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The Stiff Shoulder, is it Frozen?

A stiff shoulder is when there is loss of the full range of movement of the shoulder. Both controlled movement (active) as well as uncontrolled movement (passively moved by an external force) are limited.


Main diagnosis of a stiff shoulder:

  • Frozen shoulder
  • Glenohumeral Joint Osteo Arthritis (generally older >50 and gradual progression of pain and stiffness)
  • Cervicogenic shoulder pain (referred pain from neck causing stiffness)
  • Fracture – preceded by trauma
  • Neoplasm (cancer)
  • Locked dislocation (posterior) – usually preceded by trauma
  • Diabetic shoulder
  • Osteonecrosis (overuse of steroids)
  • Abnormal bony anatomy
  • Pseudo frozen shoulder – muscle guarding and fear


The Frozen Shoulder

The most common reason for a stiff shoulder and the most limiting shoulder condition (those that have suffered, know).


Common signs:

  • Normal x-ray
  • Functional restriction of movement (active and passive)
  • Severe shoulder pain

Frozen shoulder pain


Frozen shoulder starts as pain. That pain then becomes severe and eventually stiffness sets in.

A constant nagging pain is felt over the outside of the shoulder (over deltoid muscle) and might throb down the arm. All movements aggravate the pain and a rapid movement (jerk) even more so. Night pain is present regardless of the position you adopt in bed but especially lying on the affected shoulder. Therefore, lack of sleep is also a “sign”. Lack of sleep, in turn contributes to the pain.

Pins and needles or numbness are NOT present. The pain is not dependent on the position the shoulder is held in and anti-inflammatories are not effective in relieving pain.

Frozen shoulder can be very debilitating. It affects work, hobbies, dressing etc. It impacts on quality of daily life.


Understanding the Frozen Shoulder (FS)


Frozen shoulder is divided into 2 groups – primary and secondary.

Primary is the type where we cannot pinpoint a cause, secondary is when there is a possible contributing factor attached to the development of frozen shoulder such as surgery, illness, depression or diabetes.


Primary type, 5% of the general population. (Kelley et al, 2013)

Secondary type, 38%. (Kelley et al 2013)

Prevalence amongst diabetics is 46%. (Juel et al, 2017)

In summary, it is much more common that one would expect.

Possible contributing factors:

  • Age 40-65
  • Diabetes especially insulin dependent
  • Hyper and hypothyroidism
  • If you have had a Dupuytren’s contracture
  • Symptoms of metabolic syndrome are present (visceral obesity, insulin resistance, low HDL- cholesterol, hypertension)
  • Systemic inflammation
  • Post-operative (after shoulder surgery)
  • Family history has some linkage to frozen shoulder. 4x more likely to develop it.
  • Being overweight/obese has some linkage to FS.
  • Menopause has been linked to FS and possibly more women than men get it.
  • Parkinson’s disease
  • Stroke
  • Tuberculosis and some other pulmonary disorders
  • Emotional and psychological links


How does Frozen shoulder “work”?


It starts with pain.

Early on, the body may experience a hyper inflammatory response. This may be caused by an event or nothing obvious may trigger it. Immune reaction to the inflammation causes synovitis (highly sensitized).

This is very painful. And often a vicious cycle of immune reaction and more inflammation starts.


Tissues become fibrotic.

The vicious immune/inflammation cycle then causes tissues to adjust, becoming more contractile in nature.


Stiffness sets in.

The contractile tissue creates a contracture inside the shoulder capsule severely limiting movement. By this stage inflammation has calmed down and stiffness is the dominant factor.


Why is it so painful at night?


The thinking is that the rise in melatonin levels as we head to bed may be linked to the night pain experienced with frozen shoulder. We need melatonin to promote sleepiness and it is triggered by reduced light at the end of the day.


Frozen shoulder night pain


Does Frozen shoulder resolve on its own?


Yes, FS naturally resolves within 15-20 months after diagnosis without intervention. (Reeves, B, 1975)

However, some people (up to 50%) will still have some mild to moderate symptoms after 4 -7 years. They have an improvement but not full resolution. (Hand et al, 2008).

Most improvements happen in the first few months up to one year of the condition. Mild to moderate symptoms may persist but here is a lot someone can do in the meantime while FS follows its natural course. Some simple examples are adjusting lifestyle behaviours that could contribute like eating less inflammatory foods, improving overall health such as better sleep hygiene and exercise, developing emotional resilience.


