Frozen Shoulder

What is Frozen Shoulder?

Frozen shoulder, medically known as adhesive capsulitis, is a condition characterized by pain and severe stiffness in the shoulder joint. The shoulder capsule—a thick, fibrous tissue surrounding the joint—becomes inflamed, tight, and develops adhesions (scar-like tissue bands), dramatically restricting movement.

Unlike many shoulder conditions that develop from injury or overuse, frozen shoulder often appears without a clear cause. It typically affects one shoulder at a time, though about 20% of people who’ve had it in one shoulder will eventually develop it in the other.

Approximately 2-5% of the general population experiences frozen shoulder, with significantly higher rates among people with diabetes (10-20%).

Understanding the Three Stages

Frozen shoulder follows a predictable pattern through three distinct stages. The total process typically takes 1-3 years, though the timeline varies significantly among individuals.

Stage 1: Freezing (Painful Stage)

Duration: 6 weeks to 9 months

Characteristics:

• Gradual onset of shoulder pain
• Pain worsens progressively, especially at night
• Increasing stiffness and loss of range of motion
• Pain limits all shoulder movements
• Difficulty sleeping on the affected side

What’s happening: The shoulder capsule is becoming inflamed. Pain is the dominant symptom, though motion loss is beginning.

Stage 2: Frozen (Stiff Stage)

Duration: 4 to 12 months

Characteristics:

• Pain may improve somewhat
• Severe stiffness becomes the main problem
• Significant loss of motion in all directions
• Daily activities become very challenging
• Lifting arm overhead nearly impossible
• Reaching behind back extremely limited

What’s happening: Inflammation subsides but the capsule has thickened and tightened. Adhesions (bands of scar tissue) restrict motion even more.

Stage 3: Thawing (Recovery Stage)

Duration: 6 months to 2 years

Characteristics:

• Gradual improvement in range of motion
• Steady decrease in pain
• Slow return to normal or near-normal function
• Improvement can be frustratingly slow
• Some patients regain full motion; others have lasting restrictions

What’s happening: The shoulder capsule begins to loosen. Adhesions break down gradually, allowing more movement.

Symptoms to Watch For

Frozen shoulder develops gradually, making early recognition challenging. The hallmark is progressive pain and stiffness that limits shoulder movement in all directions.

Primary Symptoms

Distinguishing from Other Shoulder Problems

Unlike rotator cuff tears or arthritis, frozen shoulder causes:

• Global motion loss: Restricted in all directions (rotation, lifting, reaching)
• Passive restriction: Your shoulder won’t move even when someone else tries to move it
• Specific pattern: External rotation (turning arm outward) typically most limited
• No clear injury: Often develops spontaneously

Risk Factors

Medical Conditions Strongly Associated with Frozen Shoulder

• Diabetes: 10-20% of diabetics develop frozen shoulder (vs. 2-5% general population)
• Thyroid disorders: Both hypo- and hyperthyroidism increase risk
• Cardiovascular disease: Heart disease patients at higher risk
• Parkinson’s disease: Neurological conditions increase susceptibility

Triggering Events

• Immobilization: Surgery, injury, or prolonged sling use
• Shoulder injury: Even minor trauma can trigger the condition
• Stroke: Especially on the affected side
• Breast surgery: Mastectomy patients have elevated risk

Demographic Factors

• Age: Most common between 40-60 years
• Gender: Slightly more common in women
• Previous frozen shoulder: 5-10% chance of developing it in the other shoulder

Diagnosis

Frozen shoulder is primarily a clinical diagnosis based on history and physical examination.

Physical Examination

Your healthcare provider will:

• Assess active range of motion (how far you can move on your own)
• Test passive range of motion (how far they can move your shoulder)
• Look for characteristic “capsular pattern” of restriction
• Measure specific motion limits in degrees
• Rule out other shoulder conditions

Key diagnostic sign: Both active and passive motion are severely limited in a specific pattern (external rotation > abduction > internal rotation).

Imaging Studies

• X-rays: Typically normal; rules out arthritis or bone problems
• MRI: Not usually necessary; helps exclude rotator cuff tears or other pathology
• No specific test: Diagnosis is based on clinical findings, not imaging

Treatment Options

While frozen shoulder often resolves on its own over 1-3 years, treatment can reduce pain and potentially shorten the duration. Treatment varies by stage.

