Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition that causes shoulder pain, stiffness, and progressive loss of movement. It usually develops gradually and can make everyday activities such as dressing, reaching overhead, fastening clothing, driving, or sleeping comfortably very difficult. In many cases it improves over time, but recovery can be slow and some patients require more active treatment to restore movement and reduce pain.

What is frozen shoulder?

Frozen shoulder occurs when the capsule surrounding the shoulder joint becomes inflamed, thickened, and tight. As this happens, the joint loses its normal flexibility and movement becomes increasingly restricted. Both active and passive motion are affected, meaning the shoulder is difficult to move even when someone else tries to assist. The condition is most commonly seen in adults between 40 and 60 years of age and is more common in people with diabetes, thyroid disease, or after periods of shoulder immobility.

Stages of frozen shoulder

Frozen shoulder typically develops in three overlapping stages. During the freezing stage, pain gradually increases and shoulder movement starts to become limited. In the frozen stage, pain may settle somewhat, but stiffness becomes more pronounced and function remains restricted. During the thawing stage, shoulder movement slowly begins to improve, although full recovery can take many months.

Symptoms of frozen shoulder

The most common symptoms are shoulder pain, stiffness, and reduced range of motion. Pain is often felt around the outer shoulder and upper arm and may be worse at night or when lying on the affected side. Many patients notice increasing difficulty with reaching overhead, placing the hand behind the back, washing hair, fastening a bra, or putting on clothing. A key feature of frozen shoulder is marked restriction in movement, especially external rotation.

Causes and risk factors

In many cases, frozen shoulder develops without a clear cause. It can also occur after a shoulder injury, surgery, or a period of reduced use of the arm. Certain medical conditions are linked with a higher risk, particularly diabetes, thyroid disorders, cardiovascular disease, and prolonged immobilisation. Sometimes it follows another painful shoulder problem, which leads to reduced movement and progressive capsular tightening.

Diagnosis

Diagnosis is based on a clinical history and physical examination. Your surgeon will assess the pattern of pain, the degree of stiffness, and whether both active and passive movement are limited. Imaging such as X-rays may be used to rule out arthritis or other structural problems, while ultrasound or MRI can help identify associated rotator cuff disease or other shoulder pathology if needed. The diagnosis is usually made from the characteristic loss of motion and clinical pattern rather than imaging alone.

Non-surgical treatment

Most patients with frozen shoulder are initially treated without surgery. Treatment is aimed at reducing pain, maintaining as much motion as possible, and supporting gradual recovery. This may include anti-inflammatory medication, pain relief, physiotherapy, home stretching exercises, and corticosteroid injection in selected cases. Some patients also benefit from hydrodilatation, where fluid is injected into the joint to help stretch the capsule.

• Pain relief and anti-inflammatory medication where appropriate.
• Gentle stretching and range of motion exercises.
• Physiotherapy to improve movement and shoulder function.
• Corticosteroid injection to reduce inflammation and pain in selected patients.
• Hydrodilatation in some cases to assist capsular stretching.

When is surgery considered?

Surgery may be considered when symptoms are severe, progress remains limited, and non-surgical treatment has not provided satisfactory improvement. This is usually reserved for patients with significant stiffness and pain that continue to interfere with sleep, work, or normal daily activity. Surgical treatment may also be considered when the shoulder remains very restricted after an adequate period of rehabilitation.

Manipulation under anaesthesia

Manipulation under anaesthesia is one option for persistent frozen shoulder. This procedure is performed while the patient is under anaesthesia, allowing the surgeon to gently move the shoulder through a controlled range in order to stretch or break the tight capsular adhesions that are restricting motion. It is generally followed by early physiotherapy so that the improved movement can be maintained.

Arthroscopic capsular release

In more persistent or severe cases, arthroscopic capsular release may be recommended. This is a keyhole procedure in which a camera and fine instruments are inserted into the shoulder joint through small incisions. The tight and inflamed portions of the joint capsule are carefully released to improve movement. Arthroscopy also allows the surgeon to assess the joint for any associated problems that may be contributing to pain or stiffness.

How the procedure is performed

Frozen shoulder procedures are usually performed under general anaesthesia, often with a regional nerve block to assist with postoperative pain control. If manipulation under anaesthesia is performed, the shoulder is carefully mobilised through a controlled range of movement. If arthroscopic capsular release is performed, the surgeon inserts a camera into the joint, identifies the thickened capsule, and releases the tight areas using specialised instruments. In some cases, these approaches may be combined.

A typical procedure may include:

• General anaesthesia with or without a nerve block.
• Assessment of shoulder stiffness and range of motion.
• Manipulation of the shoulder to break adhesions where appropriate.
• Arthroscopic inspection of the joint through small keyhole incisions.
• Release of the thickened and contracted capsule.
• Treatment of any associated pathology if identified.
• Closure of the small incisions and application of dressings.

Benefits of treatment

The aim of treatment is to reduce pain, improve shoulder movement, and restore function. For many patients, non-surgical treatment is effective over time, although recovery may be prolonged. In persistent cases, procedures such as manipulation under anaesthesia or arthroscopic capsular release may help improve movement more quickly and allow rehabilitation to progress more effectively.

Risks and complications

As with any orthopaedic treatment or procedure, there are potential risks. These may include ongoing pain, incomplete recovery of movement, recurrence of stiffness, infection, bleeding, nerve injury, fracture in rare cases following manipulation, and the possibility that symptoms take time to improve despite treatment. Your surgeon will discuss the specific risks and expected outcomes based on your shoulder condition and overall health.

Recovery and rehabilitation

Rehabilitation is a key part of successful treatment for frozen shoulder, especially after a procedure. Early movement is usually encouraged to prevent the shoulder from becoming stiff again. Physiotherapy focuses on maintaining and improving range of motion, followed by gradual strengthening and return to normal activity. Recovery time varies between patients and depends on how long the shoulder has been stiff, the treatment performed, and whether there are other shoulder problems present.

Recovery may include:

• Early mobilisation exercises soon after treatment.
• Structured physiotherapy to maintain motion and improve function.
• Gradual reduction in pain medication as symptoms improve.
• Progressive return to work, driving, exercise, and daily activity as comfort and movement allow.

Is treatment for frozen shoulder right for you?

If shoulder pain and stiffness are not improving, or if your symptoms are significantly affecting your quality of life, an orthopaedic assessment may help clarify the diagnosis and treatment options. Management is tailored to the stage of the condition, the severity of stiffness, your general health, and your response to conservative treatment. The goal is to relieve pain, improve movement, and help you return to normal daily activities as safely and effectively as possible.