Frozen Shoulder (Adhesive Capsulitis)

Understanding Frozen Shoulder: What You Need to Know

Also known as stiff shoulder or adhesive capsulitis. 

Frozen shoulder can have a significant negative effect on people’s lives. The condition is known to be very painful, cause sleep issues, and worsen mental health (Jones et al., 2013). People with this condition often do not receive the correct diagnosis, receive ineffective treatments and conflicting information (Jones et al., 2013). This article explains what frozen shoulder is, its causes, how it's diagnosed, and what you can do to manage it

What is Frozen Shoulder?

Surprisingly, even in 2025 we don’t completely know (de La Serna et al., 2021)(Kraal et al., 2020). There seem to be a number of different processes at play including both inflammation and involvement of the immune system (de la Serna et al., 2021). These and other processes eventually lead to the thickening of ligaments of the shoulder (initially in the acromioclavicular joint (front of shoulder) and then later the complete joint) (de la Serna et al.m 2021).

How do you develop Frozen Shoulder?

The exact reason why frozen shoulder develops is actually unknown (de La Serna et al., 2021). It can occur spontaneously (idiopathic) or following an injury or shoulder surgery. However, we do not know why it will develop for some and not others.

What we do know is that some people are at higher risk compared to others. Some risk factors include:

●        Genetics

●        Sex (female)

●        Diabetes (Zreik et al., 2016)(Juel et al., 2017)(de la Serna et al., 2021)

●        Smoking

●        Age (between 40-60) (de la Serna et al., 2021)

●        Thyroid conditions (Cohen et al., 2020)(de la Serna et al., 2021)

Who can diagnose frozen shoulder?

A frozen shoulder is not a very easy diagnosis to make for healthcare professionals as it does mimic several other conditions. However, a correct diagnosis is important as it determines prognosis (duration and outlook), treatment options, and avoiding harmful treatments. Therefore, finding the right healthcare professionals is crucial, technically the following professions can diagnose a frozen shoulder, physiotherapists, general practitioners, orthopaedic surgeons. Finding one that is familiar with frozen shoulder and knows how to diagnose it is more challenging. One way to test this is by asking, “do you think this is a frozen shoulder and if not could you provide your reasoning”.

How is it diagnosed?

A frozen shoulder is a diagnosis of exclusion. It has some very typical features depending on the stage it is in. Which can include the following:

●        Pain and tenderness when pressing on the AC joint (the joint where the collarbone meets the shoulder) (Carbons et al., 2010).

●        Stiffness (active and passive) in the joint, especially with external rotation (outward rotation) (Walmsley et al., 2014)(Hanchard et al., 2012)

A healthcare professional can then complete further in person testing to increase the probability of the diagnosis.

If there is concern another cause may be causing the symptoms, having a X-Ray done is recommended (Roberts et al., 2019). As it can rule out other reasons this presentation might be present. Examples include a fracture, osteoarthritis and tumor. Once these have been ruled a frozen shoulder diagnosis can be made with some good certainty (Zuckerman & Rokito 2011).

There is no direct single test or imaging to detect frozen shoulder.

The different stages of Frozen Shoulder

Frozen shoulder often involves three stages:

Stage 1, the inflammation stage (painful stage). The hallmark here is severe pain, worse mainly at night (Itoi et al., 2015). This can last between 10-36 weeks (de la Serna et al., 2021).

Stage 2, capsular contraction (the frozen stage). The hallmark here is severe stiffness. This can last between 4-12 months (de la Serna et al., 2021),

Stage 3, resolution stage (thawing stage). This is when pain and mobility gradually improve. This can last between 1-4 years or beyond (see below) (de la Serna et al., 2021).

What is the outlook for Frozen Shoulder?

Frozen shoulder is a condition that often improves with time (Diercks & Stevens 2004)(Vastamäki et al., 2012). It is considered a painful persistent and stubborn condition.

The average duration for frozen shoulder is 30 months (2.5 years) with the majority resolving between 1-4 years (Itoi et al., 2015). With only 6% of people continuing to experience severe symptoms after 4 years (Hand et al., 2008). In a long term follow up study they found after 10 years some people continued to experience some mild symptoms.

What is the role of injections?

Glucocorticoids injection administered in the glenohumeral joint or subacromial bursitis is able to provide short term (weeks) pain relief for some people with frozen shoulders especially in the early stages (Challoumas et al., 2020).

What is the role of surgery?

There are no high quality trials that have compared nonoperative vs operative procedures for frozen shoulder. The studies that have looked at the difference between the two found no significant difference (Rill et al., 2011)(Levine et al., 2007). However, surgery is an option for frozen shoulder often seen as a last resort. The two main procedures are manipulation under anaesthetic and arthroscopic capsular release.

How can exercise help?

