DISEASES & CONDITIONS

Frozen Shoulder
Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder
becomes very hard to move.

After a period of worsening symptoms, frozen shoulder tends to get better, although full recovery may take up to 3
years. Physical therapy, with a focus on shoulder flexibility, is the primary treatment recommendation for frozen
shoulder.

Frozen shoulder most commonly affects people between the ages of 40 and 60, and occurs in women more often than
men. In addition, people with diabetes are at an increased risk for developing frozen shoulder. 

Anatomy
Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade
(scapula), and your collarbone (clavicle).

The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the
shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

The shoulder capsule surrounds the shoulder joint and rotator cuff
tendons.

Reproduced and modified from The Body Almanac. (c) American Academy of Orthopaedic
Surgeons, 2003.

Description
In frozen shoulder, the shoulder capsule thickens and becomes stiff and tight. Thick bands of tissue — called adhesions
— develop. In many cases, there is less synovial fluid in the joint.

The hallmark signs of this condition are severe pain and being unable to move your shoulder -- either on your own or
with the help of someone else. It develops in three stages:

Stage 1: Freezing

In the "freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion.
Freezing typically lasts from 6 weeks to 9 months.

Stage 2: Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the
"frozen" stage, daily activities may be very difficult.

Stage 3: Thawing

Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength
and motion typically takes from 6 months to 2 years.

In frozen shoulder, the smooth

tissues of the shoulder capsule
become thick, stiff, and
inflamed.

Cause
The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation.
A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes. The reason for this is not known. In
addition, diabetic patients with frozen shoulder tend to have a greater degree of stiffness that continues for a longer
time before "thawing."

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism,
hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to
surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure
prescribed to prevent frozen shoulder.

Symptoms
Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when
you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Doctor Examination
Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder.

Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with
the motion. The range of motion when someone else moves your shoulder is called "passive range of motion." Your
doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range
of motion"). People with frozen shoulder have limited range of motion both actively and passively.

Your doctor will test the range of motion in your shoulder.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American
Academy of Orthopaedic Surgeons, 2010

Imaging Tests

Other tests that may help your doctor rule out other causes of stiffness and pain include:

X-rays. Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder,
such as arthritis.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of soft tissues. They are not
required to diagnose frozen shoulder, however, they may help to identify other problems in your shoulder, such as a
torn rotator cuff.

Treatment
Frozen shoulder generally gets better over time, although it may take up to 3 years. The focus of treatment is to control
pain and restore motion and strength through physical therapy.

Nonsurgical Treatment

Most people with frozen shoulder improve with relatively simple treatments to control pain and restore motion.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder
joint.
Hydrodilatation. If your symptoms are not relieved by other nonsurgical methods, your doctor may recommend
hydrodilatation. This procedure involves gently injecting a large volume of sterile fluid into the shoulder joint to
expand and stretch the shoulder joint capsule. Hydrodilatation is conducted by a radiologist who uses imaging to guide
the placement of fluid. 

Physical therapy. Specific exercises will help restore motion. These may be done under the supervision of a physical
therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes
heat is used to help loosen the shoulder up before stretching. Below are examples of some of the exercises that might
be recommended.

External rotation — passive stretch. Stand in a doorway and bend your affected arm's elbow to 90 degrees to
reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30
seconds. Relax and repeat.

External Rotation - Passive Stretch

Reproduced and modified from JF Sarwark, ed: Essentials of

Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2010.

Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift
your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start
position. Relax and repeat.

Forward Flexion - Supine Position

Reproduced and modified from JF Sarwark, ed: Essentials of

Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2010.

Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without
causing pain. Hold for 30 seconds. Relax and repeat.
 Crossover Arm Stretch

Reproduced and modified from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 2010.

Surgical Treatment

If your symptoms are not relieved by therapy and other conservative methods, you and your doctor may discuss
surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments,
and the risks involved with surgery.

Surgery for frozen shoulder is typically offered during "Stage 2: Frozen." The goal of surgery is to stretch and release
the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder
arthroscopy.

Manipulation under anesthesia. During this procedure, you are put to sleep. Your doctor will force your shoulder to
move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of
motion.

Shoulder arthroscopy. In this procedure, your doctor will cut through tight portions of the joint capsule. This is done
using pencil-sized instruments inserted through small incisions around your shoulder.

In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have
good outcomes with these procedures.

These photos taken through an

arthroscope show a normal shoulder joint
lining (left) and an inflamed joint lining
affected by frozen shoulder.

Recovery. After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery.
Recovery times vary, from 6 weeks to 3 months. Although it is a slow process, your commitment to therapy is the most
important factor in returning to all the activities you enjoy.

Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and improved
range of motion. In some cases, however, even after several years, the motion does not return completely and some
degree of stiffness remains. Diabetic patients often have some degree of continued shoulder stiffness after surgery.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.
 Information on this topic is also available as an
OrthoInfo Basics PDF Handout.

For more information:

Basics Handouts
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Last Reviewed
March 2018

Contributed and/or Updated by

George S. Athwal, MD

Benjamin Widmer, MD

Peer-Reviewed by
Stuart J. Fischer, MD

J. Michael Wiater, MD

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an

educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should

consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website.