Frozen shoulder

Synonym: adhesive capsulitis of the shoulder

What is frozen shoulder?

Frozen shoulder is one of the most common causes of intrinsic shoulder pain. It is a glenohumeral disorder and can occur in one shoulder or both shoulders simultaneously. Thickening and contraction of the glenohumeral joint capsule and formation of adhesions cause pain and loss of movement.¹

Frozen shoulder can occur:

• Spontaneously.

• Following rotator cuff lesions/injury.

• In conditions causing immobility - eg, after a cerebrovascular accident or plaster immobilisation.

See the separate Shoulder pain and Shoulder examination articles.

• Adhesive capsulitis occurs in approximately 2-5% of the population with a peak incidence between 40 and 70 years of age.

• It is more common in females and bilateral in 20-30% of cases. When unilateral, the non-dominant hand is more commonly affected.

• The incidence of adhesive capsulitis is more common in those with diabetes and thyroid disorders - outcomes are worse in those with a longer duration of diabetes.

The main symptoms are pain and stiffness, caused by formation of adhesive or scar tissue in the glenohumeral joint.

• There is usually a gradual onset of severe pain in the shoulder, which is then followed by stiffness.

• Restriction of all shoulder movements, both active and passive.

• Inability to sleep on the affected side.

• Restriction of activities of daily living due to impaired external rotation - eg, driving and dressing.

• There tends to be three phases:

  • Phase 1 - severe generalised pain associated with stiffness. Daily activities are limited (eg, putting on a jacket). It can last up to nine months.

  • Phase 2 - pain usually gradually subsides but the shoulder is stiff. Movement can become more limited. External rotation is usually very limited. This phase lasts between 4-12 months.

  • Phase 3 - the shoulder becomes less stiff. There is an increase in the range of movement. This phase usually lasts 1-3 years.

Stiffness, pain and loss of motion with insidious onset are usually the major symptoms.

• The diagnosis is clinical:

  • The whole shoulder joint may be tender to palpation.

  • The main diagnostic test is the inability to do passive external rotation.

• X-rays are usually only necessary if the presentation is atypical or the patient is not responding to treatment - they are often normal.

• Consider other causes of shoulder pain.

• Blood tests and radiography should only be performed if red flag symptoms are present. For a list of these, refer to the separate Shoulder pain article.

Consider referral to secondary care if pain and significant disability are present for more than six months despite appropriate conservative management and always refer if there is diagnostic doubt.

Despite over a hundred years of treating this condition the most efficacious treatments are still largely unclear. A holistic approach to treatment should be used, considering psychological and psychosocial factors.

• The first stage is analgesia - paracetamol as first-line with non-steroidal anti-inflammatory drugs (NSAIDs) second-line, provided there are no contra-indications. Use of a transcutaneous electrical nerve stimulation (TENS) machine may also be helpful.

• Encourage early activity.

• Physiotherapy with joint mobilisation combined with stretching exercises have been shown to be better than stretching exercise alone in terms of external rotation, abduction range of motion and function score, although a 2023 systematic review was limited by lack of consistency in study designs and found that most of the benefits did not reach statistical significance. The 2025 British Elbow and Shoulder Society patient care pathway rates physiotherapy as 'likely to be beneficial'.⁶⁷

• Passive mobilisation and capsular stretching are two of the most commonly used techniques for physiotherapy.

• Injection with corticosteroids:

  • This can reduce pain and duration of symptoms in the early stages and the 2025 British Elbow and Shoulder Society patient care pathway rates injection as 'likely to be beneficial'.⁶

  • It should not be done if a previous such injection has shown no or minimal benefit, or if the patient has passed the pain stage and entered the stiffness stage.

  • Care must be taken to monitor blood sugar after the injection in patients with diabetes (they may be raised for 1-2 days) and the balance of risks and benefits should be carefully considered in those with poorly controlled diabetes.⁸

• A 2012 Cochrane review found no benefit to an ultrasound guided injection versus one without such guidance. More recent smaller studies are divided, with some finding more pain reduction with ultrasound guidance and others finding no difference - the 2025 British Elbow and Shoulder Society patient care pathway also found that this made no difference. An injection should therefore not be delayed to wait for ultrasound guidance to be available.⁹¹⁰¹¹

• Oral steroids are not recommended, although they may reduce pain in the very short term.⁸

• Surgical options include manipulation under anaesthesia and arthroscopic capsulotomy but are generally reserved for cases where non-surgical options have failed.²

Long-term pain and shoulder stiffness are possible complications.

• 80 - 90% of patients with spontaneous frozen shoulder have been shown to recover to normal levels of function and movement by two years without any treatment, with the remaining 10-20% having some residual stiffness or discomfort.^{12 2}

• Relapses in the same shoulder are uncommon.