Frozen Shoulder

What is frozen shoulder?

The shoulder joint is surrounded by the joint capsule, a layer of connective tissue that envelops it. In frozen shoulder, this capsule becomes inflamed, thickened and contracted, while adhesions (scar tissue) develop. As a result, the shoulder “tightens” and gradually loses its mobility – as if it were “freezing”.

A characteristic feature of the condition is that both active movement (when the patient moves the arm themselves) and passive movement (when someone else tries to move the shoulder) are restricted. This distinguishes frozen shoulder from other conditions, in which the restriction is mainly due to pain.

Causes and risk factors

Frozen shoulder can be primary (with no clear cause) or secondary (following an injury, surgery or prolonged immobilisation of the shoulder). Certain factors are associated with an increased risk:

• Diabetes mellitus – one of the most important risk factors.
• Thyroid disorders and other hormonal/metabolic disorders.
• Prolonged immobilisation of the shoulder (e.g. after a fracture or an operation).
• Age (most common between 40 and 60 years old) and female sex.

The stages of the disease

Frozen shoulder characteristically progresses through three stages, with a total duration that can range from a few months to as long as two to three years:

1. “Freezing” stage (painful stage): The pain gradually increases and movement starts to become restricted. It is the most painful stage.

2. “Frozen” stage (stiff stage): The pain often subsides somewhat, but the stiffness is marked and movement is severely restricted.

3. “Thawing” stage (recovery stage): Movement returns gradually and progressively.

Understanding this course helps the patient to manage their expectations realistically.

Clinical presentation – Symptoms

The main symptoms are:

• Pain in the shoulder, which in the initial stage can be severe, particularly at night.
• Progressive stiffness and severe restriction of movement in all directions.
• Difficulty with everyday activities, such as combing your hair, getting dressed or reaching behind your back.
• Restriction of both active and passive movement.

Diagnosis

The diagnosis is mainly clinical, based on the characteristic history and on the examination, which reveals loss of both active and passive movement. X-rays are as a rule normal and serve to rule out other conditions (e.g. arthritis). Magnetic resonance imaging (MRI) is used in selected cases, to rule out concomitant pathology, such as a rotator cuff tear.

The importance of adapting treatment to the stage

One of the most important elements in the management of frozen shoulder is adapting the treatment to the stage of the disease. This is what distinguishes the right approach from the wrong one: aggressive, intensive physiotherapy during the acute, painful stage (“freezing”) not only does not help, but can worsen the inflammation and the pain.

In the painful stage, the emphasis is on controlling pain and inflammation (anti-inflammatory medication, injections) and on gentle movements. In the stiff stage, physiotherapy becomes more active, with the aim of regaining range of motion. In the recovery stage, the programme focuses on fully restoring movement and strength. It is this “smart” adaptation that makes the difference, and it is one reason why guidance from a specialist doctor is important.

Treatment

The great majority of cases of frozen shoulder are treated successfully by conservative means, as the condition tends to resolve with time. Patience is important here.

Conservative treatment

This includes pain control with anti-inflammatory medication and painkillers, targeted physiotherapy for the gradual recovery of range of motion (adapted to the stage of the disease) and, in selected cases – particularly in the painful stage – local injections of corticosteroids to relieve pain and inflammation. Blood sugar control, in diabetic patients, is also important.

Interventional / surgical treatment

In resistant cases that do not respond to conservative treatment after a prolonged period, more invasive methods may be used, such as manipulation of the shoulder under anaesthesia or arthroscopic release of the contracted capsule. These methods aim at “releasing” the joint and restoring movement more quickly.

Prognosis

In the long term, the prognosis of frozen shoulder is generally good: the majority of patients regain satisfactory or full mobility. However, the course can be long and requires patience and consistency with physiotherapy. Proper guidance from the Orthopedic Surgeon – with treatment adapted to the stage of the disease – helps to manage the pain and achieve the fastest possible recovery.

Cost of treatment

The cost depends on the type of treatment (medication, physiotherapy, injections or – more rarely – invasive methods), the number of sessions and insurance cover. Precise information is given on an individual basis, after the clinical assessment. The clinic is at your disposal for any relevant information.

More about the factors that determine the cost and about cover by insurance funds: Cost of surgery.

When to see a doctor

Persistent pain and progressive stiffness of the shoulder – particularly when both active and passive movement are restricted – should be assessed by an Orthopedic Surgeon. Early diagnosis of frozen shoulder allows appropriate treatment from the outset, adapted to the stage of the disease, helping to manage the pain and speed up recovery.

Particular attention is needed in patients with diabetes or previous immobilisation of the shoulder, who are at increased risk. Proper guidance throughout the – often long – course of the disease is invaluable for the patient.

Frequently asked questions

Why is it called “frozen” shoulder?

Because the joint capsule contracts and the shoulder “tightens”, gradually losing its mobility – as if it were “freezing”. Characteristically, both active and passive movement are restricted.

How long does frozen shoulder last?

The condition progresses through three stages (freezing, frozen, thawing) and the total duration can range from a few months to as long as two to three years. It requires patience.

Will I regain my movement?

Yes, in the great majority of cases. The long-term prognosis is good, with most patients regaining satisfactory or full mobility.

Is it related to diabetes?

Yes. Diabetes mellitus is one of the most important risk factors for frozen shoulder. Good blood sugar control is important.

Is surgery needed?

In the overwhelming majority of cases, no. Invasive methods are reserved for resistant cases that do not respond to conservative treatment.

Does it affect both shoulders?

In some patients – particularly diabetics – frozen shoulder can also affect the other shoulder, either at the same time or at a different time. However, the same shoulder is rarely affected a second time.

Does exercising at home help?

Yes, guided home exercises are an important part of treatment. However, they must be adapted to the stage of the disease and performed correctly, which is why initial guidance from a physiotherapist is invaluable.