Frozen shoulder (adhesive capsulitis): stages, treatment and recovery

In frozen shoulder the tissue around the shoulder joint becomes inflamed, then tighter and shrinks, which causes pain and restricts movement. The NHS says it is often not clear why people get it. The medical name, adhesive capsulitis, refers to the joint capsule, the sleeve of tissue enclosing the ball and socket of the shoulder.

NICE CKS lists frozen shoulder among the common causes of shoulder pain along with rotator cuff disorders, instability, acromioclavicular joint disorders and arthritis, and notes that shoulder pain generally is the third most common musculoskeletal presentation in primary care. Getting the right diagnosis matters, because NICE CKS observes that treatment success probably depends on an accurate assessment of the cause.

NICE CKS describes a recognisable sequence. Pain is the main problem at first and may be worse in bed. The pain gradually improves but stiffness slowly worsens and becomes the main problem. Then the stiffness gradually resolves. The NHS puts the overall timescale as months or years, and NICE CKS calls frozen shoulder usually self-limiting but able to take months to years to resolve.

This sequence is the reason treatment changes with time. In the painful phase the focus is on pain control and keeping the arm moving gently, whereas in the stiff phase stretching and physiotherapy matter more. It also explains why NICE CKS says that when pain has settled and stiffness predominates, a steroid injection is not recommended.

The NHS says frozen shoulder can happen after an injury or surgery that stops you moving your arm normally, and that it is more likely if you have diabetes, although it is unclear why. It advises people with diabetes to keep up their regular check-ups to catch any problems early. NICE CKS says testing for diabetes should be considered for people with frozen shoulder.

The condition is described in NICE CKS as applying from age 16 onwards in its management scenario. Beyond these links, much of the time no clear trigger is found, and the sources do not give a reliable list of other risk factors, so none is given here.

Assessment is usually clinical. NICE CKS says a history and examination of the shoulder, including active and passive movements, are the basis, with the neck, arms and chest also examined for referred causes. Investigations are not usually indicated in primary care, but X-rays should be considered after trauma, if there is little improvement with conservative treatment, if symptoms last more than four weeks, if there is severe pain or restriction of movement, or if arthritis is suspected. Blood tests are done where inflammatory arthritis, polymyalgia rheumatica or malignancy is suspected.

NICE CKS lists red flags that need urgent referral, including sudden loss of ability to raise the arm, any shoulder mass or swelling, a red, hot painful joint with fever, loss of rotation after trauma suggesting dislocation, and new inflammation in several joints. Pain referred from the neck, heart or lungs is also a recognised cause of shoulder pain, which is why chest symptoms alongside shoulder pain need prompt attention.

The NHS describes treatment in three steps: pain relief with paracetamol, then an NSAID such as ibuprofen if suitable; stronger pain relief or a steroid injection if needed; and getting movement back with gentle exercises, followed by physiotherapy if pain continues. It says stronger pain relief is usually only used for a short time because of side effects. These medicines are mentioned for information, and the choice depends on your medical history.

NICE CKS describes physiotherapy as usually lasting 6 weeks, with a further 6 weeks if there is improvement, using education, exercises, manual therapy, heat or electrotherapy. The NHS says physiotherapy usually lasts at least 6 weeks and includes stretching, strengthening, posture advice and sometimes steroid injections. NICE CKS also describes an intra-articular corticosteroid injection as an option early in the course if progress is slow, and lists possible adverse effects including infection, tendon rupture, a flare of pain after the injection and a temporary rise in blood sugar in people with diabetes. It advises resting the joint for 24 hours afterwards.

NICE CKS notes that a small proportion of people are referred to orthopaedics, where options include manipulation of the shoulder under general anaesthetic and capsular release, and that evidence for both conservative and surgical treatments is limited. A step-up approach, taking account of symptoms and impact on work and leisure, is advised.

• Keep moving the shoulder gently, because the NHS says keeping it still will make the pain worse.

• Use a heat pack or wrapped hot water bottle for up to 20 minutes at a time.

• Do not invent strenuous exercises or use gym equipment, which the NHS says can make the pain worse.

• In bed, support the arm with pillows to avoid rolling onto the affected shoulder (NICE CKS).

The NHS says the pain and stiffness will usually go away eventually, even though it can take months or years. NICE CKS reports that overall shoulder pain has a variable outlook depending on the cause, and that around 40 to 50% of people with shoulder pain still have pain 6 to 12 months after consulting a primary care clinician, which is a reminder that follow-up matters if progress stalls.

Practical adjustments can help meanwhile. NICE CKS notes that advice may include time off work or away from leisure activities while the shoulder is painful, and the NHS suggests going back to the GP or physiotherapist if you are still in pain after your sessions.

On the NHS, frozen shoulder is usually managed in primary care with analgesia, physiotherapy and, where available, injection, as NICE CKS describes. The NHS notes that many physiotherapists work at GP surgeries and that in some areas you can see a physiotherapist without a GP referral, and that physiotherapy can also be obtained privately.

Private care typically offers quicker access to a physiotherapist, an ultrasound-guided injection or an orthopaedic opinion. NICE CKS stresses that if orthopaedic referral is indicated it should not be delayed, and that decisions on procedures such as manipulation or capsular release should come from a specialist after conservative treatment has been tried. The same stepwise principle applies in both settings.