Frozen shoulder

What it is

Your shoulder joint is wrapped in a thin sleeve of tissue called the joint capsule. Normally it is loose and elastic, which is what lets you lift your arm overhead and reach behind your back.

In frozen shoulder that capsule becomes inflamed, thickens, and contracts until it grips the joint. The shoulder moves less and less. The medical name is adhesive capsulitis.

What separates it from ordinary shoulder pain is that the movement is limited both ways — when you lift the arm yourself, and when someone else moves it for you while you stay completely relaxed. If a sore muscle stops you lifting but someone else can move the arm through its full range, that is usually something else.

Symptoms

There are two symptoms, and they arrive together: pain and loss of movement. The pain usually comes first, and the stiffness follows.

What people describe is:

• A deep ache in the shoulder and upper arm, sometimes down to the elbow
• Pain that is worse at night, waking you when you roll onto that side
• Difficulty reaching a high shelf, putting on a seatbelt, or reaching behind your back for a wallet
• Trouble putting on a shirt, fastening a bra, or combing your hair
• A sharp catch when you move the arm quickly without thinking

The condition runs in stages

Frozen shoulder usually follows a recognisable course. Knowing which stage you are in tells you what is worth working on now.

Stage 1 — Pre-freezing (typically months 1–3) The shoulder is sore, achy and a little stiff. Pain is mild to moderate and often worse at night or reaching in certain directions. Range of motion is still mostly normal, but the shoulder feels touchy. Moving it gently and often now is the best thing you can do.

Stage 2 — Freezing (typically months 4–9) The capsule around the joint is inflamed and beginning to thicken. Pain is much more severe, especially on movement and at night, and stiffness is increasing quickly. Do not try to force the shoulder. Control the pain first, and keep the movement you have.

Stage 3 — Frozen (typically months 10–14) The inflammation is quietening down but the capsule is now tight, and the joint feels stuck. Pain often eases and is felt mainly when you push to the limit. Stiffness is at its worst, particularly reaching out, up, and behind your back. This is the stage where patient, regular stretching earns its keep.

Stage 4 — Thawing (typically months 15–24) The capsule is starting to loosen. Movement and flexibility come back gradually and pain continues to fade. Most people regain a great deal, though some keep a little stiffness or occasional ache. Regular practice is what turns range you have borrowed into range you keep.

Causes and risk factors

In many people it simply happens, with no clear trigger; this is called primary frozen shoulder. In others it follows something that kept the shoulder still for a while — surgery, a broken arm, or a long spell in a sling.

Things known to be associated with it:

• Age 40–60, the commonest window
• Being female — it is more common in women
• Diabetes, the clearest association of all. It is more common, and usually takes longer, in people with diabetes
• Thyroid disease, both over- and under-active
• A period when the shoulder did not move — after breast surgery, heart surgery, or an arm injury

When to see a doctor

Frozen shoulder is painful and slow, but it is not dangerous. The signs below are not part of the usual pattern — they mean something else may be going on.

Apart from those, see a doctor when:

• The shoulder has been aching and stiffening for more than two or three weeks without improving
• Night pain is disturbing your sleep several nights in a row
• You are starting to avoid using that arm in everyday tasks

Going early, while the range is still good, is the easiest stage to manage — range is easier to keep than to win back.

How it is diagnosed

Most of the time the history and the physical examination are enough. Special tests are not always needed.

Examination. Your doctor measures how far you can lift and rotate the arm yourself, then measures again while moving the arm for you as you stay relaxed. When both are limited in the same way, and outward rotation especially so, that pattern may be a sign of frozen shoulder.

X-ray is often done to look for another cause underneath — shoulder arthritis, calcium in a tendon, an old fracture. In true frozen shoulder the X-ray usually looks normal.

Ultrasound or MRI is not needed in most people. Your doctor may consider it when something else is suspected alongside, such as a rotator cuff tear, or when the picture does not follow the expected pattern.

Blood tests. Your doctor may check blood sugar or thyroid function, because both are linked to this condition and both matter for the longer-term plan.

Treatment options

The goals, in order: get the pain under control, keep the range you still have, then win back the range you have lost.

Non-surgical treatment

Most people get better without surgery.

Moving and stretching yourself is the core of it. Little and often beats one long session. The exercises in the next section are grouped by stage.

Physiotherapy. A physiotherapist can match the programme to the stage you are in and check that you are doing the movements correctly. The research cannot yet say which form or frequency works best, but clinical guidelines broadly recommend exercise as the foundation of care for shoulder pain of any kind.

Pain relief. Your doctor or pharmacist may suggest paracetamol or a non-steroidal anti-inflammatory so that you can move and sleep. Each group has its own cautions, particularly if you have stomach, kidney or bleeding problems, or take blood thinners. Always ask a doctor or pharmacist before starting any medicine.

Ice or heat. An ice pack or a warm pad wrapped in a towel, up to 20 minutes, eases aching muscles — use whichever feels better for you.

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What your doctor might add — decisions for your doctor, not choices made from this page:

• An injection into the joint, when pain is the thing blocking rehabilitation
• Injection combined with physiotherapy rather than either on its own
• Other injectable options where a steroid is not suitable

Surgery

Most people do not need it. Your doctor may consider it when stiffness still limits daily life significantly after a proper trial of everything else.

