolonged programme, then in selected patients increasing the range of movement under anaesthesia or arthroscopic capsular release may be considered. The decision weighs the presence of diabetes, the phase and the patient’s functional requirements; maintaining the stretching programme afterwards directly affects the outcome.
Daily Life Suggestions
- Do your stretching several times a day, briefly and regularly — rather than one long session a week
- Stretching after a warm shower is generally better tolerated
- Do not lie on the affected side; support the arm with a pillow
- Not using the arm at all increases stiffness; keep using it for daily tasks within the limits of pain
- If you have diabetes, pay particular attention to your blood glucose control
When Should You Seek Assessment?
- If your shoulder movement is becoming progressively restricted over weeks
- If you cannot rotate your arm outwards or reach behind you
- If night pain interrupts your sleep
- If you have diabetes and shoulder stiffness has begun
- If there has been no improvement for months despite physiotherapy
When to Seek Medical Help Without Delay
- Being unable to raise the arm at all after a fall or a blow, or obvious deformity of the shoulder
- Redness, warmth and severe pain in the shoulder together with fever
- Loss of strength in the arm together with numbness, tingling and coldness
These findings require urgent assessment. Outside office hours, go to the nearest emergency department.
Frequently Asked Questions
Does frozen shoulder settle on its own?
Frozen shoulder improves markedly over time in most patients; however, this process varies considerably from person to person and some patients are left with a degree of restriction. A regular stretching programme makes the process more manageable.
Why can I particularly not rotate my arm outwards?
The part of the capsule that contracts most is the region that limits external rotation. Loss of external rotation is therefore the most typical finding in frozen shoulder and is specifically sought on examination.
I have diabetes — is the course different?
Frozen shoulder is more common in people with diabetes, the course may be longer and the response to treatment slower. Blood glucose control is assessed as part of the treatment programme.
The exercises hurt — should I continue?
Mild, temporary tightness is expected during stretching; however, pain that increases and carries over to the next day means the programme is too demanding. Intensity should be reduced and the programme reviewed with your physician or physiotherapist.
Should I have an injection?
An injection can reduce symptoms particularly in the painful phase and make it easier to start a stretching programme. It is not a treatment on its own and may not be suitable for every patient; the decision is made by your physician according to the clinical picture.
Could the same happen in my other shoulder?
In people who have had frozen shoulder in one shoulder, the likelihood of it occurring in the other is higher than in the general population. Recurrence in the same shoulder is less expected. Maintaining range of movement early is important.
Academic Work
Assoc. Prof. Bertan Cengiz, MD has scientific work published in national and international peer-reviewed journals in the field of shoulder arthroscopy and upper limb surgery and related areas. The publication list and verifiable academic sources are available on the Publications page.
Related Pages
- Shoulder and Upper Extremity
- Rotator Cuff Tear
- Shoulder Impingement Syndrome
- Shoulder Arthroscopy
- Shoulder Pain: Rotator Cuff Tear, Impingement or Frozen Shoulder?
The information on this page is for general guidance and does not replace an in-person medical examination. Diagnosis and treatment require a physician’s clinical assessment. Outcomes of any treatment or surgical intervention may vary from person to person; no guarantee of a specific result or timeframe is given on this page.