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Frozen shoulder, also known as adhesive capsulitis or periarthritis shoulder, affects approximately 2% to 5% of the general population. While specific global annual incidence figures are limited, some studies estimate an incidence rate of about 2.4 per 1,000 individuals per year.
The condition is more prevalent in women than in men. In a study of working-age adults, frozen shoulder was found to affect 10.1% of women and 8.2% of men. Another study reported incidence rates of 3.38 per 1,000 person-years for women and 2.36 per 1,000 person-years for men.
It's important to note that the prevalence of frozen shoulder is higher among individuals with certain conditions. For example, up to 36% of patients with diabetes may experience frozen shoulder.
Physiotherapy management plays a vital role in treating frozen shoulder, also known as adhesive capsulitis or periarthritis of the shoulder. While medication can help reduce pain, physiotherapy helps restore joint mobility by improving range of motion, strengthening muscles, enhancing daily activities, and correcting posture.
What Is Frozen Shoulder?
Frozen shoulder, also known as adhesive capsulitis or periarthritis, is a degenerative condition of the shoulder joint characterized by a gradual decrease in synovial fluid, inflamed, reduction in joint capsule elasticity and joint space, leading to pain, stiffness, and limited range of motion.
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| Normal vs Inflamed shoulder |
There are Four Stages of Frozen Shoulder
1. Pre-Freezing Stage (Painful Stage)
Duration: A few weeks to months.
What Happens:
- Gradual onset of shoulder pain, especially with movement.
- Sleep may be disturbed due to night pain.
- Range of motion may still be normal, but pain begins to limit use.
2. Freezing Stage
Duration: 6 weeks to 9 months.
What Happens:
- Pain increases and becomes more constant.
- Stiffness sets in.
- Range of motion begins to decrease significantly.
- Daily activities become harder (like combing hair or reaching overhead).
3. Frozen Stage (Adhesive Stage)
Duration: 4 to 12 months.
What Happens:
- Pain may start to decrease.
- Stiffness remains or worsens.
- Movement is highly restricted.
- Muscle weakness may begin due to disuse.
4. Thawing Stage (Recovery Stage)
Duration: 6 months to 2 years.
What Happens:
- Gradual return of range of motion.
- Pain continues to decrease.
- Function slowly improves with therapy and time.
Symptoms of Frozen Shoulder
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| Postural asymmetry |
1. Shoulder Pain
- Dull, aching pain deep in the shoulder.
- Can radiate to the upper arm.
- Worse at night or with sudden movement.
2. Stiffness
- Increasing difficulty with everyday movements (e.g., reaching overhead, behind your back, or across your chest).
- Limits in both active and passive range of motion.
3. Limited Mobility
- Difficulty lifting the arm.
- Restricted rotation and elevation of the shoulder joint.
4. Sleep Disturbance
- Night pain often disrupts sleep, especially when lying on the affected side.
5. Progressive Onset
- Symptoms develop gradually and worsen over time.
- Usually progresses through 4 stages (pre-freezing- freezing- frozen-thawing).
6. Postural Asymmetry
- Postural asymmetry is commonly observed in patients with frozen shoulder, due to limited range of motion, stiffness and compensatory movements.
Assessment of Frozen Shoulder
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| Postural Assessment |
Subjective Assessment (Patient History)
1. Onset & Duration of Symptoms
- Gradual or sudden?
- How long has the stiffness/pain been present?
2. Pain Characteristics
- Location (typically lateral shoulder or deltoid area).
- Nature (dull, aching).
- Aggravating/relieving factors.
- Night pain?
3. Functional Limitations
- Difficulty dressing, combing hair, reaching overhead or behind back.
4. Past Medical History
- Diabetes, thyroid disorders, past shoulder injuries/surgeries, immobility.
5. Injuries History
- Asked to the patient he/she has previously injured on the shoulder.
Physical Examination
1. Inspection
- May appear normal externally or show muscle wasting (especially deltoid).
- Postural asymmetry.
2. Palpation
- Localized tenderness around the shoulder.
- Warmth (rare in early inflammation phase).
3. Range of Motion (ROM) Tests
- Active and passive ROM.
- External rotation (most affected).
- Abduction.
- Internal rotation.
- Painful end range in early stages.
4. Strength Testing
- Muscle strength usually preserved but may be reduced due to disuse.
- Pain may limit true strength testing.
- Check trigger point and constructed muscles.
5. Special Tests (to rule out other causes)
- Apley's Scratch Test (limited reaching behind the back).
- Drop Arm Test (to rule out rotator cuff tear).
- Neer’s & Hawkins Test (to rule out impingement).
Radiological Examination
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| Normal vs Periarthritis x-ray |
- X-ray: To rule out arthritis, calcific tendinitis
- MRI or Ultrasound: May show thickening of joint capsule or rule out rotator cuff tears
Pathological Examination
- Blood Test: Fasting blood sugar test, random blood sugar test, hemoglobin A1C test, and glucose tolerance test.
- Uric acid test: Measures uric acid levels in the blood or urine, helping diagnose and monitor conditions like Arthritis.
Physiotherapy Management Goals of Periarthritis Shoulder
- Reduce pain and inflammation.
