Frozen Shoulder: Stages, Symptoms, Exercises and Treatment

Quick answer

Pain, then stiffness, then thaw: keep gently moving and be patient

Frozen shoulder affects about 2–5% of people, mostly aged 40–60 and more often women. The joint capsule thickens and tightens, so both active and passive movement are limited, especially external rotation and reaching overhead or behind the back. Stages are freezing (increasing pain, 2–9 months), frozen (stiffness with less pain, 4–12 months) and thawing (gradual return of movement, 5–24 months). Risk factors include diabetes, thyroid disease, shoulder injury or surgery and immobilisation. Treatment includes pain relief, heat, gentle stretching and physiotherapy, steroid injections in the early stage, hydrodilatation, and, in resistant cases, manipulation under anaesthesia or arthroscopic release. Most people regain good function, though it can take 1–3 years.

Important. Shoulder pain with chest pain, breathlessness, sweating or pain radiating to the jaw or arm needs emergency care, since heart problems can cause shoulder pain. Fever, a hot red swollen joint, sudden weakness, numbness in the arm or shoulder pain after trauma also need urgent assessment.

What is frozen shoulder?

The shoulder is a ball-and-socket joint surrounded by a thin capsule. In frozen shoulder, the capsule becomes inflamed, then thickened and scarred, shrinking the joint space. This makes movement painful and stiff in all directions, even when someone else moves the arm for you (passive movement), which helps distinguish it from rotator cuff problems. See hombro congelado (Spanish) and supraspinatus tendon injury.

The three stages

Freezing (painful) stage, about 2–9 months: pain gradually increases, worse at night and with movement, while the range of motion begins to shrink.
Frozen (stiff) stage, about 4–12 months: pain often eases, but the shoulder is very stiff; daily tasks such as dressing, reaching or washing hair are hard.
Thawing stage, about 5–24 months: movement gradually returns.
The total duration is typically 1–3 years, but treatment can ease symptoms and shorten the course for some.

Symptoms

Dull or aching shoulder pain, often at the outer shoulder and upper arm.
Pain at night that disturbs sleep, particularly lying on the affected side.
Marked stiffness, especially turning the arm outward (external rotation), lifting it overhead and reaching behind the back.
Difficulty with dressing, fastening a bra, combing hair or reaching a seat belt.
Pain at rest in the early stage.
Normal strength early on, with later muscle wasting from disuse.
Usually one shoulder; the other shoulder is affected in about 20% of people within five years.

Causes and risk factors

Age 40–60 and female sex.
Diabetes: higher risk (10–20% of people with diabetes) and often a more severe, longer course.
Thyroid disease (underactive or overactive), Parkinson’s disease and heart or lung disease.
Immobilisation after injury, surgery, a stroke or a broken arm.
Shoulder injury or surgery, including breast surgery.
Dupuytren’s contracture and a family history.
In many people, no cause is found (primary frozen shoulder).

How it is diagnosed

A clinician checks both active and passive movement. In frozen shoulder, passive range is also markedly limited, particularly external rotation. X-rays are usually normal but exclude arthritis, fractures or calcific deposits; ultrasound or MRI are used if a rotator cuff tear or other problem is suspected. Blood tests may check for diabetes and thyroid disease. Differential diagnoses include rotator cuff injuries, calcific tendonitis, osteoarthritis and neck problems. See calcific tendonitis.

Managing pain

Paracetamol or anti-inflammatories (if suitable) for pain.
Heat before exercises and ice after if sore.
Sleep on your back or the unaffected side with a pillow supporting the arm.
Avoid painful overhead activities in the early stage, but do not immobilise the shoulder completely.
Transcutaneous electrical nerve stimulation (TENS) may help some people.
Suprascapular nerve blocks and steroid injections for severe pain.

Exercises that help

Exercises should be gentle and regular, to the point of mild stretch without sharp pain. In the painful early stage, focus on pain-free range of motion; in the stiff stage, stretches can be more assertive.

Pendulum swings: lean forward, supported by the good arm, let the sore arm hang and swing gently in small circles for a minute.
Table slides: sit with the arm on a table, slide a towel forward by leaning the trunk.
Wall walks: face the wall and “walk” the fingers up the wall as far as comfortable.
Cross-body stretch: use the good arm to gently pull the sore arm across the chest.
External rotation with a stick: hold a cane or broomstick in both hands, elbow at the side, and push the sore hand outward with the good arm.
Towel stretch behind the back for internal rotation.
Doorway stretch for the chest and front of the shoulder.

Do each for 20–30 seconds, 2–3 times, 2–3 times a day, ideally after a warm shower. A physiotherapist can supervise the programme.

Medical and surgical options

Corticosteroid injection into the joint, most helpful in the early painful stage, with benefit for weeks to months.
Hydrodilatation (capsule distension) with saline, steroid and anaesthetic, to stretch the capsule.
Physiotherapy, including manual therapy and graded stretching.
Manipulation under anaesthesia, moving the shoulder through a full range while asleep, for resistant stiffness.
Arthroscopic capsular release, cutting the tight capsule through keyhole surgery, followed by intensive physiotherapy.
Extracorporeal shockwave and other modalities have limited evidence.
Surgery is only considered after 6–12 months of non-operative care without adequate improvement.

When to see a doctor

Shoulder pain and stiffness lasting more than 2–4 weeks.
Inability to lift or rotate the arm, even passively.
Night pain that disturbs sleep.
Diabetes or thyroid disease with new shoulder stiffness.
Chest pain, breathlessness, sweating or radiating arm or jaw pain: emergency.
Fever, redness or a hot swollen shoulder.
Weakness, numbness or neck pain with arm symptoms.

Three common situations

A 52-year-old woman with night shoulder pain and difficulty fastening a bra: classic frozen shoulder; pain control, gentle stretching and consider an injection early on.

A person with diabetes whose shoulder stiffened after a wrist fracture: start movement early and keep blood sugar controlled.

A person with sudden weakness and inability to lift the arm after a fall: consider a rotator cuff tear; see a doctor.

Key points to remember

Frozen shoulder is painful and stiff but eventually improves. Keep the shoulder gently moving, manage pain, consider an injection early and see a physiotherapist. Seek care for chest pain, weakness or a hot swollen joint. Our physiotherapy team can guide your recovery.

This guide is for general information and does not replace an assessment by your own doctor or physiotherapist.

Questions about frozen shoulder

These answers are general information and do not replace an examination or individual medical advice.

How long does frozen shoulder last?

Typically 1–3 years across three stages, though treatment can ease the course.

What exercises help frozen shoulder?

Pendulum swings, wall walks, towel stretches, cross-body stretch and stick-assisted external rotation.

Should I rest the shoulder?

No, avoid painful activities but keep gentle movement to prevent more stiffness.

Do steroid injections help?

They can reduce pain, particularly early on, for weeks to months.

Is surgery needed?

Rarely; it is considered if months of treatment fail.

Why does diabetes increase the risk?

High blood sugar can stiffen the joint capsule; frozen shoulder is more common and prolonged in diabetes.

Sources

This guide is for general information and does not replace medical advice. How a problem is diagnosed and treated depends on your examination and medical history. If you think you have an emergency, contact your local emergency services.