Frozen shoulder

Frozen shoulder, medically known as adhesive capsulitis, is a condition that causes stiffness, pain, and limited range of motion in the shoulder joint (1). It typically develops gradually, worsens over time, and then slowly improves, often taking months to years to resolve fully. The condition occurs when the connective tissue surrounding the shoulder joint (the joint capsule) thickens and tightens, restricting movement (1).

Frozen shoulder is more common in adults between the ages of 40 and 60, and it often affects women more than men (2). Although not typically associated with severe injuries, it can significantly impact daily life by making it difficult to perform simple activities, such as reaching overhead, fastening a seatbelt, or even dressing. Understanding its symptoms, causes, and treatment options is essential for early intervention and effective management.

Symptoms

Frozen shoulder symptoms usually develop gradually and progress through three stages, each lasting several months (2):

• Freezing stage
  • The shoulder becomes painful with movement, and pain often worsens at night.
  • Range of motion begins to decline.
• Frozen stage
  • Pain may reduce slightly, but stiffness increases significantly.
  • Daily activities become very difficult due to limited mobility.
• Thawing stage
  • Shoulder motion slowly improves.
  • Pain gradually decreases, although stiffness may persist for some time (2).

Common symptoms include

• Persistent, dull, or aching pain in the shoulder.
• Stiffness and reduced flexibility.
• Difficulty moving the shoulder in all directions.
• Discomfort that disrupts sleep, particularly when lying on the affected shoulder.

Causes

The exact cause of frozen shoulder is not fully understood, but it develops when the capsule of connective tissue surrounding the shoulder joint becomes inflamed and tight. This leads to scar tissue formation, further restricting movement (2). Several factors contribute to this condition, including:

• Immobilization: Keeping the shoulder inactive for prolonged periods, often due to injury, surgery, or another health issue.
• Inflammation: Chronic inflammation of the shoulder tissues, such as from bursitis or tendinitis.
• Underlying conditions: Diabetes and thyroid disorders are strongly associated with frozen shoulder.
• Unknown reasons: In some cases, it develops without a clear cause (idiopathic).

Risk Factors

Certain individuals are more likely to develop frozen shoulder (3). The main risk factors include:

• Age and Gender: Most common in people between 40 to 60 years, with women at higher risk.
• Medical Conditions:
  • Diabetes (people with diabetes are 2–4 times more likely to develop it).
  • Hypothyroidism or hyperthyroidism.
  • Cardiovascular disease and Parkinson’s disease.
• Prolonged Shoulder Immobility: After surgery, fracture, or an injury that limits arm movement.
• Previous Shoulder Conditions: Rotator cuff injuries, arthritis, or prior shoulder surgery increase susceptibility.

Diagnosis

Frozen shoulder is diagnosed primarily through a combination of medical history, physical examination, and imaging tests to rule out other conditions (3).

• Medical history: Doctors ask about symptoms, previous injuries, surgeries, or underlying conditions such as diabetes.
• Physical examination: The shoulder is checked for pain, stiffness, and restricted range of motion in different directions.
• Imaging tests
  • X-rays help rule out arthritis or bone-related issues.
  • MRI or ultrasound may be used to examine soft tissues and confirm the absence of rotator cuff tears or other shoulder problems.

Treatment Options

Treatment aims to reduce pain and restore shoulder mobility. The condition often resolves over time, but management can shorten recovery and improve function (3). Common approaches include

• Non-surgical Treatments

• Pain management: Over-the-counter pain relievers like acetaminophen or NSAIDs (ibuprofen, naproxen) can reduce discomfort.
• Physical therapy: Stretching and strengthening exercises are the most effective long-term treatment. A physiotherapist can design a program tailored to restore motion gradually.
• Heat therapy: Applying heat before exercises helps relax muscles and improve flexibility.
• Corticosteroid injections: These can reduce pain and inflammation, especially in the early stages (3).
• Hydrodilatation: A procedure in which sterile fluid is injected into the joint capsule to expand it and improve movement.

• Surgical Treatments

If symptoms persist after several months of conservative care, surgery may be considered:

• Manipulation under anesthesia: The shoulder is moved forcefully to break adhesions while the patient is under anesthesia.
• Arthroscopic capsular release: A minimally invasive surgery where small instruments are used to cut through tight portions of the joint capsule.

Recovery from surgical treatments also requires ongoing physical therapy to maintain improved mobility (3).

Living With or Prevention

Frozen shoulder can take a long time to heal, but with the right care, most people regain full or near-full function (4). Living with the condition requires patience and a proactive approach:

• Stay consistent with physical therapy: Regular stretching exercises are key to recovery.
• Pain management strategies: Use prescribed medications, hot compresses, or gentle massage to ease discomfort.
• Modify daily activities: Use the unaffected arm more often for tasks that strain the shoulder.

Prevention

Although frozen shoulder cannot always be prevented, certain strategies lower the risk:

• Keep the shoulder moving: After an injury or surgery, try to perform gentle range-of-motion exercises to prevent stiffness.
• Manage chronic conditions: Controlling diabetes and thyroid disorders reduces risk.
• Post-surgery care: Follow rehabilitation protocols closely after shoulder or chest surgeries (4).

References

1. Gadgaard NR, Veres K, Henderson VW, Pedersen AB. Frozen Shoulder and the Risk of Parkinson’s Disease: A Danish Registry-Based Cohort Study. Clin Epidemiol. 2024 Jun 27;16:447-459. doi: 10.2147/CLEP.S463571. PMID: 38952571; PMCID: PMC11216321.
2. Lee BC, Kim BS, Lee BJ, Moon CW, Park CH, Kim DH, Yun DH, Park D, Kim DY, Kim DH, Kim GW, Kim HJ, Jung IY, Kim IJ, Park JH, Lee JH, Ahn J, Lim JY, Yoon JA, Lee JH, Hwang JM, Kim K, Uhm KE, Choi KH, Nam KE, Min K, Chang MC, Park MW, Kim N, Park HK, Kim SH, Yang S, Won SJ, Moon SG, Chung SJ, Jee S, Lee WH, Park YB, Na Y, Won YH, Im YJ, Yoon YS, Lee YJ, Soh Y, Han JY. Clinical Practice Guidelines for Diagnosis and Non-Surgical Treatment of Primary Frozen Shoulder. Ann Rehabil Med. 2025 Jun;49(3):113-138. doi: 10.5535/arm.250057. Epub 2025 Jun 30. PMID: 40602400; PMCID: PMC12231400.
3. Abudula X, Maimaiti P, Yasheng A, Shu J, Tuerxun A, Abudujilili H, Yang R. Factors associated with frozen shoulder in adults: a retrospective study. BMC Musculoskelet Disord. 2024 Jun 26;25(1):493. doi: 10.1186/s12891-024-07614-8. PMID: 38926699; PMCID: PMC11200817.
4. Cao W, Chen J, Pu J, Fan Y, Cao Y. Risk Factors for the Onset of Frozen Shoulder in Middle-Aged and Elderly Subjects Within 1 Year of Discharge From a Hospitalization That Involved Intravenous Infusion: A Prospective Cohort Study. Front Med (Lausanne). 2022 Jun 20;9:911532. doi: 10.3389/fmed.2022.911532. PMID: 35795630; PMCID: PMC9251169.