Pseudo Frozen shoulder


This is when a stiff and painful shoulder behaves exactly like a frozen shoulder, however, the fibrosis and contracture of the capsule are not present. Unfortunately, this can only be truly tested under anaesthetic but it is much easier to resolve over a shorter time.


This phenomenon occurs after an injury or inflammation is present but is stiffness is rather due to muscle guarding, fear of movement, anxiety, pain inhibition or weakness of muscles.


A telltale sign is if there is a “miraculous” improvement within a very short time after an intervention like a cortisone injection or one manual treatment.


How do I manage Frozen Shoulder?


More than 90% of people respond well to non-surgical treatment.

Therefore, a good approach is the following (Lewis, J. 2015):


1. First get an accurate diagnosis as soon as possible

See a physiotherapist and if they feel they need more information, they will refer you on.


2. Gain insight into the natural history of the condition

This article should provide some of the answers but seeing a physiotherapist will help you find the answers especially finding contributing factors than can be changed.


3. Understand what you can do to get it better i.e. self-management techniques.

A physiotherapist can guide you in this space. The starting point will be determined by how irritable your shoulder pain is and how much activity you can tolerate. Determining if pain or stiffness is more dominant, directs advice on daily task adjustment or need for treatment. Provision of individualised exercises. A group class setting has been shown to be the most effective although a supervised or home exercise programme is helpful too.


4. Is there any active treatment that can help?

This is based on shoulder irritability, stiffness or pain dominance. A physio can be very beneficial in helping direct and understand options.


Active treatment supported by evidence.


1. Exercise therapy/movement (loading) based on the irritability level of the shoulder.

A physio can help manage this programme, supervise and progress it as needed. General exercise that you enjoy like walking, yoga (if manageable), cycling, are also helpful in reducing the pain. General exercise will help the body cope better with the inflammatory process of the frozen shoulder as well as the emotional aspect of pain management. (Lowe et al, 2019)

Frozen shoulder exercise

3. Corticosteroid injection followed by supervised exercise therapy

This treatment option seems to be better than injection or the exercise on its own (moderate evidence). (Lowe et al, 2019)


3. Hydrodilatation injection and intra articular steroid injection

Both are good for pain relief and improved function in the short to medium term (3-6 months) but you may have more benefit from exercise therapy over the long term. 2 injections are NOT better than 1. (Saltchev et al, 2018)

Frozen shoulder injection

4. Manipulation under anaesthetic (MUA)

Costly and effective however, it is not more superior than home exercise in the short, medium or long term. (Brealey et al, 2017).


5. Capsular release

This is not superior to MUA. (Brealey et al, 2017)

Frozen shoulder surgery

Medical Disclaimer

This content is for education and information purposes only. It is not intended to replace professional medical advice, diagnosis or treatment. If you have any health concerns or pain, please contact your local healthcare provider directly.



  1. Juel, N. G., Brox, J. I., Brunborg, C., Holte, K. B., & Berg, T. J. (2017). Very High Prevalence of Frozen Shoulder in Patients With Type 1 Diabetes of >/=45 Years’ Duration: The Dialong Shoulder Study. Arch Phys Med Rehabil, 98(8), 1551-1559. doi:10.1016/j.apmr.2017.01.020
  2. Kelley, M. J., Shaffer, M. A., Kuhn, J. E., Michener, L. A., Seitz, A. L., Uhl, T. L., . . . McClure, P. W. (2013). Shoulder pain and mobility deficits: adhesive capsulitis. J Orthop Sports Phys Ther, 43(5), A1-31. doi:10.2519/jospt.2013.0302
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  10. Brealey, S., Armstrong, A. L., Brooksbank, A., Carr, A. J., Charalambous, C. P., Cooper, C., . . . Rangan, A. (2017). United Kingdom Frozen Shoulder Trial (UK FROST), multi-centre, randomised, 12 month, parallel group, superiority study to compare the clinical and cost-effectiveness of Early Structured Physiotherapy versus manipulation under anaesthesia versus arthroscopic capsular release for patients referred to secondary care with a primary frozen shoulder: study protocol for a randomised controlled trial. Trials, 18(1), 614. doi:10.1186/s13063-017-2352-2
  11. Hand, C., Clipsham, K., Rees, J. L., & Carr, A. J. (2008). Long-term outcome of frozen shoulder. J Shoulder Elbow Surg, 17(2), 231-236. doi:10.1016/j.jse.2007.05.009

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