However, it is a condition that can take a very long time and treatment options are limited. In this article we go through some important facts about frozen shoulder, or adhesive capsulitis as it is called in medical terminology.
Two types of frozen shoulder
We distinguish between two variants of adhesive capsulitis, primary and secondary capsulitis. Primary capsulitis occurs without a previous injury to the shoulder, but is often linked to an underlying disease such as diabetes. The onset of pain here is usually gradual, not sudden. Secondary capsulitis occurs after a previous injury or trauma to the shoulder. Examples are rotator cuff injuries, fractures, or surgery, to name a few. Here the onset of pain is often more acute compared with primary capsulitis.
The different phases
We typically say that the condition moves through 3 phases. The condition starts with a painful phase of 2-9 months, characterised by increasing pain in the shoulder. Next comes a stiffening phase of 4-12 months, in which we see a gradual stiffening of the shoulder while the pain may ease. Finally there is a thawing phase of 12-24 months, in which we see a gradual loosening of the shoulder and normalisation of function. However, as many as 20-50% experience a complete normalisation of function. These phases do not have to be separate in the way we present them here, and there are large individual variations.
The disease process
The disease process is not yet fully understood, but we have a good idea of what is going on. The condition seems to start with an inflammatory process in which we see inflammation inside the joint capsule and in the joint fluid. This is thought to be the cause of the pain people experience. We also believe that this inflammation triggers what is called fibrosis, a term meaning an increase in connective tissue. It is the joint capsule around the shoulder that experiences this increase, and it ends up thickened and therefore tighter. This causes the stiffening of the shoulder.
Typical signs and how the diagnosis is made
Typical signs of frozen shoulder are increasing pain followed by stiffening of the shoulder. What often distinguishes frozen shoulder from other conditions is a loss of both active and passive movement, as many other conditions often cause a loss of active movement only. The ability to rotate the arm outwards, and to lift it out to the side, is often among the first things to be affected. The diagnosis is made clinically, meaning by a healthcare professional after a thorough examination. Further tests may be relevant if an underlying disease is suspected, and imaging of the shoulder can be considered if another injury to the shoulder is suspected. This is the case, for example, with secondary capsulitis after trauma to the shoulder.
Treatment
There is no treatment that will cure a frozen shoulder or affect the course of the disease to any great extent. We can, however, take measures to relieve pain, and it is important that we also work on maintaining strength, mobility and muscle mass around the shoulder. Below is a list of different treatment options.
Painkillers / anti-inflammatory medication
Particularly useful in the painful phase to function as well as possible in everyday life. A good plan should be drawn up in consultation with a doctor / practitioner.
Physiotherapy / exercise and mobilisation
An important measure to maintain good function in the shoulder / prevent unnecessary loss of function. Exercise without provoking more pain is completely safe and can help maintain strength and muscle mass. We generally say that physiotherapy is most relevant in the last phase of the condition.
Cortisone injections
Can help with the pain in the painful phase, but is a temporary solution, and not without risk. Should be considered together with a doctor / practitioner. Some evidence may suggest that early injections can give a milder course of the disease, but this is still uncertain.
Surgery and other options
Surgery is reserved for those who do not regain normal mobility with time. The surgeon can then go into the shoulder and release the tight capsule to create better mobility. This is not a measure without risk either. Another option is manipulating the shoulder through its range of movement under local anaesthetic or under general anaesthetic. Here the shoulder can be mobilised without muscle tension and pain limiting it, but studies on this have not shown convincing results.
Frozen shoulder can be a frustrating condition that takes a long time. Even though there is no treatment that cures the condition, there are many different things you can try to achieve a better everyday life while the disease process runs its course. Early diagnosis is important so that the condition is not treated as something else, and it is wise to have a practitioner on your team when making decisions about which measures to try.
Our practitioners have good experience with diagnosing and treating various shoulder problems.
- St Angelo JM, Taqi M, Fabiano SE. Adhesive Capsulitis. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532955/
- Georgiannos D, Markopoulos G, Devetzi E, Bisbinas I. Adhesive Capsulitis of the Shoulder. Is there Consensus Regarding the Treatment? A Comprehensive Review. Open Orthop J. 2017 Feb 28;11:65-76. doi: 10.2174/1874325001711010065. PMID: 28400876; PMCID: PMC5366387.