Frozen Shoulder

picture of woman from behins with her arms up flexing muscles
This page has been designed to provide you with the right information about frozen shoulder and the rehabilitation that may help you in your recovery.

What is a frozen shoulder?

The term ‘frozen shoulder’ is often used to describe a shoulder that has become painful and the movement has become limited. A frozen shoulder is not a dangerous problem and has nothing to do with damage to your shoulder.

Many shoulder problems will often get labelled as frozen shoulder, however a true frozen shoulder is actually quite rare, with only 2-5% of the population thought to be affected (Neviaser and Hannafin, 2010).

The name ‘frozen shoulder’ is in itself a bit controversial but it is a name that most people have heard of, and therefore it is the name we will use for the rest of this information page.

Woman with arms up, flexing arm muscles and neutral facial expression.

Who tends to get frozen shoulder?

Frozen shoulder can affect anyone, however it is more common in both men and women in their 50s (Lewis, 2015).

Some other health conditions can raise the chances of developing a frozen shoulder such as diabetes, hypothyroidism, being a smoker and if a previous family member has had it before (Smith et al., 2012; Wang et al., 2013).

So what actually happens with a frozen shoulder?

Well, firstly it is still not clear why some people develop a frozen shoulder and some people don’t. As we’ve mentioned before, they are relatively rare (despite lots of shoulder pain being given the label of frozen shoulder) and are not dangerous issues and have nothing to do with any damage inside your shoulder.

What is thought to happen is that your immune system (your defence system that helps with fighting infections and repairing any damage) ‘malfunctions’ and starts to cause a reaction in your shoulder. A number of cells that would normally be used to help fight infections or repair you after an injury start to affect some of the parts of your shoulder making them sore and less flexible.

In essence, frozen shoulder is linked to a reaction from your immune system that leads to lots of new blood vessels being made and a thickening of normally very flexible and mobile tissue, leaving them very sore and much less flexible.

Lady shrugging shoulders to indicate confuion.

That sounds scary, should I be worried?

A frozen shoulder is not something that is considered dangerous, meaning it is not something that will harm you and it will normally get better over time for most people.

It is useful to add that in most cases, frozen shoulders can be extremely painful to begin with. It is totally normal, and only human, to find yourself feeling a bit worried if you have high levels of pain. We have written this self-help page to help you understand that even though a frozen shoulder can be tough to endure, and can be really limiting to your normal everyday activities, it is not dangerous or damage, and in most cases, it will get better. You are safe to be sore.

So, nothing is actually frozen in my shoulder then?

Correct, nothing is frozen in your shoulder. The term 'frozen shoulder' can be misleading and a lot of people don’t fully understand why it is called that if nothing is actually frozen. The term 'frozen shoulder' was first used back in the 1930s and was thought to be linked to the stiffness and limited movement that it caused.

It really is worth remembering that nothing in your shoulder is frozen or stuck or caught. What is likely to be happening is that some important structures (known as soft tissues) are very irritated and are less flexible (i.e. cannot stretch) as much as before.

a human hand performing the thumbs up gesture on white background.

So, what causes a frozen shoulder?

Sometimes a frozen shoulder can follow an injury or surgery, but for most people, it simply comes on by itself.

Why did you say not all frozen shoulders are actually frozen shoulders?

The shoulder itself is a complicated joint. It has a unique anatomy because it has a very unique and important job, which is to make sure you can move your hand to where you need it. Diagnosing shoulder issues is difficult at the best of times, and sometimes a shoulder problem can look like a frozen shoulder, but it is actually something different i.e. a muscle issue or it is coming from the neck. In fact, some shoulder issues can behave so similar to a frozen shoulder that it can be hard to tell them apart.

True frozen shoulders are rare as we’ve mentioned before. A physiotherapist has the skills and knowledge that can help diagnose if something is a frozen shoulder or not.

How do you diagnose a frozen shoulder?

As with a number of common aches and pains, a decision about what might be going on can be made by asking some specific questions, rather than necessarily having to touch or move your shoulder. Of course, a physical assessment (touching, moving joints, checking strength) is a key part of an assessment as it can help confirm or deny any suspicions that your physiotherapist may have.

In some cases, an X-ray might be considered as part of the assessment, but this is not normally required.

 

What are the symptoms of a frozen shoulder?

