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Date issued: December 2023

Review date: December 2025

Ref: A-450/PM/Physiotherapy/Frozen shoulder v2

PDF:  Frozen Shoulder 2023 v2.pdf[pdf] 404KB

What is a frozen shoulder?

Frozen shoulder (Adhesive Capsulitis) is a painful condition in which the shoulder becomes increasingly stiff, with a gradual progression of symptoms. It is self-limiting but can take a long time to settle. The joint capsule and ligaments become inflamed and thickened. Adhesions form which constrict over time.

What causes it?

In most cases, frozen shoulder develops without a specific cause; however, there are some factors that make you more susceptible to experience the condition.

These factors are:

• Trauma to the shoulder.

• Diabetes.

• Over 40 years old.

• Hyperthyroidism.

• Post Shoulder Surgery.

How long does it last for?

The natural course of frozen shoulder is between 12-42 months, with some people (15%) experiencing ongoing stiffness. There are three phases to the process of the condition:

Freezing Phase (2-9 months):

• Characterised by pain in the shoulder at rest and with movement.

• Worst at night, patients often have difficulty sleeping.

• The pain can intensify as the stiffness increases.

Frozen Phase (4-12 months):

• Pain is less prominent.

• Stiffness is the main symptom of this phase.

• Pain at night often improves.

Thawing Phase (4-12 months):

• A gradual increase in shoulder range of motion.

• Increasing functional ability.

• By the end of this phase most patients have regained full use of their shoulder and can perform normal activities.

What can I do if it’s painful?

Medication: It is important to discuss this with your GP and take any analgesia or anti-inflammatory medicines as prescribed.

Heat Treatment: This can help to soothe the surrounding muscles and joint.

Posture Correction: Maintaining a good posture will prevent undue excess strain to the shoulder muscles

Keep Moving: It is really important to keep your shoulder moving as your pain allows. Your therapist will advise you on exercises to help your shoulder. DO NOT wear a sling.

Steroid Injection: Hydrocortisone injections have been shown to be effective alongside exercises in the management of pain and are best when administered in the early stage of the condition. These can be performed by your GP or a specialist physiotherapist at Derriford Hospital. Steroid injections are not as effective for shoulders that are no longer painful and remain purely stiff but your therapist/GP will discuss this with you.

Don’t try to ‘soldier through’; if you are in pain, please seek advice. Well-managed frozen shoulders have better long-term outcomes.

Home Exercise Program:

Freezing Phase

It is important not to aggravate your shoulder, particularly in this early painful phase. The following exercises should be performed within the range you can tolerate, for a short duration each time. Repeat exercises up to 4 times per day.

Pendulum

Support yourself with your unaffected arm on a table. Lean forward, letting the affected arm dangle down towards the floor. Allow the arm to move gently back and forth, side to side and round in circles for up to 5 seconds at a time. Stand upright between exercises to rest.

Assisted Shoulder Flexion

Lay on your back with a pillow under your head for support. Hold your affected arm at the wrist using your non-affected hand. Slowly raise your arms, keeping the elbows straight, towards the ceiling. Gently lower your arms back down.

Assisted External Rotation

In sitting, place a towel under your affected arm to keep the upper arm locked to your side. Bend the elbow and use a stick or broom handle to gently encourage the lower arm to rotate out to the side.

Shoulder Rolls

In sitting, raise both shoulders, then squeeze your shoulder blades back and down for a few seconds before relaxing. You should feel a slight stretch across the front of your chest and shoulder but it should not be painful.

Assisted Internal Rotation

In standing, grasp your affected arm at the wrist using your unaffected hand or hold a cane or stick behind your back. Slide both hands up your back before relaxing down.

Frozen Phase

If you are pain free, you can challenge your shoulder more with stretching exercises to increase your movement and function. If you are still experiencing some pain, continue to work within your tolerated range. You can also start to strengthen your muscles at this stage. Repeat the stretching exercises up to four times per day and the strengthening exercises up to twice per day.

Inferior Capsule Stretch

Sit with your affected arm resting on a table. Slide your arm away from you while applying a downward pressure on the shoulder with your opposite hand. Hold for up to 10 seconds.

Anterior Capsule Stretch

Stand with you elbow at 90 degrees and your hand against a doorframe. Slowly turn your body away from the doorframe to encourage a stretch across the front of the shoulder. Hold for up to 10 seconds.                                

Posterior Capsule Stretch

Lay on your affected side with the arm raised to 90 degrees of flexion and the elbow bent up towards the ceiling. Using your opposite hand, apply a downward pressure to the back of your hand to encourage rotation of the arm down to the bed. Hold for up to 10 seconds.

Isometric External Rotation

Keeping your elbow firmly against your side and your elbow bent to 90 degrees, press outwards with the back of your hand against either a doorframe or your opposite hand. Maintain pressure for up to five seconds and relax. Repeat 10 times.

Isometric Internal Rotation

Keeping your elbow firmly against your side and your elbow bent to 90 degrees, press inwards with the palm of your hand against either a doorframe or your opposite hand. Maintain pressure for up to five seconds and relax. Repeat 10 times.

Thawing Phase

You will now be noticing a gradual return of range of motion and function of the shoulder. It is really important to get the shoulder back to normal as quickly as possible by working on stretches and strengthening.

Stretches:

Continue with the capsule stretches you were carrying out in the previous phase but push your limits and hold the stretch for up to 10 seconds and repeat 10-15 times. You can also push into all directions of movement with the following exercises:

Shoulder Flexion

Walk your hand up a wall or door as far as you can. Once you have reached the top of your movement, bend your knees to encourage a further stretch. You can do this in flexion (to the front) and abduction (to the side).

Towel Stretch

Dangle a towel behind your head with you unaffected arm. Grasp the other end of the towel with your affected arm behind your back. Use the towel to pull upwards and encourage the bottom hand to slide up the back.

Weight-Bearing Exercises:

Encouraging weight through your arm will increase the activity of the rotator cuff muscles which will help your recovery. Repeat each exercise for up to 60 seconds or until you feel sore/tired.

Four Point Kneeling

On all fours, slowly rock your bodyweight forward and backward, sided to side and in small circles to increase the weight through your arms. You can progress this by bring the hands closer together or by doing it one handed.

Wall Press Ups

Stand facing the wall with your hands placed against the wall level with your shoulder. Slowly lower your chest forwards towards the wall and push back up. It is important to keep your shoulders relaxed.

Strengthening:

You can use a weight (water bottle/food tin/book) at home or resistance band if you have access to this for these exercises. Aim to repeat up to 20 repetitions with each exercise.

Flexion

Raise your arm slowly up in front of your body as high as you can take it. Then slowly lower your arm back down.                                         

Abduction

Raise your arm slowly out to the side of your body, as high as you can take it. Then slowly lower your arm back down.

External Rotation

With your elbow bent at 90 degrees, slowly take your arm outwards keeping the elbow still. You can perform this in a neutral position (a) or in a raised position (b).     

Internal Rotation

With your elbow bent at 90 degrees, slowly bring your arm inwards towards your body keeping the elbow still. You can perform this in neutral (a) or in a raised position (b).

You may require further input such as:

Imaging:

Your GP may arrange x-rays to identify any features that may require an alternative treatment approach.

Referral to a specialist/Orthopaedic Team:

Your GP may arrange an onward referral to see a shoulder specialist or an Orthopaedic Shoulder Team for further investigation and guidance on management/treatment options. Surgical intervention may be considered if your symptoms fail to improve with conservative measures.