Frozen Shoulder
1. Introduction
Adhesive capsulitis or ‘frozen shoulder’ is a common condition where a shoulder becomes painful with restricted movement. Shoulder movements are reduced, sometimes completely ‘frozen’. It is thought to be due to scar-like tissue forming in the shoulder capsule (the protective sleeve that surrounds the joint). Without treatment, symptoms go in about 90% of cases but this may take up to 2-3 years. Various treatments may ease pain and improve the movement of your shoulder.
Frequently Asked Questions
- Adhesive capsulitis (AC), also known as ‘frozen shoulder’, is an insidious (no direct cause), painful condition of the shoulder persisting for more than 3 months.
- Although not common, adhesive capsulitis can affect 2%-5% of the population (1).
- No.
- This is a self-resolving condition and with appropriate treatment, symptoms can improve more quickly.
- Can affect people of all ages, but most commonly it affects ages 40-65 years; the median age is 50-55 years.
- It is more common in women than in men.
- The incidence of adhesive capsulitis is two to four times higher in those with diabetes than in the general population (1).
- It is also found in people with thyroid problems.
- Pain and stiffness in the shoulder.
- Gradual onset of pain in the shoulder can be severe in some people associated with stiffness and restricted shoulder movement.
- The majority of people notice pain in the shoulder before stiffness (2).
- Stiffness in this case can be extreme with often less than 50% of normal movement.
- Advice from a qualified physiotherapist will be helpful in most cases.
- Depending upon the stage of the frozen shoulder, treatment can often involve exercises and manual therapy.
- Occasionally a shoulder injection/hydro-dilation is performed to allow increased movement.
- Overall, the condition will self-resolve in 90% of the population over time.
- This process can vary significantly in timeframes but on average it will take 1-3 years.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
The typical symptoms are pain, stiffness and limited movement of one, or sometimes both, of your shoulders, commonly seen in three phases:
- Phase one – the ‘freezing’, painful phase. This typically lasts 2-9 months. The first symptom is usually pain followed by a gradual increase in stiffness and limitation in movement. The pain is typically worse at night and when you lie on your affected side and can disturb sleep.
- Phase two – the ‘frozen’, stiff (or adhesive) phase. This typically lasts 4-12 months. The pain gradually eases but stiffness and limitation in movement remain and can become worse. The limited movement can be seen in all movements of your shoulder. However, the movement most severely affected is usually a rotation of the arm outwards.
- Phase three – the ‘thawing’, recovery phase. This typically lasts between 6- 18 months. The pain and stiffness gradually go and movement gradually returns to normal, or near normal. Symptoms often cause difficulty with daily tasks such as driving, dressing and sleeping. Activities involving putting your hand behind your back often become extremely difficult such as scratching your back or putting your hand in a rear pocket. Work may be affected in some cases.
There is great variation in the severity and length of symptoms. Untreated, on average the symptoms can last for 2-3 years. In some cases, it is much less than this. In a minority of cases, symptoms last for several years. Appropriately timed treatment including physiotherapy and exercise can often help to reduce this recovery time.
3. Causes
The cause is not clear, although it is thought that some scar tissue forms in the shoulder capsule. The shoulder capsule is a thin tissue that surrounds and protects the shoulder joint. The scar tissue may cause the capsule to thicken and contract, limiting the movement of the shoulder. The reason why the scar tissue forms are unknown.
A frozen shoulder can start following a shoulder injury or period of immobilisation, such as using a sling. This is not the norm though usually and most cases occur for no apparent reason.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing a frozen shoulder. It does not mean everyone with these risk factors will develop symptoms. Risk factors include:
- Adults between the ages of 40 and 60, but this condition can occur at any age.
- Gender – Women are more likely to develop frozen shoulder. Experts suspect this is due to changes in hormone levels, such as menopause.
- Diabetes – People with diabetes have a higher rate of frozen shoulder (10%-20%) compared to the general population (2%).
Other diseases and conditions. In addition to diabetes, other health issues increase the risk of developing frozen shoulder, including:
- Thyroid problems (hypothyroidism and hyperthyroidism)
- Depression
- Cardiovascular disease
- Lung disease
- Breast cancer
- Open heart surgery
- Polymyalgia rheumatica (an inflammatory condition causing stiffness and muscle discomfort)
- Parkinson’s disease
5. Prevalence
- Most commonly, it affects ages 40-65 years; the median age is 50-55 years.