Conservative Treatments (First-Line)

Physical Therapy

• Gentle stretching exercises: Most important treatment component
• Range-of-motion exercises: Pendulum swings, wall walks, pulley exercises
• Heat therapy: Before stretching to relax muscles
• Avoid aggressive stretching: Can worsen inflammation in early stages

Home Exercise Program

• Consistent daily stretching (2-3 times per day)
• Gentle progressive exercises
• Patience—improvements are gradual
• Continue exercises for months

Pain Management

• Over-the-counter NSAIDs (ibuprofen, naproxen)
• Ice for acute pain flares
• Heat before stretching exercises
• Avoid immobilization

Injection Therapies

Advanced Interventions

When conservative treatment fails after 6-12 months:

Hydrodilatation (Distension Arthrography)

• Injection of large volume of fluid to stretch the capsule
• Moderate evidence for effectiveness
• Performed under ultrasound or fluoroscopic guidance

Manipulation Under Anesthesia

• Forceful stretching while patient is asleep
• Breaks up adhesions
• Risk of fracture or rotator cuff tear
• Less commonly used today

Arthroscopic Capsular Release

• Surgical release of tight capsule
• Reserved for severe, refractory cases
• Good results in appropriate patients
• Requires intensive post-op physical therapy

The Diabetes Connection

People with diabetes face significantly higher risk of frozen shoulder and often experience more severe, prolonged symptoms.

Why diabetics are at higher risk:

• High blood sugar causes inflammation
• Glycation (sugar binding to proteins) may affect capsule tissue
• Collagen abnormalities in diabetic tissue
• Impaired healing and tissue repair

If you have diabetes:

• Maintain good blood sugar control (may reduce risk)
• Be especially vigilant about shoulder symptoms
• Start treatment early
• Be patient—resolution may take longer
• Work closely with both endocrinologist and orthopedist

Living with Frozen Shoulder

Frozen shoulder is frustrating because it limits basic daily activities and recovery is slow. These strategies can help:

Adapting Daily Activities

• Dressing: Button-front shirts, loose sleeves, dress affected arm first
• Grooming: Long-handled brushes and combs, electric toothbrush
• Reaching: Step stool instead of reaching high, place commonly used items lower
• Sleeping: Use pillows to support arm, try recliner or wedge pillow
• Driving: Position seat closer, use hand-over-hand steering technique

Exercise Tips

1. Be consistent: Daily stretching is essential, even when progress is slow
2. Use heat first: Warm shower or heating pad before exercises
3. Gentle, not aggressive: Forceful stretching can worsen inflammation
4. Hold stretches: 20-30 second holds, repeat multiple times
5. Track progress: Take weekly measurements to see gradual improvements

Psychological Support

• Frozen shoulder can be emotionally challenging due to pain, limitation, and slow recovery
• Connect with others who’ve been through it
• Set realistic expectations (full recovery takes many months)
• Celebrate small improvements
• Consider counseling if symptoms cause significant distress

Prognosis and Recovery

Good news: The vast majority of people with frozen shoulder (80-90%) eventually recover most or all shoulder function.

Timeline:

• Average duration: 1-3 years from onset to resolution
• With treatment: May shorten duration and reduce pain
• Full recovery: Many regain near-normal function; some have persistent mild limitation
• Recurrence: 5-10% develop frozen shoulder in the opposite shoulder

Factors affecting recovery:

• Early treatment may improve outcomes
• Diabetes associated with longer recovery time
• Consistent physical therapy crucial
• Patience is essential—rushing can worsen the condition

Prevention

While frozen shoulder cannot always be prevented, you can reduce risk:

• Avoid prolonged immobilization: After shoulder injury or surgery, begin gentle motion as soon as cleared
• Manage underlying conditions: Good diabetes control, treat thyroid disorders
• Stay active: Regular shoulder range-of-motion exercises, especially if at high risk
• Early treatment of shoulder pain: Don’t let pain lead to disuse and stiffness

Questions to Ask Your Healthcare Provider

1. What stage of frozen shoulder am I in?
2. Should I have imaging to rule out other problems?
3. What exercises are safe at this stage?
4. Would a corticosteroid injection help in my case?
5. How long do you expect my recovery to take?
6. What signs indicate I should call you between appointments?
7. When should we consider more aggressive interventions?
8. If I have diabetes, what else should I do to manage this condition?

References

1. Adhesive capsulitis: epidemiology and risk factors. American Academy of Orthopaedic Surgeons.

2. Treatment of adhesive capsulitis: A review. JAMA, 2020. Full Text

3. Physical therapy for frozen shoulder: systematic review and meta-analysis. Physical Therapy, 2018.

4. Diabetes and frozen shoulder: updated review. Journal of Shoulder and Elbow Surgery, 2022.

5. Intra-articular injections for adhesive capsulitis: systematic review. Orthopaedic Journal of Sports Medicine, 2021.

Related Resources

• Shoulder Osteoarthritis Guide
• Rotator Cuff Injuries: Complete Guide
• Physical Therapy for Joint Pain
• Cortisone Injection Risks and Benefits
• Shoulder Pain Red Flags