Understanding Frozen Shoulder: Causes, Stages, and Treatment
Frozen shoulder, medically referred to as Adhesive Capsulitis, is a condition that affects the glenohumeral (shoulder) joint. It is characterised by a gradual onset of pain and a significant reduction in the joint’s range of motion, eventually impacting daily life and function.
While it may seem like a relatively minor issue at first, frozen shoulder can be a debilitating and frustrating condition that affects one’s ability to perform even the simplest tasks like getting dressed, reaching overhead, or sleeping comfortably.
What Is Frozen Shoulder?
Frozen shoulder occurs when the capsule surrounding the shoulder joint becomes inflamed, thickened, and tight. This capsule is a connective tissue sheath that normally allows for a wide range of movement. In frozen shoulder, adhesions (stiff bands of tissue) develop within the capsule, limiting movement and causing pain.
Imagine the shoulder joint like a ball-and-socket structure. Normally, the capsule is a loose sleeve that allows the “ball” to move freely in the “socket.” When adhesive capsulitis sets in, this sleeve tightens like shrink-wrap, severely restricting movement in all directions.
Causes and Risk Factors
The exact cause of frozen shoulder is often unclear, which can be distressing for patients. The condition is considered idiopathic in many cases, meaning it occurs without a clear trigger. However, several contributing factors and conditions have been identified.
Primary (Idiopathic) Frozen Shoulder
This type develops spontaneously with no identifiable cause. It is thought to be related to a low-grade inflammatory process and may involve an autoimmune component.
Secondary Frozen Shoulder
This form arises after an event such as:
Trauma or surgery (e.g., rotator cuff repair, shoulder fracture)
Prolonged immobilisation (e.g., due to stroke, heart surgery, or injury)
Systemic disease such as:
Diabetes (especially Type 1 – up to 20% may develop frozen shoulder)
Thyroid dysfunction (both hypo- and hyperthyroidism)
Cardiovascular disease
Parkinson’s disease
Other risk factors include:
Age between 40–60 years
Female gender (4x more common than in men)
History of adhesive capsulitis in the other shoulder
Symptoms of Frozen Shoulder
The hallmark signs and symptoms include:
Gradual onset of shoulder pain – often described as a deep, dull ache
Stiffness – leading to difficulty with daily tasks like putting on a shirt or brushing hair
Night pain – sleep can become disrupted, especially when lying on the affected side
Loss of both active and passive range of motion – movements are restricted whether you try to move the arm yourself or someone else moves it for you
The Three Stages of Frozen Shoulder
Frozen shoulder progresses through three distinct stages, each with its own clinical features:
1. Freezing Stage (Painful Stage)
Duration: 2 to 9 months
Features: Gradual onset of pain that worsens over time. Pain is often felt at the end ranges of movement and can be sharp and intense. People often report night pain that disrupts sleep. Movement begins to become limited, especially in external rotation.
2. Frozen Stage (Stiff Stage)
Duration: 4 to 12 months
Features: Pain begins to stabilise or even reduce, but the shoulder becomes increasingly stiff. Simple activities such as reaching behind your back or overhead become near impossible. People may start to compensate with neck or upper back movements, leading to secondary issues.
3. Thawing Stage (Recovery Stage)
Duration: 5 months to 2 years (sometimes longer)
Features: Gradual return of movement and reduction in pain. Range of motion starts to improve slowly. However, in some individuals, full recovery is not achieved without medical or therapeutic intervention.
⏳ The total duration of frozen shoulder varies from 1 to 3 years, but in some cases, symptoms can persist for up to 10 years if not appropriately managed.
Diagnosis
Frozen shoulder is primarily diagnosed through:
Clinical assessment by a physiotherapist, chiropractor, or doctor
Physical examination showing reduced active and passive range of motion in multiple directions (especially external rotation)
Medical history including potential risk factors like recent trauma or systemic disease
Imaging: While not always necessary, X-rays, ultrasounds, or MRIs may be ordered to rule out other conditions such as arthritis, rotator cuff tears, or calcific tendinitis
Ultrasound may show capsular thickening or joint capsule oedema, particularly in the early stage.
Treatment Options
Management of frozen shoulder depends on the stage and severity of symptoms.
Early Stage (Freezing)
Pain management is the priority
Corticosteroid injections can be helpful in reducing inflammation and relieving pain, especially when guided by ultrasound
Gentle range-of-motion exercises under the guidance of a physiotherapist may be recommended
💡 While cortisone injections can reduce pain, they do not necessarily speed up recovery or improve long-term outcomes.
Mid to Late Stages (Frozen & Thawing)
Physiotherapy-led rehabilitation becomes essential
The focus is on:
Restoring range of motion
Correcting compensatory movement patterns
Strengthening surrounding muscles, especially the rotator cuff and scapular stabilisers
Manual therapy, dry needling, cupping, and stretching may all be used depending on the practitioner’s approach
Additional Options
Hydrodilatation: A procedure involving saline and corticosteroid injection to stretch the joint capsule
Manipulation under anaesthesia (MUA): The shoulder is moved forcibly while the patient is under general anaesthesia
Surgical capsular release: Keyhole surgery to cut the tight portions of the capsule—typically only used in severe, non-resolving cases
Living With Frozen Shoulder
Frozen shoulder can be a long and mentally exhausting condition, particularly due to its impact on sleep, work, and everyday activities. It’s essential for individuals to:
Stay active within pain limits
Follow through with physiotherapy appointments
Understand that recovery takes time and often comes in waves
Use heat therapy and gentle stretching to manage stiffness
Final Thoughts
Frozen shoulder may be frustrating and painful, but with the right support and treatment plan, recovery is absolutely achievable. Early diagnosis, patient education, and a staged rehabilitation approach are key to managing this complex condition.
If you're struggling with shoulder pain or stiffness, don't delay—seek guidance from a qualified healthcare professional. The earlier frozen shoulder is identified and managed, the better the chances of a full recovery.