Frozen shoulder

What is 'frozen shoulder'?

Frozen shoulder, also known as adhesive capsulitis, is a condition that affects the shoulder joint, causing pain and stiffness. Frozen shoulder progresses gradually and limits the range of motion in the shoulder. It affects approximately 2% to 5% of the general population and is most common among individuals aged 40 to 70 years.

Causes

The exact cause of frozen shoulder is unknown. It may be associated with certain medical conditions such as diabetes, thyroid disorders, or a stroke. It can also occur after a previous shoulder injury or surgery.

Symptoms

1. Pain: Persistent shoulder pain, often increasing at night.
2. Limited range of motion: Difficulty in moving your shoulder, particularly when lifting your arm, resulting in a reduced ability to perform daily tasks such as washing your hair and drying your back.

Diagnosis

A frozen shoulder is generally diagnosed by taking a history of the symptoms and examining the shoulder to check the range of movement. Basic imaging such as a plain x- ray is done to exclude other diagnoses, such as osteoarthritis. The x-ray appearances will be normal with a frozen shoulder.

Treatment options

1. Pain relief: Over-the-counter or prescribed medications may manage pain and inflammation.
2. Physiotherapy: Specific exercises and stretches to improve shoulder mobility and strength.
3. Heat and ice therapy: Applying heat or ice can help alleviate pain and reduce inflammation, whichever feels better for you.
4. Suprascapular nerve block injection: A steroid injection performed at the same time as your initial assessment in the clinic by a healthcare provider that you have already met. It works by blocking pain signals from a nerve in the back of the shoulder (suprascapular nerve), providing pain relief. Movement often takes several more months to return and repeated injections may be required.
5. Hydrodistension: In some cases where symptoms persist despite the above measures, sterile water or saline with steroid can be injected into the joint under ultrasound or x-ray guidance to stretch the joint capsule and expand it. This will be carried out at a later date several weeks after your clinic appointment.
6. Rarely - Surgical management:

• Manipulation under anaesthesia (MUA): A procedure where the arm is manipulated to break up adhesions and improve mobility.
• Arthroscopic capsular release: This minimally invasive surgical procedure involves cutting through the tight joint capsule to improve range of motion.

Surgery is rarely used as studies have not shown benefit over the non-surgical methods, so it is only used when the non-surgical methods have not helped to relieve symptoms.

Home exercises

Try to do these exercises little and often throughout the day to maintain or improve shoulder mobility.

Start with five repetitions of each exercise and increase up to 20 repetitions as you are able. Mild discomfort while exercising is expected as you will be stretching your shoulder. If you find any exercise is more painful than this, leave it and try it again later that day. You should find that all exercises become more comfortable the more you practice them.

1. Shoulder blade position

• Circle your shoulders backwards.
• Gently draw the shoulder blades back and down.
• Try to keep the neck relaxed and don’t squeeze the shoulder blades together too hard.
• Hold for 30 seconds and repeat five times.

Once you have achieved this, you can progress to the following exercises. Maintain the alignment of the shoulder blades while you do them.

2. Shoulder rolls

• While sitting or standing, roll your shoulders forwards and backwards.
• Make the movement as big as possible.
• Repeat 10 to 20 times.

3. Pendulum movements

• Stand leaning on a table with one hand, let your affected arm hang relaxed straight down.
• Swing your arm forwards and backwards and then circle it, as if drawing a circle on the floor. Make the movement as large as possible.
• Change direction.
• Repeat 10 to 20 times each direction.

4. Forward stretch

• Stand with your hands on a table. Slowly walk backwards letting your body lean forwards and keeping your hands on the table. You can bend the knees.
• Think about bringing your armpits gently down towards the floor.
• Repeat this five times. Hold for 15 to 20 seconds.

5. Elevation stretch

• Lie on your back.
• Lift your affected arm over your head and gently push it down towards the floor, assisting with your other hand.
• Keep the back of your ribcage and lower back against the floor and try not to arch your back.
• Hold for five to ten seconds and repeat five times.

6. Outwards rotation stretch

• Sit with your elbows bent and a towel between your elbow and trunk.
• Hold a stick and push the hand of the affected arm out to the side, whilst keeping your elbow close to the body.
• Repeat this five times. Hold for ten seconds at the end of the movement.

7. Wall slides – forwards and sideways

• Place a towel on the wall with your unaffected side and then place the hand of your affected side on the towel. Drop the unaffected side.
• Standing facing the wall, step forwards and slide the towel upwards with your affected side.
• Step in towards the wall and bring your armpit as close to the wall as you can.
• Then step back and slide the towel down again.
• Turn and stand with your affected arm side-on to the wall.
• Step sideways towards the wall as you slide the towel upwards, bringing your armpit as close as possible to the wall.
• Then step sideways, away from the wall and slide the towel down again.
• Repeat five to ten times.

8. Hand behind back stretch

• Place your affected hand behind your back and hold with your other hand.
• Gently take your affected hand up your back, helping with the other hand.
• You can also try gently pushing the hand of your affected side away from your back, using your other hand to help.
• Alternatively, you can assist the movement with a towel if easier.
• Repeat five to ten times.

9. Assisted sideways stretching with stick

• Hold a stick in your hands.
• Lift the affected arm up to the side and assist by pushing with your other hand.
• Hold at the top of the movement for five seconds and then lower down.
• Repeat ten times.

Expected course of frozen shoulder

• Improvement over time: Given enough time, frozen shoulder should resolve.
• Patience is key: Recovery may take several months to years, and progress can be slow. Be patient and stay committed to your exercise routine.
• Most recover well: The majority of individuals with frozen shoulder achieve significant relief with appropriate care and management.

When to seek medical attention

If you experience sudden and severe shoulder pain or if your symptoms worsen despite following the recommended treatments, seek medical attention promptly.

MyChart

We would encourage you to sign up for MyChart (opens in a new tab). This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device. More information is available on our website.

References/sources of evidence

• BESS/BOA Patient Care Pathways. Frozen Shoulder. Shoulder & Elbow (2015)
• UK FROST Trial. The Lancet (2020)
• Intra-articular Steroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis. American Journal of Sports Medicine (2016)
• The Impact of Suprascapular Nerve Interventions in Patients with Frozen Shoulder: A Systematic Review and Meta-Analysis. Journal of Bone and Joint Surgery (2021)
• Distension arthrogram in the treatment of adhesive capsulitis has a low rate of repeat intervention. Bone and Joint Journal (2020)
• Randomized controlled trial of supervised physiotherapy versus a home exercise program after hydrodilatation for the management of primary frozen shoulder. Journal of Shoulder and Elbow Surgery (2017)

Privacy and dignity

Same-sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one-to-one care is required.