Frozen Shoulder

Frozen shoulder or adhesive capsulitis is a painful shoulder stiffness in which the joint capsule of the shoulder is affected.

The joint capsule is a fibrous cuff that surrounds and contains the shoulder joint.
It is a very important structure because it keeps the humerus connected to the shoulder.
A characteristic feature of a frozen shoulder is the suspension of mobility in all levels of movement.

Raising the arm is fraught with great pain, even if the movement is performed passively.
The joint capsule is not inflamed, but scarring adhesions form and collagen production increases.
This leads to the formation of new fibrous tissue.

The capsule becomes thicker and more voluminous, loses elasticity and retracts, hindering the movements of the shoulder.
The amount of synovial fluid contained in the capsule is decreasing more and more.
This disease affects women more often than men, in right-handers the left shoulder will be affected.

The age of the patients is between 45 and 65 years.
Only rarely does adhesive capsulitis occur bilaterally.
The disease can extend over several months and years, usually a cure occurs within 1/2 to <> years.


What are the causes?

There are no definite causes, but some factors favor the appearance of painful shoulder stiffness.
It is frequently found in the following groups of people:

  • those suffering from diabetes, high cholesterol (hypercholesterolemia) and heart disease (cardioparthia);
  • who has suffered severe trauma, such as a broken bone or dislocation;
  • who has undergone surgery, such as mastectomy.

There are many different theories, on the one hand metabolic disorders and neurological, endocrine causes are assumed, on the other hand it is assumed that the disease occurs as a side effect of certain drugs.

What are the symptoms?

Adhesive capsulitis can be divided into three stages.

The first stage (initial phase) consists of inflammation of the joint capsule and contracture of the rotator cuff of the shoulder.
The shoulder pain is very severe and can occur especially at night.
This stage usually lasts about 6 to 12 weeks.

In the second stage, the stiffening of the shoulder occurs.

The restriction of movement increases more and more and reaches its peak after about 2 months, especially when the arm is lifted forward, turned inwards or outwards or spread; the stretching of the arm backwards is rarely restricted.
The main difference between painful shoulder stiffness and other shoulder complaints lies in the stiff movement blockage when the limit of movement is reached.

The full range of motion cannot be obtained, even if the arm movement is forced.
The scope of active and passive movements is the same.
The functional limitation can be very serious, the person concerned is unable to perform manual work and the exercise of normal everyday activities can become problematic.
Everyday movements that require internal rotation of the shoulder may no longer be possible, such as closing the bra, washing the back, brushing your hair, pulling your wallet out of your pocket or fastening your seat belt.
In addition, climatic factors can worsen the symptoms: cold weather and change in weather.

Repetition activities can increase the pain temporarily.
Some patients are unable to perform physiotherapy exercises due to the pain.
The second stage lasts about a year.

In the third stage (solution phase), the scar tissue becomes more elastic.
The mobility of the joint increases and in 90% of cases the patient regains full range of motion in the shoulder joint.

Which imaging diagnostic methods are used?

Magnetic resonance and CT are among the most useful examination methods.
Both indicate the condition of the soft tissues, i.e. the joint capsule, ligaments and tendons.
In painful shoulder stiffness, examinations indicate thickening of the capsule and depressions containing synovial fluid.

The doctor may also order a blood test to check blood sugar and cholesterol levels.

How is frozen shoulder diagnosed?

The diagnosis is made clinically, the orthopedist analyzes the medical history and conducts a physical examination.
Typical is the restriction of the range of motion in passive shoulder movement.
The doctor must conduct an active and passive movement test; if both have the same result, there is a suspicion of adhesive capsulitis.
All movements cause pain, especially the bending and twisting movements.
In differential diagnosis, lesions of the rotator cuff, calcium deposits, periarthritis, bursitis and impingement syndrome should be taken into account.


For painful shoulder stiffness, treatment consists mainly of pain relief and physiotherapy. Most patients are already helped by a few simple exercises, even if the entire treatment can take several months.

