8/13/2019 Patient education: Frozen shoulder (Beyond the Basics) - UpToDate

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Author: Tore A Prestgaard, MD

Section Editor: Karl B Fields, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2019. | This topic last updated: May 28, 2019.

FROZEN SHOULDER OVERVIEW

Frozen shoulder is a condition that causes shoulder pain and limits the shoulder's range of motion.
The limitation in movement affects both active and passive range of motion. That means that your
movement is restricted at the shoulder joint both when you try to move your own arm and when
someone else (such as your doctor) tries to move your arm for you.

Frozen shoulder is also called "adhesive capsulitis," "painful stiff shoulder," and "periarthritis." We
will use the term "frozen shoulder" throughout this article.

EPIDEMIOLOGY

Frozen shoulder is a fairly common condition in the general population. The condition is most
common in people in their 50s and 60s and rarely affects anyone younger than 40. Women are
more often affected than men.

Frozen shoulder usually affects only one shoulder (left or right) and gets better on its own, but it can
last two to three years or even longer. People who get frozen shoulder on one side can go on to
develop it on the other.

FROZEN SHOULDER CAUSES

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Frozen shoulder often happens as a result of a shoulder injury (such as a rotator cuff tear), a bone
fracture affecting the shoulder, or shoulder surgery. It can also happen after people have other types
of surgery, such as heart or brain surgery.

Frozen shoulder can also happen without a preceding injury and tends to preferentially affect people
with certain diseases and conditions. People with diabetes, for example, have an increased risk of
developing frozen shoulder. In fact, 10 to 20 percent of people with diabetes develop the condition.

Frozen shoulder also seems to be more common among:

● People who have been immobilized for prolonged periods

● People who have had a stroke
● People who have Parkinson disease
● People who have taken antiretroviral medications (particularly medications called protease
inhibitors) to treat HIV infection
● People who have diseases affecting the thyroid gland, a gland in the neck that produces
hormones that control how the body uses and stores energy

Experts do not know for sure what causes frozen shoulder, but they suspect it develops when the
joint becomes inflamed and scar tissue forms. As this happens, the tissues inside the joint shrink
and harden, making the shoulder harder to move.

FROZEN SHOULDER SYMPTOMS

People who have frozen shoulder often go through three phases of symptoms:

● The first phase lasts two to nine months and involves diffuse, severe, and disabling shoulder
pain that is worse at night. During this phase, the shoulder becomes increasingly stiff.

● The second (intermediate) phase lasts 4 to 12 months. During this phase, the shoulder
becomes very stiff and has limited mobility, but the pain gradually lessens.

● The third (recovery) phase lasts 5 to 24 months. During this phase, people gradually regain
range of motion.

If you have frozen shoulder, the pain and stiffness it causes may seriously interfere with your ability
to do everyday tasks, such as dress and bathe, or even work. Even once the pain of frozen
shoulder starts to improve, the shoulder stiffness may still be quite limiting. For example, the
condition might impede you from reaching overhead, to the side, or across your chest; or from

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rotating your arm all the way around from front to back. This could make it impossible for you to
scratch your back or put on a coat.

FROZEN SHOULDER EVALUATION AND DIAGNOSIS

If you have symptoms of frozen shoulder, your health care provider will examine you to learn what
movements elicit symptoms and how limited your mobility is. As part of the evaluation, he or she will
likely ask to watch as you move your own arm and shoulder (called active range of motion), and
also explore what you feel if he or she moves your arm and shoulder for you (called passive range
of motion).

People with frozen shoulder have limitations in both active and passive range of motion (picture 1).
They also tend to have the most trouble rotating their arm or shoulder outward, away from their
body, and putting the affected arm behind their back. When they reach the limit of their range of
motion, the problem is not just that moving beyond a certain point is painful; it actually feels as
though the arm is stuck.

In most cases, health care providers can tell when a person has frozen shoulder based on the
results of the physical exam. Still, in some cases, it's hard to tell the difference between frozen
shoulder and other shoulder problems, such as a painful or torn rotator cuff. If your health care
provider is uncertain about your diagnosis, he or she might refer you to an orthopedist or physiatrist
(a doctor who specializes in muscle and joint problems).

Injection test — An injection test can help determine whether a person has frozen shoulder or
another shoulder condition. The test involves injecting the person's shoulder with an anesthetic. In
people with frozen shoulder, an injection test will not improve mobility, whereas in people with other
shoulder problems, it usually does.

Imaging — People with suspected frozen shoulder very rarely need imaging tests such as x-rays,
magnetic resonance images (MRIs), or ultrasounds. Still, health care providers do sometimes order
them to make sure other problems are not causing the symptoms.

FROZEN SHOULDER TREATMENT

In most cases, frozen shoulder gets better on its own, even without treatment. However, there are
cases in which people never regain the full range of motion they had before.

There are a few treatment options for frozen shoulder, which can be combined, but there's no
obvious course of action that is right for everyone. Treatment options include physical therapy,
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medications to manage pain and inflammation, and – in extreme cases – surgery.

