Frozen shoulder (adhesive capsulitis)

Waking up with a stiff, achy shoulder that seems to get worse over time can be worrying and debilitating. If moving your shoulder becomes increasingly difficult and painful, you might be dealing with a condition commonly known as frozen shoulder, or medically termed adhesive capsulitis. It’s a condition characterised by significant pain and stiffness in the shoulder joint, often developing slowly and limiting your ability to perform everyday tasks like reaching overhead or behind your back.

Understanding frozen shoulder is the first step towards finding relief. It involves the shoulder capsule, the strong connective tissue surrounding the shoulder joint, becoming thick, tight, and inflamed. This tightening restricts space within the joint, making movement painful and eventually very difficult. While the exact cause isn’t always clear, it’s known to affect people differently, progressing through distinct stages. This article will guide you through what frozen shoulder (adhesive capsulitis) entails, its typical progression, potential causes and risk factors, how it’s diagnosed, and the most effective treatment options available to help you regain movement and reduce pain.

Understanding the Stages of Frozen Shoulder

Frozen shoulder typically progresses through three distinct phases, each with its own set of symptoms and duration. Recognising these stages can help you understand your condition better and manage expectations during recovery.

  1. The Freezing Stage (Painful Phase):

    • This initial stage is often marked by the gradual onset of shoulder pain.
    • Any movement of the shoulder causes pain, and as the pain worsens, the shoulder’s range of motion starts to become limited.
    • You might notice increasing difficulty with reaching movements.
    • This stage can last anywhere from 6 weeks to 9 months. The predominant feature is pain, often worse at night.

  2. The Frozen Stage (Stiffening Phase):

    • During this stage, the pain may actually begin to diminish. However, the shoulder stiffness becomes more pronounced.
    • Moving the shoulder becomes significantly more difficult, impacting daily activities. The joint capsule has significantly thickened and tightened.
    • Loss of external rotation (rotating the arm outward) is a hallmark sign. Both active range (moving your arm yourself) and passive range (when someone else moves your arm) of motion are markedly reduced.
    • This stage typically lasts 4 to 6 months, although it can persist longer.

  3. The Thawing Stage (Resolution Phase):

    • Gradually, the shoulder’s range of motion begins to improve during this final stage.
    • The stiffness eases, and you’ll find it easier to perform tasks that were previously challenging.
    • Complete return to normal, or near-normal, strength and motion can take time.
    • The thawing stage can last anywhere from 6 months to 2 years or more.

While these stages provide a typical timeline, the duration and severity can vary significantly from person to person. Patience and consistent management are key throughout the process.

What Causes Frozen Shoulder and Who is at Risk?

The exact reason why some people develop adhesive capsulitis is often unclear, leading to the term “primary” or “idiopathic” frozen shoulder. However, we know that the condition involves the shoulder capsule becoming inflamed, thick, and contracted.

There are also instances of “secondary” frozen shoulder, which can develop after a shoulder injury, surgery, or period of immobilization. Keeping the shoulder still for prolonged periods, perhaps due to pain from another condition like a rotator cuff tear, fracture, or post-operative recovery, can increase the risk.

Several risk factors are known to increase the likelihood of developing frozen shoulder:

  • Age: It most commonly affects people between the ages of 40 and 60.
  • Sex: Women are more likely to develop frozen shoulder than men.
  • Immobility or Reduced Mobility: As mentioned, prolonged immobilization after surgery, fracture, or injury is a significant risk factor.
  • Systemic Diseases: Certain medical conditions significantly increase the risk, including:
    • Diabetes: People with diabetes are much more likely to develop frozen shoulder, and it may be more severe and harder to treat. The connection is strong, though the exact reason is still being researched.
    • Thyroid Disease: Both overactive (hyperthyroidism) and underactive (hypothyroidism) thyroid conditions are associated with an increased risk.
    • Other conditions: Cardiovascular disease, Parkinson’s disease, and tuberculosis have also been linked to frozen shoulder.

Understanding these risk factors can help in early recognition and management, especially if you fall into a higher-risk category and start experiencing shoulder pain and stiffness.

How is Frozen Shoulder Diagnosed?

Diagnosing frozen shoulder (adhesive capsulitis) primarily relies on a thorough medical history and a physical examination by your doctor or a physiotherapist.