Exercises and stretching

In adhesive capsulitis, the stretching exercises have two main functions:

  • increase the mobility of the joint;
  • minimise the loss of muscle tone of the arm concerned (hypotrophy of the muscle).

One should not underestimate the importance of stretching exercises, as they are the key to treatment success. However, positive results can only be recorded if the exercises are carried out not only in the presence of the physiotherapist but several times a day.


The physical therapist can help the patient develop a program that combines stretching exercises with ultrasound, cold, heat treatment, and other rehabilitation methods. As already mentioned, it is important to do the stretching exercises several times a day (not only in cooperation with the physiotherapist).


Anti-inflammatory drugs have no significant influence on the healing of painful shoulder stiffness, but can provide relief through their pain-relieving effect.


Cortisone injections are commonly used to relieve inflammation in the shoulder. It’s not entirely clear how much benefit a cortisone injection can bring, but it certainly helps reduce pain, which in turn makes it possible to increase stretching exercises.
However, it is known that cortisone is only an effective treatment method for painful shoulder stiffness if it is used in combination with physiotherapy.

Surgical treatment for frozen shoulder

If the symptoms persist despite physiotherapy and pharmacological treatment, surgical intervention may be considered.
It is important to determine the potential healing process together with the doctor, continuing the exercises or performing surgical intervention.

The aim of the operation is to loosen and widen the stiffened joint capsule.
The most frequently used surgical procedures include anesthesia manipulation and arthroscopy of the shoulder.

In anesthesia manipulation, the doctor moves the shoulder in different directions, forcing the joint capsule tissue to widen or tear. This loosens the joint capsule and increases the range of motion.
With arthroscopy of the shoulder, the doctor cuts small parts of the joint capsule; to do this, he uses pen-like devices that are inserted through small incisions in the shoulder.

In many cases, manipulation and arthroscopy are combined to achieve an optimal treatment outcome.
In the majority of patients, very good results can be achieved with these two procedures.


After the procedure, physiotherapy is again very important in order to maintain the degree of movement achieved by the operation. Recovery times range from 6 weeks to 3 months.
Even if the healing process is lengthy, the patient’s behavior during therapy is the basic prerequisite for the resumption of all everyday activities.

Long-term results after surgery are usually good.
Most patients can significantly increase the range of motion through pain relief.
In some cases, however, full mobility cannot be regained even after years and a small proportion of residual stiffness remains.

Although it is rare, relapses are possible with painful shoulder stiffness, especially with diabetes.

Household remedies

Anyone suffering from painful shoulder stiffness must involve the affected limb in the exercise of everyday activities, as far as the pain allows. Using heat and cold packs on the shoulder can help relieve pain.

Moist-warm envelopes

Moist-warm compresses can loosen the shoulder joint and relieve pain. Three times a day, the envelopes should be applied and stretching exercises should be performed; for the warming compresses, a cloth is immersed in warm water and placed on the shoulder for about 10 minutes before stretching.

Alternative medicine

Acupuncture has been used in China for thousands of years. Very fine needles are inserted into certain points of the body and remain there for 15-40 minutes. During this time, they can be moved or manipulated. Because the needles are extremely thin and pliable, and are usually inserted superficially, most acupuncture treatments are largely painless.

In transcutaneous electrical nerve stimulation (TENS), key points in the nerve supply area are stimulated by weak current. The current is transmitted through electrodes attached to the skin, which is neither painful nor harmful. The exact mode of action of TENS is not known, but it is assumed that the release of pain-inhibiting molecules (endorphins) is stimulated or the pain impulse-transporting fibers are inhibited.


One of the most common causes of painful shoulder stiffness is immobility of the shoulder, which could be due to a shoulder injury, broken arm, or stroke. After an injury that makes the movement of the shoulder difficult, it is necessary to consult the doctor or physiotherapist, who can maintain the mobility of the affected shoulder with the help of appropriate exercises.