A frozen shoulder will often present as a very painful shoulder or arm with the movement either slightly or very restricted. Most people find the pain quite hard to control initially and will find even the simplest of things like sleeping or dressing really quite a struggle.

Frozen shoulders are often thought to go through different phases over time. To try and make this easier to understand (as the treatment may differ dependent on which stage you are in), the two general phases are:

But my pain is in my arm, not my shoulder, is that the same thing?

In most cases, shoulder issues cause pain in the shoulder itself, however, for a number of people the pain can be mostly felt further down into their arm. If your pain is mostly in your upper arm and not necessarily in the shoulder, it is still right to call it shoulder pain as it is most likely that the pain is travelling down from the shoulder to that area. This is called 'referred pain'. In some cases, it is possible for shoulder pain to travel all the way down to the hand.

 

I think I might have a frozen shoulder, what should I do?

Firstly, try not to worry. As we’ve mentioned a few times, a frozen shoulder can be very sore and can make even the simplest of things like concentrating on a task, moving the arm or even just finding a comfortable position, really quite tough.

It is totally understandable to find yourself feeling a bit worried with high levels of pain, but as we’ve said before, it is really important to remember that most people do get better over time.

If you have shoulder pain that seems to fit with some of the things mentioned in this self-help page, it would be a good idea to explore some of the advice and exercises to see if you can start to help things recover.

If you have tried some of the exercises and advice (remember, some of these may take a number of weeks to help) and you are still struggling, you can refer yourself to physiotherapy.

If you’ve looked at the information on this page and you think your shoulder issue might be something different, please feel free to explore our other self-help pages where you will hopefully find something to help you on your way to recovery.

 

What else can I do?

Often, one of the most useful (and challenging) things to do in the early stages of a frozen shoulder is to control the pain.

If your pain is not well controlled, you should speak with your GP about what options you have.

What about an injection for my shoulder, would that help?

For some people, a steroid injection into the shoulder can considerably help to manage the pain and improve the function (being able to do things). However, the benefits seem to be temporary and tend to be more effective when completed during the phase when pain is worse than the stiffness (Carette et al., 2003; Blanchard et al., 2010; Maund et al., 2012). As with all drugs, steroids can have side-effects and cannot/ should not be used for the long-term management of shoulder issues. You should discuss the option of an injection with your physiotherapist or GP for more information.

picture of woman from behins with her arms up flexing muscles

Do I need to have a scan?

For most people, a scan or an X-ray is not something that they will need to help them either diagnose or treat their shoulder issue.

If your GP or physiotherapist thinks that investigating your issue with something like an X-ray would be useful, then they will discuss this with you. However, an X-ray or scan is not normally needed for the assessment and treatment of a frozen shoulder.

 

If it is frozen shoulder, what can I expect?

As we’ve said before, most people with frozen shoulders do make a recovery, however, it normally takes quite a long time. A review of the evidence (experiments, clinical studies and expert opinion) suggests that the average time for a frozen shoulder to improve is just over 30 months (Lewis, 2015). It is worth noting that this is the average timescale for recovery, which means that some people recover in a short period of time and some may take longer. A proportion of people are left with a lingering issue after their frozen shoulder has eased.

That sounds like a very long time, are you sure?

It is a very long time but as mentioned, frozen shoulder does tend to move through different phases and a lot of people tend to find ways of working with/around the stiffness after the pain settles.

Given these timescales, it is important that your shoulder is assessed and diagnosed by a physiotherapist or appropriate healthcare practitioner to make sure you are on the right treatment pathway for frozen shoulder, or a different pathway if it appears your shoulder pain is caused by something else.

What can I do to help my shoulder?

Although your shoulder is sore and it will be difficult (sometimes really difficult) to move it, keeping your shoulder moving is really important. Most people find themselves worrying that because their shoulder is so sore, that moving must be causing more harm or damage somehow. As we’ve mentioned in this self-help page, despite its soreness and the problems it can cause, a frozen shoulder is not a damage or dangerous problem. Moving your shoulder, albeit sore and tough, will not make it worse. Think of the pain as a bit like a bruise; if you poke a bruise it is sore but you’re not actually making the bruise worse. In other words, you are safe to be sore.

If you try to move your arm as far as you can comfortably as often as you can, then you are doing something to help keep the rest of the shoulder mobile. You might not be able to do much, but anything is better than nothing.

 

What can physiotherapy do to help me?

