Frozen Shoulder: How to Recognise and Manage the Pain

What Is Frozen Shoulder?

Frozen shoulder, also known as adhesive capsulitis, is a condition that causes pain and stiffness in the shoulder joint. The shoulder capsule becomes inflamed and tight, restricting movement. Frozen shoulder typically develops gradually, worsens over time, and then slowly improves, usually resolving within 1 to 3 years.

The condition often follows a period of shoulder immobilisation, such as after an injury, surgery, or fracture. This is why frozen shoulder is sometimes called "frozen", because pain discourages use of the affected shoulder, causing further tightening and stiffness of the joint capsule. While frozen shoulder rarely recurs in the same shoulder, it can develop in the opposite shoulder within about five years.

Symptoms of Frozen Shoulder

The hallmark symptoms of frozen shoulder are persistent shoulder pain accompanied by significant stiffness and loss of motion. Both active movement (moving the shoulder yourself) and passive movement (having the shoulder moved for you) are affected. The pain is often described as a dull ache that worsens with movement and at night, disrupting sleep.

The condition is now understood to progress through the 4 stages of frozen shoulder:

• Pre-freezing stage (up to 3 months): Subtle symptoms begin, such as mild discomfort, occasional pain with certain movements, or stiffness after periods of inactivity. At this point, many people mistake it for a minor strain or overuse injury.
• Freezing stage (2–9 months): Pain increases, and the range of motion progressively declines.
• Frozen stage (4–12 months): Pain may lessen, but stiffness becomes the main problem, significantly limiting daily activities.
• Thawing stage (5–24 months): Shoulder motion gradually improves, and function slowly returns.

Causes of Frozen Shoulder

The precise causes of frozen shoulder remain unclear. However, studies suggest they involve thickening and tightening of the shoulder joint capsule, leading to the formation of scar tissue (adhesions) that restricts motion. Prolonged immobilisation of the shoulder, such as after surgery or injury, increases the risk of developing a frozen shoulder.

Risk Factors

Several factors can increase the likelihood of developing a frozen shoulder:

Age and Sex

Frozen shoulder occurs most commonly between the ages of 40 and 60 and is more frequently seen in women. The condition is uncommon in younger adults.

Immobility or Reduced Mobility

Keeping the shoulder still for extended periods, such as after an injury, surgery, or fracture, raises the risk of frozen shoulder. Painful shoulder conditions like rotator cuff tendinitis or bursitis can also lead to disuse and increased vulnerability.

Systemic Diseases

Certain health conditions, including diabetes, thyroid disorders, Parkinson's disease, and heart disease, are associated with a higher incidence of frozen shoulder. Managing these underlying conditions can influence recovery time.

Diagnosis

A frozen shoulder test is administered to arrive at a clinical diagnosis based on the patient's history and physical examination. It is to find the shoulder pain with stiffness and limited range of motion, particularly in external rotation.

• Doctors may perform a diagnostic injection test, using a numbing medication to differentiate between true capsular tightness and pain-related guarding.
• Imaging tests are mainly used to exclude other possible causes of shoulder pain and stiffness. X-rays can rule out arthritis or calcific tendinitis. Ultrasound or MRI may be ordered if a rotator cuff tear or other pathology is suspected.
• A thorough evaluation also takes into account risk factors such as recent immobilisation and associated systemic diseases like diabetes or thyroid problems.

Key factors that point to a frozen shoulder diagnosis include:

• Capsular pattern of restricted motion
• Pain that is worse at night
• Staging based on symptom progression (freezing, frozen, thawing)
• Normal joint surfaces on imaging

Treatment

The goals of frozen shoulder treatment are to control pain and restore shoulder motion using a stepwise approach, beginning with conservative measures and progressing to more invasive options if needed.

Medications

• Over-the-counter medicine for frozen shoulder would include nonsteroidal anti-inflammatory drugs (NSAIDs) that can help reduce pain and inflammation.
• Steroid injections into the joint, sometimes combined with a numbing medication, can provide short-term pain relief and improved mobility, especially in the early stages.

