Frozen shoulder: the three stages and what helps at each

What frozen shoulder is

Frozen shoulder, or adhesive capsulitis, is a condition in which the capsule surrounding the shoulder joint becomes inflamed, thickened and tight. The result is pain and a progressive loss of movement, particularly turning the arm outwards and reaching up or behind the back. It is most common between the ages of 40 and 60, affects women slightly more often than men, and is more common in people with diabetes or thyroid conditions. It can follow an injury or a period of immobility, but often starts for no clear reason.

Frozen shoulder is usually described as passing through three overlapping stages. The boundaries are blurred, the timings vary widely between people, and the whole process commonly takes between one and three years. Knowing which stage you are in helps set realistic expectations and choose treatment that fits.

Stage 1: freezing (painful)

The first stage is dominated by pain. It often starts as a dull ache that becomes sharper with movement, is worse at night and can make lying on that side impossible. Movement gradually becomes more restricted as the pain increases. This stage often lasts between two and nine months.

What may help:

• Pain management. Keeping the shoulder comfortable enough to sleep and function is the priority. Ask your GP or pharmacist about suitable pain relief.
• Gentle movement within pain limits. Pushing hard into pain at this stage tends to make things worse. Short, frequent, gentle movements and pendulum-type exercises may help maintain what range you have.
• Advice on positioning. Supporting the arm on a pillow when sitting and sleeping, and avoiding sudden reaching, may reduce flare-ups.
• A prescribed anti-inflammatory injection. For some people in the painful stage, an injection into the joint may reduce pain and inflammation enough to sleep and to tolerate exercise. Whether it is appropriate for you, the likely benefits and the risks are discussed with a clinician at assessment; see joint injection therapy. Hydrodilatation, where fluid is injected to stretch the capsule, is another option that may be discussed.
• Adjuncts such as interferential therapy may help with pain for some people as part of a wider plan.

Stage 2: frozen (stiff)

In the second stage pain often eases, particularly at rest, but stiffness is at its peak. Everyday tasks such as fastening a bra, reaching a high shelf, washing your hair or putting on a coat can be difficult. This stage commonly lasts between four and twelve months.

What may help:

• Progressive stretching and mobility work. With pain less dominant, this is the stage where more purposeful stretching into the stiff directions, guided by a physiotherapist, may start to restore range.
• Hands-on treatment. Joint mobilisation and soft-tissue techniques may help movement and comfort when combined with a home programme.
• Strengthening. The muscles around the shoulder blade and the rotator cuff often weaken through disuse. Gradually rebuilding them helps function and prepares the shoulder for the final stage.
• Keeping active. Walking, cycling and lower-body exercise maintain general fitness and mood while the shoulder recovers.

Stage 3: thawing (recovery)

In the final stage movement gradually returns and pain continues to settle. This can take anywhere from six months to two years, and some people are left with a small permanent loss of range that rarely affects daily life.

What may help:

• Progressing the exercise programme. Larger ranges, more load and functional tasks, such as reaching, lifting and sport-specific movements.
• Addressing habits that developed during the stiff phase. Many people learn to hitch the shoulder or avoid using the arm; retraining normal movement patterns helps the recovery stick.
• Patience. Improvement in this stage is steady but slow. Keeping a simple record of what you can reach or lift helps you see progress.

What an assessment adds

Several shoulder problems can look like frozen shoulder, including rotator cuff tendinopathy, shoulder impingement and shoulder osteoarthritis, and the treatment differs. A physiotherapy assessment distinguishes between them from your history and examination; where a scan would change the plan, for example to rule out arthritis or a tear, we can arrange a fast-track X-ray or MRI through our imaging partner. Surgery is rarely needed and is usually considered only when a long period of appropriate care has not helped.

Outcomes vary from person to person. Evidence suggests that physiotherapy, injection and hydrodilatation may each help at different stages, and that combining an injection with a structured exercise programme may give better results than either alone for some people. Your clinician will explain what fits your stage and your goals.

When to book

If shoulder pain is disturbing your sleep, or stiffness is starting to limit everyday tasks, an initial assessment is worthwhile; early diagnosis helps you choose the right approach for the stage you are in rather than waiting for the shoulder to "sort itself out". If shoulder pain followed a fall, is severe and worsening, or comes with fever or a history of cancer, call us for a same-day assessment and imaging; for more severe symptoms, such as a suspected fracture or dislocation, go straight to A&E, and call 999 for life-threatening signs such as chest pain. Our clinic is in Bloomsbury, a few minutes from Russell Square and Holborn, and fees are on the fees page.