A frozen shoulder is a challenging complaint for all healthcare professionals to manage, all the way from your GP to your physiotherapist.

As we’ve mentioned, a frozen shoulder tends to go through phases as time goes on, and the treatment offered generally goes in line with those phases.

If pain is your main issue, then your physiotherapist will work with you to try and get your pain under control. This might include liaising with your GP about pain relief or a steroid injection. These options often have different effects for different people, but if things aren’t working out for you and your pain is not controlled after trying some simple options, your physiotherapist may talk to your GP about what other options may be suitable, which may include a consultation with a specialist hospital doctor.

If stiffness is the main issue, your physiotherapist has a number of options to explore to try and help you. At the top of the list are exercises aimed at regaining some flexibility in the shoulder. These might be offered in a one-to-one or class setting. How long it takes to respond to these exercises is unfortunately very hard to predict as everyone will react within their own timeframes.

Can physiotherapy really help?

In short, yes it can, but does it work in the same way for everyone? Probably not, but rehabilitation which includes help understanding the issue, education about ways of managing and working with the symptoms, reassurance that despite the pain it is safe to move and use the shoulder, along with exercises, can be helpful in frozen shoulders (Jain and Sharma 2014).

a human hand performing the thumbs up gesture on white background.

How long will it be before I feel better?

As we’ve mentioned before, a frozen shoulder is often something that can take quite a while to settle. Most available evidence (clinical studies and experiments) suggests that the average time for a frozen shoulder to settle is about 30 months. As with most people, some might get better quicker and some might get better slower. As also mentioned before, some people can be left with a lingering issue after the frozen shoulder has ‘settled’ i.e. ongoing difficulty with certain movements.

Frustratingly, it is very difficult to predict how each person will react to their frozen shoulder and their rehabilitation. Often, the best way to think about your recovery and response is in weeks to months, rather than days.

 

What happens if it isn’t getting better?

If you find yourself making no progress with your rehabilitation, you will be able to discuss this with your physiotherapist. It is possible that if all the most appropriate steps have been taken to try and help your shoulder have not worked out, then a referral onto a specialist shoulder doctor may be appropriate. It is worth noting that this is most likely to happen if you are in the phase where pain is the pain issue rather than stiffness.

 

You mentioned that I can do some exercises, where can I find these?

You’re right, we did!

You can find a selection of exercises below. We’ve divided them up into those exercises that would be best to explore in either the painful or the stiffness phases.

Pain worse than stiffness phase:

Exercise 1
Exercise 2
Exercise 3
Exercise 4
Exercise 5
Exercise 6
Exercise 7
Exercise 8
Exercise 9
Exercise 10
Exercise 11
Exercise 12
Exercise 13
Exercise 14

Stiffness worse than pain phase:

Exercise 1
Exercise 2
Exercise 3
Exercise 4
Exercise 5
Exercise 6
Exercise 7
Exercise 8
Exercise 9
Exercise 10
Exercise 11
Exercise 12
Exercise 13
Exercise 14
Exercise 15
Exercise 16
Exercise 17
Exercise 18
Exercise 19

Need more help? Refer yourself here.

References:

 

Blanchard, V., Barr, S. and Cerisola,  F.L. (2010). The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy ;96:95e107.

Carette, S., Moffet, H., Tardif, J., Bessette, L., Morin, F., Fremont, P. et al. (2003). Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis & Rheumatology; 48:829e38.

Jain, T.K & Sharma, N.K. (2014). The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: A systematic review. Journal of Back and Musculoskeletal Rehabilitation.  27( 3): 247-273.

Maund, E., Craig, D., Suekarran, S., Neilson, A.,Wright, K., Brealey, S. et al. (2012). Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technology Assessment; 12;16:1e264.

Neviaser,  A.S. & Hannafin, J.A. (2010). Adhesive capsulitis: a review of current treatment. American Journal of Sports Medicine; 38:2346e56.

Smith,  C.D., White W.J. and Bunker T.D. (2012).The associations of frozen shoulder in patients requiring arthroscopic release. Shoulder & Elbow; 4:87e9.

Wang, K., Ho, V., Hunter-Smith, D.J., Beh, P.S., Smith, K.M. and  Weber, A.B. (2013). Risk factors in idiopathic adhesive capsulitis: a case control study. Journal of Shoulder Elbow Surgery; 22. e24e9.