Exercise and movement have very well established general benefits (Gopinath et al., 2018). However, for frozen shoulder there is no evidence that it has any positive effects in the early stage. There is even some suggestions that exercises/movement/stretching into painful ranges can worsen pain overall in the ‘painful’ stage (Diercks & Stevens 2004). Stretching may be tempting as the shoulder will slowly feel stiffer however, it can actually make it worse. However, once the shoulder is past the painful stage stretching can be included.

What other options exist?

Manual therapy (including dry needling, massage, shockwave therapy, TENS, manipulations, etc) has the potential to provide short term pain relief however, there is no evidence supporting it’s use in frozen shoulder (Page et al., 2014)(Dogru et al., 2008). So it is important to consider risk vs reward. Mobilisation is a form of manual therapy which can be used in stage 2 & 3 of frozen shoulder to improve and mobility (Cavelleri et al., 2020). 

Alternative therapies (e.g., supplements) are called alternative for a reason, if there was evidence that they worked they would be used in the mainstream and no longer be considered alternative. It is understandable that you may want to explore options if you are in a lot of pain. However, it is important to know that alternative therapies are often not regulated and safety has often not been studied.

Mirror therapy can be options for a subset of people with frozen shoulders with some positive results seen (Sawyers et al., 2018)(Baskaya et al., 2018).

Do nothing and wait. This is not an unreasonable option. Research for frozen shoulder treatments have often shown little to no effect or to be riddled with low quality studies (Maund et al., 2010).

Top tips for Frozen Shoulder

1. Ensure you have the correct diagnosis, consult with a healthcare professional that is qualified and is experienced in making the diagnosis.

2. Quit smoking, smoking can worsen pain in frozen shoulder. If you need assistance in this process consult with a GP.

3. Keep as much normality as possible, if you are able to and within reason, continue to work and stay social. Continue to do things that are meaningful and enjoyable, they are especially good for your mental health.

4. Avoid stretching and other pain aggravating movement and exercise (especially in the early stages of frozen shoulder). If you want to continue exercising, try and keep it relatively pain free. A appropriate healthcare professional (physiotherapist or exercise physiologist) can guide you with this.

5. Glucosteroid injections can be an option in early stages of frozen shoulder for short term pain relief.

6. Pace your activity throughout the day, vs getting in a boom-bust cycle. Avoid doing too much general activity resulting in significant pain, instead space out more physical activities over the day with regular planned breaks.

7. Check in on your mental health. This condition can have a significant impact on your mental well-being. If you find you are not coping, consider consulting with a healthcare professional (psychologist).

A gentle movement example for mobility: https://www.youtube.com/watch?v=9-DOa672Hxk

References

1. Başkaya, M. Ç., Erçalık, C., Karataş Kır, Ö., Erçalık, T., & Tuncer, T. (2018). The efficacy of mirror therapy in patients with adhesive capsulitis: A randomized, prospective, controlled study. Journal of back and musculoskeletal rehabilitation, 31(6), 1177–1182. https://doi.org/10.3233/BMR-171050 
   

2.  Carbone, S., Gumina, S., Vestri, A. R., & Postacchini, R. (2010). Coracoid pain test: a new clinical sign of shoulder adhesive capsulitis. International orthopaedics, 34(3), 385–388. https://doi.org/10.1007/s00264-009-0791-4 

   
   

3. Cavalleri, E., Servadio, A., Berardi, A., Tofani, M., & Galeoto, G. (2020). The Effectiveness of Physiotherapy in Idiopathic or Primary Frozen Shoulder: a Systematic Review and Meta-Analysis. Muscle Ligaments and Tendons Journal, 10(01), 24. https://doi.org/10.32098/mltj.01.2020.04 

   
   

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8. Diercks, R. L., & Stevens, M. (2004). Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. Journal of shoulder and elbow surgery, 13(5), 499–502. https://doi.org/10.1016/j.jse.2004.03.002

   
   

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16. Juel, N. G., Brox, J. I., Brunborg, C., Holte, K. B., & Berg, T. J. (2017). Very High Prevalence of Frozen Shoulder in Patients With Type 1 Diabetes of ≥45 Years' Duration: The Dialong Shoulder Study. Archives of physical medicine and rehabilitation, 98(8), 1551–1559. https://doi.org/10.1016/j.apmr.2017.01.020 

    
    

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23. Sawyer, E. E., McDevitt, A. W., Louw, A., Puentedura, E. J., & Mintken, P. E. (2018). Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor Imagery in an Individual With Frozen Shoulder. The Journal of orthopaedic and sports physical therapy, 48(3), 174–184. https://doi.org/10.2519/jospt.2018.7716 

    
    

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29. Zuckerman, J. D., & Rokito, A. (2011). Frozen shoulder: a consensus definition. Journal of shoulder and elbow surgery, 20(2), 322–325. https://doi.org/10.1016/j.jse.2010.07.008 

Written by Samuel Bulten

Largely taken from the excellent masterclass by Dr Angela Cadogan