Therapy

• Supervised physical therapy, along with a regular home exercise programme, is the mainstay of treatment for frozen shoulder.
• Therapy focuses on gentle, progressive stretching and range-of-motion exercises, such as pendulum swings, forward elevation, and external rotation moves.
• These frozen shoulder exercises should be done consistently every day, staying within pain tolerance.
• Manual techniques and physical modalities applied by the therapist can also help improve tolerance to stretching.

Surgical and other procedures

If significant symptoms persist despite several months of non-surgical treatment, more invasive options may be considered:

• Hydrodilatation involves injecting a large volume of fluid into the joint to stretch the capsule.
• Manipulation under anaesthesia uses controlled force to break up adhesions and loosen the stiff joint capsule.
• Arthroscopic capsular release divides the tight portions of the capsule and removes scar tissue through small incisions using a camera-guided probe.

These techniques are typically reserved for cases that do not respond to conservative care and are followed by intensive physical therapy to maintain the improvements in shoulder motion. However, the majority of patients with frozen shoulder improve with non-surgical management, and only about 5-10% require surgical intervention.

Lifestyle and Home Remedies

In addition to formal therapy, you can use some simple home strategies to manage frozen shoulder symptoms. Applying heat before stretching and ice after activity can help with pain control. Perform gentle range-of-motion exercises daily within your pain threshold. Avoid painful, aggressive movements, and modify activities that involve reaching overhead or behind your back during flare-ups while still trying to maintain shoulder mobility.

Alternative Medicine

Acupuncture

Some individuals with frozen shoulder seek out acupuncture for pain relief. However, research on its effectiveness has yielded mixed results. If you do try acupuncture, be sure to go to a licensed practitioner who uses sterile needles, and use it to complement, not replace, your standard treatment plan. Discuss the potential benefits and risks with your doctor first.

Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) is a technique that uses a battery-powered unit to deliver mild electric currents through the skin, which may help reduce pain by modifying nerve signalling.

The quality of evidence supporting TENS for frozen shoulder is variable, so it is considered a complementary treatment rather than first-line therapy. A healthcare professional can guide you on proper use as part of a comprehensive rehabilitation programme.

Conclusion

Frozen shoulder can significantly limit your daily life, but with timely diagnosis and consistent treatment, most people regain shoulder mobility over time. A diagnostics centre like Metropolis Healthcare can help by offering convenient at-home blood tests to check vital parameters, detect any contributing factors, and support your doctor in creating a personalised frozen shoulder treatment plan.

FAQs

1. How long does frozen shoulder rehabilitation take?

Recovery is gradual; most people see improvement within 1-3 years, but daily frozen shoulder exercises may be needed for several months. Some individuals require up to a year for near-complete recovery.

2. Is it okay to massage a frozen shoulder?

Light soft-tissue work may offer temporary pain relief, but avoid deep, painful massage. Focus on heat, gentle stretching, and therapist-recommended techniques within your comfort level.

3. Which exercise is best for frozen shoulder?

Range-of-motion exercises, including pendulum swings, assisted forward elevation, and external rotation stretches, performed gently and regularly, are key. Work with a physical therapist to develop an individualised plan.

4. How to sleep with a frozen shoulder?

Use pillows to support your affected arm and avoid lying on the painful side. Consider heat before bed, and talk to your doctor about medication or injection options to reduce night pain.

5. What is the new treatment for frozen shoulder?

The core frozen shoulder treatment remains physical therapy and corticosteroid injections as needed. For resistant cases, hydrodilatation, manipulation, and surgery are established next steps rather than "new" options.

6. What to avoid with frozen shoulder?

Avoid shoulder immobilisation and forceful, painful movements. Limit strenuous overhead activity and behind-the-back motions during flares. Instead, focus on gentle, frequent motion to prevent increased stiffness.