A Physical Therapy Guide to Frozen Shoulder (Adhesive Capsulitis)
If you are one of the millions of people in the United States who suffer from frozen shoulder, also known as adhesive capsulitis, you may know how debilitating this condition can be. The pain and stiffness can make it difficult to do even the simplest tasks.
This guide will provide an overview of physical therapy for frozen shoulder, including what causes the condition, how it is diagnosed, and the various treatment options available.
Frozen shoulder affects primarily women (up to 70%) and is most prevalent between the ages of 35 and 65 years.1 Keep reading to learn more about how to effectively treat it with a CityPT clinician.
- Understanding Frozen Shoulder
- Symptoms of Adhesive Capsulitis
- What are the Most Common Causes of Frozen Shoulder?
- Diagnosing Frozen Shoulder
- What to Expect from Physical Therapy for Frozen Shoulder
- Preventing Adhesive Capsulitis (Frozen Shoulder)
- Is It Time to Seek Treatment?
The shoulder joint, also known as the glenohumeral joint, is a unique joint that provides a blend of stability and movement to help you with daily tasks like reaching, pushing, pulling, driving, cooking, etc. The shoulder joint's overall stability is reinforced by connective tissue known as the joint capsule. This capsule is intended to keep the joint stable, distribute the biomechanical strain on the joint, and protect it by restricting extreme range of motion.
This joint capsule can become inflamed, stiff, and fibrous, resulting in adhesive capsulitis (frozen shoulder).2 When this occurs, overall shoulder function can be severely limited due to the onset of pain and limited joint range of motion.
The Stages of Frozen Shoulder
There are three distinct stages of frozen shoulder:3
- Freezing: This stage is characterized by the sudden onset of pain in the shoulder. The pain is often worse at night and can make it difficult to sleep. During this stage, the range of motion in the shoulder starts to decrease.
- Frozen: This stage is when the pain starts to lessen, but stiffness and loss of range of motion continue to get worse.
- Thawing: In the final stage, the range of motion in the shoulder starts to improve — typically spontaneously. This final stage can occur 1 to 3 years after initial onset (and even beyond in rarer cases).
All people with frozen shoulders will experience all three stages, but the length of time each stage lasts (and overlaps) will vary. Up to 15% of those with frozen shoulders will experience chronic symptoms and long-term disability beyond 3 years.4
The most common symptom of adhesive capsulitis is pain. This pain may start gradually, but worsen over time as the condition progresses. Pain is often directly in the shoulder, but can also range from the base of the skull to the fingers as well.
Other symptoms can include:
- Stiffness and loss of range of motion in the affected shoulder, particularly with external rotation
- A dull, aching pain that is most often present at rest and at night
- Pain that is worse with movement
- Weakness in the affected arm (more of a secondary symptom due to pain and stiffness)
These symptoms can make it difficult to perform activities of daily living, work tasks, or recreational activities. Tasks that are most difficult include reaching overhead and reaching behind the back.
The underlying cause of frozen shoulder is a hotly debated subject. Plus, a large majority of people suffering from report an insidious onset (no known cause).
Let's review possible correlations that can increase the risk of developing frozen shoulder:1
- Systemic conditions: Diabetes, hypothyroidism, and Parkinson's disease have all been linked to an increased risk of developing adhesive capsulitis.
- Trauma or surgery: Frozen shoulder has been reported following trauma to the shoulder joint (i.e. rotator cuff tear or surgical repair) or upper arm (i.e. fracture).
- Age and gender: Women aged 40 years or older are more likely to develop frozen shoulder than men.
- Immobility: Those who have recently sustained an injury or undergone surgery in the shoulder may be at an increased risk if the arm is placed in a sling for an extended period of time.
If you experience any of the symptoms mentioned above, it's important to consult with your doctor or a CityPT shoulder specialist. They will be able to conduct a thorough examination to determine your functional deficits and rule out other potential shoulder dysfunction or injury.
During the examination, your clinician will assess:
- Medical history
- Range of motion (active and passive)
- Special tests to rule out other shoulder injuries
- Upper body strength and coordination
- Lifestyle changes and your personal goals for recovery
If needed, though not often necessary, imaging may also be ordered to rule out any other potential causes of shoulder pain (if suspected).
The focus for frozen shoulder physical therapy will vary, depending on the stage.
Let's review the top treatment options by stage:
- Stage one (freezing): The focus of treatment will be on pain management. This can be done in a variety of ways, including gentle exercise, manual therapy, dry needling, joint mobilization, modalities, taping, etc.3
- Stage two (frozen): The focus of treatment will be on minimizing range of motion and strength loss, with the goal of gradually returning function to previous levels. This is done with exercise, end-range stretching, shoulder mobilization, neuromuscular training, biomechanical re-education, and modalities as needed for pain relief and exercise tolerance.5
- Stage three (thawing): The focus of treatment will be on regaining range of motion and overall function that was lost during the frozen stage. This will involve a gradual progression of active shoulder range of motion, stretching, and movement.
Regardless of stage, there are a few important treatment modalities that are key to recovery:
- Exercise: Keeping the shoulder as mobile as possible has many benefits for recovery when curated by a movement expert at CityPT — ranging from reduced sensitivity to improved mechanics hat help keep you doing the things you love.
- Patient education: Learning about your condition, the stages of healing, and what you can do to promote your recovery is paramount.
Frozen Shoulder is Self Limiting: What Does This Mean?
Frozen shoulder is a self-limiting condition, meaning that it will eventually resolve on its own. It's important to understand that too much or too little movement with a frozen shoulder can prolong unnecessary suffering.
Overall, this can be a long and frustrating process for patients, as symptoms may persist for months or even years. Currently, other treatment options like opioid use, injections, nerve blocks, and joint distention have not shown long-term effectiveness.3
There are a few things you can do to help prevent adhesive capsulitis or frozen shoulder:
- Keep your shoulder moving: If you have sustained an injury or undergone surgery, it is important to keep your shoulder moving as much as possible within the limits of pain (and while still following your doctor's orders).
- Stay active: There are so many benefits to regular exercise, and maintaining an active lifestyle is one way to help prevent a frozen shoulder and promote general tissue health.
- Manage diabetes: If you have diabetes, it is important to keep your blood sugar levels under control to reduce the risk of systemic inflammation.
- Make healthy lifestyle choices: Eating a nutritious diet, getting enough sleep, managing stress, and supporting your overall mental health are all important for feeling your best and reducing risk of general injury or inflammation.
If you are dealing with shoulder pain, loss of function or feeling frustrated with your shoulder, it may be time to seek out the help of a physical therapist.
At CityPT, we are movement experts who can help you understand your shoulder, identify any roadblocks to recovery, and create a personalized plan to get you feeling better. We'll provide guidance and support every step of the way — from pain management to regaining full range of motion — so that you can get back to doing the things you love.
If you're ready to take the first step, book an appointment with us today. We look forward to meeting you!
This guide is intended for informational purposes only. We are not providing legal or medical advice and this guide does not create a provider-patient relationship. Do not rely upon this guide (or any guide) for medical information. Always seek the help of a qualified medical professional who has assessed you and understands your condition.
Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005; 331:1453-6 ↩
Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: A retrospective cohort study. Phys Ther 2009;89:419-429 ↩
Tedla JS, Sangadala DR. Proprioceptive neuromuscular facilitation techniques in adhesive capsulitis: a systematic review and meta-analysis. Journal of musculoskeletal & neuronal interactions. 2019 Dec 1;19(4):482-91. ↩