Anatomy of the shoulder

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint. To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

The shoulder capsule surrounds the shoulder joint and rotator cuff tendons. In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

Shoulder Anatomy

What is frozen shoulder?

Frozen shoulder (also called "Adhesive Capsulitis"), occurs when the shoulder capsule thickens and becomes tight. Stiff bands of tissue (called adhesions) develop in the shoulder. In many cases, there is less lubrication fluid (synovial fluid) in the joint. The main symptom of frozen shoulder is having limitation of movement of your shoulder in all directions.

Frozen shoulder causes pain and progressive stiffness in the shoulder. Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60 and is more common in women.

Stages of a frozen shoulder

Frozen shoulder is named due to the way the conditions develops. Frozen shoulder goes through the following stages:

  1. Freezing: In the "freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

  2. Frozen: Painful symptoms may improve during this stage, but the stiffness of the shoulder remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

  3. Thawing: Shoulder motion slowly improves during the "thawing" stage of frozen shoulder. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.
Normal and inflamed frozen shoulder


Pain from frozen shoulder is usually dull or aching and can be very severe. It is typically worse early during the disease and when you move your arm. The pain associated with frozen shoulder is usually located over the outer shoulder area and sometimes the upper arm. You may experience pain at night and may have difficulty sleeping on the affected side.

Causes of a frozen shoulder?

We don't fully understand the causes of a frozen shoulder. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk or is associated for developing frozen shoulder:

Frozen Shoulder
  1. Diabetes: 10-20% of individuals with diabetes are affected. The reason is not known.

  2. Other diseases: Thyroid problems, Parkinson's disease, and heart disease.

  3. Immobilization: Frozen shoulder can develop after a shoulder has been immobilized for a period due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

How is frozen shoulder diagnosed?

Physical Examination

After discussing your symptoms and medical history, Dr van den Berg will examine your shoulder. Your orthopaedic surgeon will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion". Your doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have a stiff shoulder and have limited range of motion both actively and passively.

Imaging Tests

Other tests that may help your doctor rule out other causes of stiffness and pain include:

  1. X-rays: X-rays may show other problems in your shoulder, such as arthritis.

  2. Ultrasound: Cost-effective way of excluding other causes of pain or stiffness.

  3. Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of problems with soft tissues, such as a torn rotator cuff.

How is frozen shoulder treated?

Frozen Shoulder Management –

Frozen shoulder generally gets better over time, although it may take up to 3 years. The focus of treatment is to control pain and restore motion and strength through physical therapy.

Nonsurgical Treatment

More than 90% of patients with frozen shoulder improve with relatively simple treatments to control pain and restore motion.

  1. Non-steroidal anti-inflammatory medicines. Drugs like diclofenac and ibuprofen reduce pain and swelling.

  2. Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint and subacromial bursa.

  3. Physical therapy. Specific exercises will help restore motion. These may be under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before the stretching exercises. Below are examples of some of the exercises that might be recommended.

    • External rotation — passive stretch. Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.

    • Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.

    • Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

Surgical Treatment

If your symptoms are not relieved by non-operative measures for a period of at least 6 months, you and your doctor may discuss surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments, and the risks involved with surgery for frozen shoulder. The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy:

  1. Manipulation under anesthesia: Under general anesthetic your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.

  2. Shoulder arthroscopy: In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.

In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients with frozen shoulder have very good outcomes with these procedures.

These photos are taken through an arthroscope to show a normal shoulder joint lining (left) and an inflamed joint lining damaged by frozen shoulder

normal shoulder and inflamed joint lining Arthroscopic images - release of a frozen shoulder

What to expect after surgery?

Physiotherapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to three months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy. Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion.

In some cases, however, even after several years, the motion does not return completely, and a small amount of stiffness remains. Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.