- It affects around 3% of the adult population.
- It is more common in women.
- The incidence of adhesive capsulitis is two to four times higher in those with diabetes than in the general population (1).
- It is also found in people with thyroid problems.
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like magnetic resonance imaging (MRI) or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your frozen shoulder. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
Physiotherapy and exercise are the mainstays of treatment for adhesive capsulitis. You may wish to contact your local pharmacist or GP for advice regarding appropriate medication to help you manage any pain. Over the course of the recovery, you should see a gradual increase in your range of movement in your shoulder accompanied by a reduction in your pain levels and increased functional ability.
Physiotherapy with joint mobilisation combined with stretching exercises has been shown to be better than stretching exercise alone in terms of the range of motion and function score (3). Physiotherapy can prevent further reduction in the range of motion and eventually increase the range of motion in the affected shoulder (4). Passive mobilisation and capsular stretching are two of the most commonly used techniques for physiotherapy.
9. Frozen Shoulder
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
The exercises at this stage are aimed at trying to increase the amount of movement in the joint or at least maintain the movement that is available. Pain should not exceed 4/10 on your self-perceived pain scale whilst completing this exercise programme.
- 0
- 1
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- 910
Exercises at this stage continue to work on developing and increasing the amount of movement but also exercises are aimed at increasing strength in the shoulder. Pain should not exceed 4/10 on your self-perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
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- 8
- 910
This plan is a progression on the exercises from the intermediate programme with a particular focus on regaining strength as movement begins to return in the later stages of the condition. Pain should not exceed 4/10 on your self-perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
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- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.
11. Other Treatment Options
In the early stages of this condition, different types of steroid injection have been shown to be effective at reducing pain. Accompanying this with an individually tailored physiotherapy management plan is ideal. One study has shown that the most effective treatment for frozen shoulder was the combination of intensive mobilisation (hands on treatment) and steroid injection with capsular distension, which helped to control inflammation, extend joint space and recover range of movement(5).
References
- Uddin MM, Khan AA, Haig AJ, et al;. (2014). Presentation of frozen shoulder among diabetic and non-diabetic patients. J Clin Orthop Trauma. 2014 Dec;5(4):193-8. doi: 10.1016/j.jcot.2014.09.008. Epub 2014 Oct 7.
- Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder; Chartered Society of Physiotherapists.
- Celik D, Kaya Mutlu E;. (2015). Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial. Clin Rehabil. 2015 Jul 30. pii: 0269215515597294.
- Uppal HS, Evans JP, Smith C; (2015). Frozen shoulder: A systematic review of therapeutic options. World J Orthop. 2015 Mar 18;6(2):263-8. doi: 10.5312/wjo.v6.i2.263. eCollection 2015 Mar 18.
- Park SW, Lee HS, Kim JH; (2014). The effectiveness of intensive mobilization techniques combined with capsular distension for adhesive capsulitis of the shoulder. J Phys Ther Sci. 2014 Nov;26(11):1767-70. doi: 10.1589/jpts.26.1767. Epub 2014 Nov 13.
Other Conditions in
Shoulders, Rheumatology
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An injury which typically occurs following a road traffic collision, often affecting the soft tissues of the neck.
Thoracic Outlet Syndrome
A condition presenting with pain in the arm as a result of compression of structures around the neck/shoulder.
Shoulder Osteoarthritis (OA)
Age and activity related changes to the joints of the shoulder which can lead to pain and stiffness.
Shoulder Impingement
Shoulder impingement is an umbrella term used to describe a variety of conditions that can cause pain in the shoulder.
Shoulder Dislocation
An injury in which your upper arm bone ‘pops out’ of the cup-shaped socket of your shoulder blade.
Rotator Cuff Tendinopathy
Pain and weakness affecting the shoulder and limiting function.
Calcific Tendinopathy
A rare condition causing pain and loss of free movement in tendons and joints.
Biceps Tendinopathy
A tendon-related issue affecting the long bicep tenon at the front of the shoulder.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Acute Torticollis
Sometimes referred to as “wry neck”, this is a condition causing muscle spasms and associated neck pain.
Acromioclavicular Joint Injury
Injury to a small joint at the end of the collar bone (clavicle)/top of your shoulder.