Frozen shoulder, also known as adhesive capsulitis, is an inability to lift your arm up above your head or move your arm in different directions, initially because of pain and later because of stiffness. It has four phases: pain, stiffening, frozen and thawing. The natural course of recovery for a frozen shoulder (if you do nothing), from initial pain to thawing and resolution of symptoms is 2–3 years.  

What are the four phases of frozen shoulder?

First phase—pain phase
The pain is unbearable and there seems to be no position where your arm feels comfortable. Sleeping is particularly difficult at this time, because of the severe pain.

Second phase—stiffening phase
The covering around the shoulder joint (known as the capsule) is becoming stuck to the bone, so you struggle to move your shoulder partly due to pain but partly due to it ‘freezing’ into place.

Third phase—frozen phase
The capsule is completely stuck to the bone so the shoulder can’t move, not because of pain but because of stiffness.

Final phase—thawing phase
The capsule is loosening, allowing the shoulder to move.


What causes frozen shoulder?

Frozen shoulder can occur after a shoulder or arm injury, particularly if the arm has been immobilised in a sling. It can also occur after shoulder surgery, open-heart surgery, or breast cancer treatment (either after the surgery or with radiotherapy treatment). But sometimes there is no obvious cause for the frozen shoulder.

Frozen shoulder is more common in the non-dominant arm of women of menopausal age. It is also more common if you have diabetes, have had a stroke or have Parkinson’s disease. There seems to be a genetic tendency for frozen shoulder and it has also been linked to a family history of a condition called Dupuytren’s contracture, where the tendons of the ring finger and little finger shorten so the fingers can’t straighten.


How do I know if I have frozen shoulder?

The first signs of frozen shoulder vary between women and men—a woman may have difficulty doing up her bra, or a man may have trouble getting his wallet out of the back pocket of his pants. Your shoulder may also be painful when you reach to put on a seat belt or to take the ticket from the machine in the car park.

A quick test that your physiotherapist will do is to ask you to tuck your elbows into your side with your forearms bent to 90o, and then ask you to take your forearms out from your side. That movement will be restricted on the painful side.


How can physiotherapy help with frozen shoulder?

In the initial stages where you can’t move your shoulder due to pain, if anyone massages, mobilises or dry needles your shoulder your symptoms will increase because the lining of the joint is highly reactive. At this stage, you need:

  • advice about how to support your arm for sleeping
  • strategies to minimise your driving as this will make your symptoms worse
  • forearm support on your office chair to decrease the gravitational loading of your arm.

You may find heat, cold or acupuncture is helpful in decreasing your pain. It is a case of trial and error, as everyone is different. Low-level laser can be effective for pain relief in this initial stage. Taping to support the shoulder can be helpful in minimising the shoulder pain and helping you to sleep. At this stage, loosening the mid-section of your back between the shoulder blades (provided you don’t experience any increase in pain) can promote better activity of the shoulder blade muscles, which may improve the position of the shoulder and help your shoulder pain.

Your physiotherapist may give you gentle exercises such as lightly swinging the arm while resting the other arm on a table or crawling your fingers as high as you can up the wall. However, all of these activities must be in the pain-free range and not provoke your pain. Sometimes your physiotherapist may give you a home pulley device where you can slowly work on your own range.

In the stiffness and thawing phases you may find that mobilisation, massage, trigger point therapy and dry needling by your physiotherapist are helpful in improving the mobility of your shoulder. Any treatment you’re given should not increase your symptoms, so it’s important to let your physiotherapist know if you experience pain. You may be given a home program of exercises to improve the way your rotator cuff and shoulder blades stabilise, as well as some stretching exercises.


How effective is physiotherapy for frozen shoulder?

No treatment, surgical or otherwise, has been shown to be effective for frozen shoulder. Although individual trials have suggested that certain treatments can be helpful, these are not considered to be of a high enough quality to be useful. Other trials have shown treatments to make a difference initially, but in the long-term there was no difference.

There is evidence that although the condition resolves itself, many people don’t have full restoration of their range of movement without some form of intervention, whether it is individualised physiotherapy or a class-based program. Once the thawing stage is evident, physiotherapy can be a great strategy to regain as much movement as possible and to retrain muscles that have been under-used for many months. This will help you to achieve a healthy, strong and useful shoulder (and arm), while being careful not to overload this area.


What can I do at home?

The best thing to do at home is to make sure your arm is supported with a pillow when you are sleeping because if you don’t get sleep, life becomes difficult. You should try to minimise driving because this will make your symptoms worse. You can try pendular exercises (swinging your arm back and forth while resting the other arm on a table). ‘Crawling’ your hand up the wall with your fingers is helpful in the shower as the warm water may decrease muscle spasm and you can measure your progress using the tiles. Maintaining strength in your shoulder and upper body with exercises that are pain-free may help to improve the outcome of your injury and your ability to use your shoulder.


How long until I feel better?

Frozen shoulder is one of the most painful musculoskeletal conditions, with the pain stage lasting anywhere from 3–6 months. At this point you need to do anything you can to minimise your symptoms, which may mean even taking a few weeks off work if your pain is continually being aggravated by your work.

The stiffness phase is not very painful but it can be frustrating because the arm simply cannot move, which restricts your daily activities. At this time you can try doing some gentle stretches to improve your range of movement. It can take 2–3 years before your arm feels normal again.