- Restore full range of motion (ROM).
- Improve muscle strength and joint stability.
- Enhance functional independence in daily activities.
- Correct postural imbalances.
- Prevent long-term stiffness and recurrence.
Physiotherapy Management of Frozen Shoulder
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| The subject has shown improvement in posture |
1. Pre-Freezing / Freezing Stage (Painful Phase):
Goals:
- Control pain and inflammation
- Maintain available ROM (avoid further stiffness)
- Promote relaxation
Modalities & Techniques:
- Interferential Therapy (IFT) / TENS/ IRR/ SWD/Moise Heat Pack for pain relief.
- Dry needling and Soft tissue manipulation.
- Hot or cold packs
- Gentle pendulum exercises
- Isometric strengthening exercises
- Patient education: activity modification, posture correction.
2. Frozen Stage (Stiff Phase):
Goals:
- Increase joint mobility.
- Minimize muscle atrophy.
- Reduce compensatory movements.
Therapy Focus:
- Matrix Rhythm Therapy / Vibration Therapy / Ultrasound Therapy.
- Passive & active-assisted ROM exercises.
- Cupping Therapy and IASTM.
- Pulley Exercise and Shoulder wheel Exercise.
- Joint mobilizations and Manipulation, i.e - AP Glide, PA Glide, Traction and Distraction, Caudal Glide, Scapular protraction and retraction, (Grade I–II for pain, III–IV for stiffness).
- Capsular stretching (especially external rotation and abduction).
- Use of moist heat before stretching.
- Strengthening surrounding muscles (isometrics → dynamic).
3. Thawing Stage (Recovery Phase):
Goals:
- Restore full ROM.
- Rebuild strength and function.
- Postural Correction.
- Return to normal ADLs (Activities of Daily Living)
Approach:
- Progressive resistive exercises.
- Full ROM Exercises.
- Functional and task-specific training.
- PNF (Proprioceptive Neuromuscular Facilitation) patterns.
- Correct posture and scapular rhythm.
- Stretching and self-mobilization techniques.
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| Subject Doing Pulley Exercise |
Topical Sprays & Gels for Frozen Shoulder
Analgesic Sprays and Gel Examples:
Volini Spray, Moov Spray, Relispray, Volini Gel, Dynapar QPS, Diclofenac Gel, Magnesium Oil, D.F.O Red, etc.
Ingredients:
Diclofenac, Methyl Salicylate, Menthol, Camphor, Magnesium, Capsaicin.
Effect:
- Quick and cooling effect.
- Reduces surface pain and inflammation.
- Reduces capsular inflammation and muscle soreness.
Usage Tip:
Use spray or gel 2–3 times daily on the affected area (do not rub if very sensitive).
Common Medicines used in the Management of Frozen Shoulder
1. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
Examples:
Aceclofenac+Paracetamol, Ibuprofen, Naproxen, Diclofenac, Etoricoxib, Etodelac.
Purpose:
Reduce pain, swelling, and inflammation.
2. Corticosteroids
Examples:
- Oral (e.g., Prednisolone).
- Intra-articular injection (e.g., Triamcinolone, Methylprednisolone).
Purpose:
Decrease capsular inflammation and severe pain.
3. Muscle Relaxants (Optional)
Examples: Tizanidine, Baclofen.
Purpose:
Help reduce muscle guarding and spasms, especially at night.
3. Neuropathic Pain Modulators (if needed)
Examples: Gabapentin, Pregabalin.
Purpose:
For persistent, burning or nerve-related shoulder pain.
4. Supplements (Supportive)
Examples: Collagen, Calcium, Vitamin D3, Magnesium.
Purpose:
Bone and joint support, especially in elderly or post-menopausal patients
Frequently Asked Questions (FAQs)
What causes frozen shoulder?
It can occur spontaneously (idiopathic) or after shoulder injury, surgery, or prolonged immobility. It’s more common in people with diabetes, thyroid issues, or those aged 40–60.
Is frozen shoulder permanent?
No, most people recover fully with proper physiotherapy and sometimes medication. However, it can take months to years.
Is physiotherapy necessary for frozen shoulder?
Yes! Physiotherapy is the cornerstone of treatment, helping restore movement, reduce pain, and prevent long-term stiffness.
Can medication cure frozen shoulder?
Medication like NSAIDs or steroid injections can reduce pain and inflammation but won’t restore movement without exercise therapy.
How long does frozen shoulder last?
It usually progresses over 1 to 3 years, through four stages: pre-freezing, freezing, frozen, and thawing.
Is surgery ever needed for frozen shoulder?
Rarely. In severe cases that don’t improve by conservative management, than procedures like physiotherapy manipulation under anesthesia (MUA) or arthroscopic capsular release may be considered.
Can frozen shoulder affect both shoulders?
Yes, but usually one shoulder at a time. About 20–30% may develop it in the opposite shoulder later.
What are the best exercises for frozen shoulder?
- Pendulum swings
- Wall climbing/stretch
- Towel stretches behind the back
- Passive and active ROM exercises
(Consult with a Physiotherapist, always do exercises under guidance from a physiotherapist)