Frozen Shoulder

(Adhesive Capsulitis)

Frozen shoulder is a condition where the shoulder capsule becomes inflamed, thickened, and tight, severely restricting movement. It affects around 2-5% of the population and typically resolves spontaneously over 1-3 years. Treatment aims to shorten this timeline and reduce pain.

The Three Stages

The shoulder capsule becomes acutely inflamed. Pain is dominant, often severe, constant, and worse at night. Movement gradually reduces. The most painful and hardest-to-treat stage.

Stage 1 | Freezing (2-9 months)

Pain begins to subside but stiffness becomes the dominant problem. The shoulder is significantly restricted in all planes, especially external rotation. Patients find this more functionally limiting.

Stage 2 | Frozen (4-12 months)

Inflammation resolves and range of movement gradually returns. Recovery is slow but most patients achieve full or near-full movement by the end of this stage.

Stage 3 | Thawing (6-24 months)

Who is at risk?

Diabetes

Up to 20% of diabetic patients develop frozen shoulder, often more severe and slower to resolve. Good glycaemic control is important.

Female sex, 40-60

Most commonly affects women between 40 and 60. Hormonal factors may play a role.

Associated conditions

Thyroid disease, cardiac disease, and Dupuytren's contracture are associated with higher incidence.

Shoulder Immobility

Prolonged arm immobilisation after injury, surgery, or stroke can trigger adhesive capsulitis.

Symptoms

  • Gradual onset of deep aching pain around the shoulder, often radiating into the upper arm, worse at night.

  • Progressive stiffness in all directions, particularly loss of external rotation, which is lost earliest.

  • Difficulty with daily tasks: reaching behind the back, fastening clothing, overhead activities.

  • Disturbed sleep - inability to lie on the affected side, waking up at night.

⚠ Not all stiff, painful shoulders are frozen shoulder. Your surgeon will exclude other causes including rotator cuff tears, arthritis, and cervical spine pathology before confirming the diagnosis.

Treatment - Stepwise Approach

Analgesia and anti-inflammatories

NSAIDs help manage pain, particularly in the freezing stage. Regular analgesia around the clock is more effective than taking it only when pain peaks.

1

Physiotherapy

Gentle stretching and range-of-movement exercises maintain what mobility remains. Aggressive stretching in the freezing phase can worsen pain - the programme is tailored to the current stage.

2

Corticosteroid injection

An intra-articular or subacromial steroid injection can potentially provide significant pain relief. Evidence supports early injection to reduce duration and severity.

3

Hydrodistension (hydrodilatation)

A larger volume of saline, steroid, and local anaesthetic is injected under image guidance to stretch the contracted capsule. Many patients notice immediate improvement in range of movement, and the success rate is high ( 80-90%).

4

Arthroscopic capsule release

Reserved for patients failing conservative measures after 6 months. Arthroscopic release offers more controlled results with a lower risk of fracture than manipulation under anaesthesia from the past.

5

The natural history of frozen shoulder is eventual resolution, most patients recover full or near-full movement within 1-3 years even without surgery.

FREQUENTLY ASKED QUESTIONS

  • Around 90% of patients recover full or near-full movement over time. A small proportion, particularly those with diabetes, may have persistent mild stiffness. Early treatment reduces the total duration of symptoms.

  • No, particularly in the freezing stage. Aggressive stretching when the shoulder is acutely inflamed can increase pain and delay recovery. Gentle, regular stretching within a comfortable range is more effective.

  • Recurrence in the same shoulder affects around 5% of patients. However, the opposite shoulder is affected in approximately 20-30% of patients, usually within 5 years of the first episode.

This guide is intended for patient education purposes and does not replace a formal surgical consultation. Treatment decisions are always individualised based on your specific history, examination findings, and imaging. Please discuss your symptoms and management plan directly with your orthopaedic surgeon.