If you are being treated for frozen shoulder, remember that recovery can be a slow process and that
you need to give treatment time to work. If you are in pain, you can take nonprescription pain
medications, such as acetaminophen (sample brand name: Tylenol), or medications called
nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen (sample brand names: Advil,
Motrin). If your pain is severe and does not get better with these options, your health care provider
may offer you a prescription-strength painkiller.

Exercises to help recovery — Once the initial pain of frozen shoulder lessens, your health care
provider might want you to do certain exercises to improve your shoulder mobility. Depending on
your situation, your health care provider might recommend that you see a physical therapist or
suggest that you do these exercises on your own. Start out slow, and do not push yourself too much
at first. Let pain be your guide. If an exercise hurts too much, modify it or stop doing it. Later, as
your pain subsides and your mobility improves, you can try to push yourself – and your arm and
shoulder – further.

During the first two to three months of recovery, rest your shoulder and do gentle range-of-motion
exercises (picture 2).

As you start to get better, you can add in more exercises that build strength, but don't do exercises
that cause undue pain. Some strength-building exercises are shown in the movies:

● Abduction-adduction with exercise band (movie 1)

● Flexion extension with exercise band (movie 2)

● Seated external rotation with elbow resting on table (movie 3)

Steroid pills and injections — Medications called "glucocorticoids," known commonly as

"steroids," can provide some relief from frozen shoulder symptoms for several weeks up to a few
months. When using steroids to treat frozen shoulder, health care providers typically inject them
directly into the shoulder joint. They tend not to prescribe steroids in pill form for frozen shoulder
because the pills can cause widespread side effects, and because injections tend to be more
effective. Still, even the injections provide relief for a limited time and work best if given early in the
development of symptoms. What's more is that it's not always easy to get the needle into the right
spot in the joint, so the medication does not always end up where it is needed.

Another treatment, called "hydrodilatation," involves injecting the shoulder with glucocorticoid and
saline to expand the joint, and this often provides effective short-time relief. However, it remains
unclear whether relief stems from the glucocorticoid or dilation of the joint.

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Unproven treatments — There are some treatments of frozen shoulder that remain unproven,
such as laser therapy.

Surgery — People who do not get better with other treatment options can undergo surgery to
"release" the shoulder joint, but experts recommend waiting at least a year before considering
surgery. In some cases, surgery can help, but surgery also carries risks and can cause damage of
its own.

SUMMARY

● Frozen shoulder is a painful condition that limits the shoulder's range of motion. The condition
can happen on its own or as a result of an injury, such as a rotator cuff tear, and it usually gets
better on its own.

● Experienced doctors can usually diagnose frozen shoulder based on the symptoms it causes
and how it limits movement. They do not usually need to do imaging or other tests to diagnose
the condition.

● There is no clear recommendation on how to treat frozen shoulder, but we believe it is best to
rest the shoulder at first and do gentle shoulder mobility exercises. Later, when the symptoms
start to improve, people can do increasingly ambitious range-of-motion exercises.

● In people with moderate to severe symptoms, steroid injections directly into the shoulder joint
usually provide short-term relief.

● Only people who have had symptoms for a year or more and are not getting better should
consider surgery.

WHERE TO GET MORE INFORMATION

Your health care provider is the best source of information for questions and concerns related to
your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics
for patients, as well as selected articles written for health care professionals, are also available.
Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who want a general

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overview and who prefer short, easy-to-read materials.

Patient education: Frozen shoulder (The Basics)

Patient education: Rotator cuff injury (The Basics)
Patient education: Separated shoulder (The Basics)
Patient education: Shoulder impingement (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are best for patients who want in-depth information
and are comfortable with some medical jargon.

Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)

Patient education: Rotator cuff tendinitis and tear (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and
other health professionals up to date on the latest medical findings. These articles are thorough,
long, and complex, and they contain multiple references to the research on which they are based.
Professional level articles are best for people who are comfortable with a lot of medical terminology
and who want to read the same materials their doctors are reading.

Evaluation of the adult with shoulder complaints

Frozen shoulder (adhesive capsulitis)
Radiologic evaluation of the painful shoulder in adults
Shoulder impingement syndrome

The following organizations also provide reliable health information:

● National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

● American Academy of Orthopaedic Surgeons

(http://orthoinfo.aaos.org/)

● National Institute of Arthritis and Musculoskeletal and Skin Disease

(www.niams.nih.gov)

● American Physical Therapy Association

(www.apta.org)

● Arthritis Foundation

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(www.arthritis.org)

[1-5]

REFERENCES

1. Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: the effectiveness of conservative and
surgical interventions--systematic review. Br J Sports Med 2011; 45:49.

2. Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis.
Cochrane Database Syst Rev 2006; :CD006189.

3. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane
Database Syst Rev 2003; :CD004016.

4. Buchbinder R, Green S, Youd JM, et al. Arthrographic distension for adhesive capsulitis
(frozen shoulder). Cochrane Database Syst Rev 2008; :CD007005.

5. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane

Database Syst Rev 2003; :CD004258.

Topic 710 Version 15.0

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