  • Medical History: Your doctor will ask about your symptoms, when they started, the nature of the pain, activities that make it worse, and any previous shoulder injuries or relevant medical conditions (like diabetes or thyroid disease).
  • Physical Examination: This is crucial for diagnosis. Your doctor will assess:
    • Active Range of Motion: You’ll be asked to move your shoulder in various directions (e.g., reaching up, out to the side, behind your back) to see how far you can move it yourself.
    • Passive Range of Motion: The doctor will then gently move your arm in different directions to assess the end range of movement and the degree of restriction. A key sign of frozen shoulder is a significant limitation in both active and passive range of motion, particularly external rotation.
    • Pain Assessment: The doctor will note which movements cause pain.
  • Imaging Tests: While often not necessary for diagnosis, imaging might be used to rule out other conditions that can cause similar symptoms, such as arthritis or a rotator cuff tear.
    • X-rays: Can help identify bone problems like arthritis or fractures.
    • MRI or Ultrasound: May be used occasionally to check for soft tissue problems like rotator cuff tears, although the thickened joint capsule characteristic of frozen shoulder isn’t always obvious on standard imaging.
  • Diagnostic Injections: In some cases, an injection of local anaesthetic into the shoulder joint can help differentiate frozen shoulder from other conditions. If the pain is relieved but the range of motion remains restricted, it supports the diagnosis of adhesive capsulitis.

The differential diagnosis is important, as conditions like shoulder arthritis or rotator cuff injuries can also cause pain and limited movement, but the pattern of restriction in frozen shoulder (especially the loss of passive external rotation) is often distinctive.

Effective Treatments for Frozen Shoulder (Adhesive Capsulitis)

The main goals of treating frozen shoulder are to control pain and preserve, or gradually restore, the shoulder’s range of motion and function. Most cases improve over time with conservative treatments, although recovery can be slow.

Non-Surgical Treatments: These are the first line of defence:

  • Pain Relief:
    • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen or naproxen can help reduce pain and inflammation. Paracetamol may also be recommended.
    • Heat/Ice Packs: Applying heat or ice can help manage pain and discomfort.
  • Physical Therapy and Exercises: This is a cornerstone of treatment. A physiotherapist will guide you through specific shoulder exercises designed to:
    • Stretch the joint capsule.
    • Improve range of motion.
    • Maintain muscle strength.
      Consistency is key, and exercises should be done regularly as prescribed, often multiple times a day. Gentle stretching is crucial, pushing slightly into the discomfort but avoiding severe pain.
  • Corticosteroid Injections: An injection of steroids (corticosteroids) directly into the shoulder joint can significantly reduce inflammation and pain, particularly effective in the early ‘freezing’ stage. This pain relief can make physical therapy more effective.
  • Hydrodilatation (Distension Arthrography): This involves injecting a large volume of sterile fluid (saline, sometimes with steroid and local anaesthetic) into the shoulder joint under imaging guidance. The aim is to stretch and expand the tight joint capsule to improve range of motion.

Surgical Treatments: If conservative treatments fail to provide adequate relief after several months (typically 6 months or more), more invasive options might be considered:

  • Manipulation Under Anesthesia (MUA): While you are asleep under general anaesthesia, the surgeon carefully moves your shoulder through its full range of motion. This forces the tight capsule to stretch or tear, freeing up the joint. MUA is usually followed by intensive physical therapy.
  • Shoulder Arthroscopy (Capsular Release): This is a keyhole surgery. The surgeon inserts tiny instruments through small incisions to view the inside of the joint and cut through (release) the tightened portions of the joint capsule (arthroscopic capsular release). This procedure allows for more controlled stretching of the capsule. It’s often combined with MUA and followed by physiotherapy.

The best treatment approach depends on the stage of your frozen shoulder, the severity of symptoms, and your individual health status. Early intervention often leads to better outcomes.

Key Takeaways and Next Steps

Frozen shoulder (adhesive capsulitis) can be a painful and frustrating condition, significantly impacting your daily life due to stiffness and restricted movement. Remember these key points:

  • It involves the thickening and tightening of the shoulder capsule.
  • It typically progresses through three stages: freezing (painful), frozen (stiff), and thawing (recovery).
  • While the exact cause is often unknown, risk factors include age (40-60), female gender, diabetes, thyroid disease, and prolonged immobilization.
  • Diagnosis is mainly clinical, based on assessing range of motion limitations.
  • Treatment focuses on pain relief and restoring movement, primarily through physical therapy, shoulder exercises, and sometimes steroid injections or hydrodilatation.
  • Surgery (manipulation under anesthesia or arthroscopic capsular release) may be considered if conservative methods fail after several months.

Recovery takes time and patience, often lasting months or even years, but most people eventually regain good shoulder function. If you are experiencing persistent shoulder pain and stiffness, don’t delay seeking medical advice. Early diagnosis and appropriate management are crucial for a better outcome.

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Mr. David Shields specialises in diagnosing and treating shoulder conditions like frozen shoulder (adhesive capsulitis). To discuss your symptoms and explore treatment options:

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