The options are:

• Manipulation under anaesthesia — your doctor moves the shoulder through its full range while you are asleep, to release the tight capsule
• Arthroscopic capsular release — a small camera goes into the joint and the tightest part of the capsule is cut

The thing to understand is that surgery does not end in the operating theatre. The range gained on the day only stays if rehabilitation continues afterwards. Ask your doctor about the benefits, the drawbacks and what you will have to do afterwards before deciding.

Recovery and rehabilitation

The exercises below are grouped by stage. Do the ones for the stage you are in now — not all of them.

Stage 1 — keep the range you still have

Pendulum swing

10 each direction

Lean forward and let the arm hang completely loose. Small circles, then small forward-and-back swings.

Watch for — if your shoulder is working, you are doing it too big.

▶Leaning forward with one hand on a table, the person lets the sore arm hang and swing gently in small circles, then stands up.

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Assisted outward rotation

8 reps · hold 5 seconds

Elbow tucked at your side and bent to 90°. Use a stick or your other hand to turn the forearm outward.

Watch for — the elbow stays against your ribs the whole time.

▶Lying on the back with the sore elbow tucked at the side on a folded towel, the person holds a stick in both hands and uses the good arm to push the sore forearm slowly outwards, then back.

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Stage 2 — control the pain, protect the movement

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Assisted overhead reach

8 reps · hold 10 seconds

Hold a stick with both hands and use the good arm to push the stiff arm upward.

Watch for — breathe out as you move into the stretch.

▶Lying on the back with the knees bent, the person holds a stick in both hands and raises it slowly overhead, the good arm doing the lifting, then lowers it to the chest.

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Outward rotation stretch

5 reps · hold 20 seconds

Elbow supported at your side, rotate outward and hold at the end of the comfortable range.

Watch for — this is the movement that stays stuck longest. Be patient with it.

▶Sitting on a chair with the sore elbow at the side, the person holds a stick in both hands and pushes the sore forearm outwards with the good arm, holds, then returns.

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Towel stretch behind the back

6 reps · hold 10 seconds

Towel over the good shoulder. Grip the low end with the stiff arm and gently pull it upward.

Watch for — this is what gets you back into a jacket.

▶Standing, the person holds a towel over one shoulder with the top hand and its lower end behind the back with the other hand, pulls upwards so the lower hand slides up the back, then lets it down.

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Stage 3 — start building strength

Band outward rotation

2 sets · 12 reps each

Band anchored at waist height, elbow at your side, rotate the forearm outward against the band.

Watch for — slow on the way back is where the strength comes from.

▶Standing side-on to a band fixed at waist height, with a rolled towel under the sore elbow, the person turns the forearm outwards against the band and slowly back.

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Band inward rotation

2 sets · 12 reps each

Same setup, rotating the forearm in toward your stomach.

Watch for — keep a rolled towel under the elbow if it drifts.

▶Standing side-on to a band fixed at waist height, elbow at the side, the person pulls the band in across the front of the body towards the stomach and slowly back.

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Band row

2 sets · 12 reps each

Pull both elbows back past your ribs, squeezing the shoulder blades together.

Watch for — lead with the elbows, not the hands.

▶Facing a band fixed in front at chest height, the person pulls both handles back towards the body, drawing the shoulder blades together, then lets the arms forward slowly.

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Light forward raise

2 sets · 10 reps each

Light weight or no weight. Raise the arm forward to shoulder height and lower slowly.

Watch for — add weight only once this is easy without a shrug.

▶Standing, the person holds a small weight at the side, lifts the straight arm forward to shoulder height, and lowers it slowly.

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Loaded carry

3 times · 30 seconds each

Carry a bag or weight at your side, walking tall.

Watch for — the most useful strength exercise there is.

▶The person walks tall across a room holding a weight at the side in one hand, shoulders level, then stops.

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Stage 4 — back to your life

This stage is not measured in repetitions but in what you can do. Work up one level at a time.

1. Self-care — put on a shirt, wash your face, comb your hair, without planning around the shoulder. Daily.
2. Everyday reach — reach a shelf, put on a seatbelt, reach behind your back.
3. Load — carry a full bag, lift overhead, do resistance work. Three times a week.
4. Your life — back to the gym, the sport, or the specific thing your job asks of your shoulder.

Once your movement is back to normal and your pain is minimal, keep a short maintenance routine going so the stiffness does not creep back.

Sleep

Night pain is the hardest part of the painful stage for most people. These positions help while it settles.

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Prevention and self-care

There is no proven way to stop frozen shoulder happening. What you can do is reduce the chance of it becoming severe and drawn out.

Keep moving, gently. Stopping all movement makes stiffness worse. Stretch to a mild pull, stop at the first sign of sharp pain, and avoid sudden or jerky reaches.

Look after the conditions that go with it, particularly diabetes and thyroid disease.

Do not let a shoulder sit still after an injury or an operation. If you have to wear a sling, ask your doctor how much you may move the elbow, wrist and shoulder blade from day one.

Dressing and showering

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Questions to ask your doctor

• Do my symptoms fit frozen shoulder, and which stage am I likely in?
• Do I need any further tests, and would the result change the treatment?
• Which exercises should I do, how often, and when should I stop?
• Should I see a physiotherapist, and how often?
• When should I come back, and what would make me come back sooner?