Shoulder capsulitis (frozen shoulder)

Adhesive capsulitis causes shoulder pain and makes it difficult to move the shoulder. This stiffness can interfere with sleep, getting dressed, and performing daily activities. Treatment aims to relieve pain and restore range of motion, with a progression tailored to your shoulder’s condition, particularly through physical therapy for adhesive capsulitis.

What is Frozen Shoulder (Adhesive Capsulitis) and How Does It Progress?

Adhesive capsulitis is a shoulder condition that causes pain and a gradual loss of range of motion, with recovery often taking several months. Clinical reviews describe pain and stiffness as the main symptoms and note that the duration of the classic stages varies from person to person.¹ The term “frozen shoulder” describes this stiffness, without implying that the joint is actually frozen.

The joint capsule is a layer of tissue that surrounds the joint. In capsulitis, this layer can thicken and become less flexible. However, these changes alone do not fully explain the pain or the duration of the symptoms.

Capsulitis mainly affects middle-aged adults and is more commonly reported in women.² Age and gender alone are not sufficient to predict a person’s condition.

A randomized trial—a study in which participants are randomly assigned to the groups being compared—evaluated a suprascapular nerve block, an injection near a nerve in the shoulder, as an option added to usual care. Among 54 people who were already receiving an injection into the shoulder joint and physical therapy, the repeated addition of the block reduced the average time until symptoms resolved—5.4 months compared with 11.2 months with the placebo, a comparison injection containing no active medication. The block also improved pain, range of motion, and the ability to perform daily activities. This result applies to the addition of the block to these treatments and does not predict your own recovery time.³

• Pain is more pronounced at first. The shoulder gradually becomes painful, and the range of motion is reduced. The pain can also interfere with sleep.
• Active and Passive Range of Motion: Active range of motion, performed by the patient, and passive range of motion, performed by the examiner, can both be limited, though they are not necessarily identical. A 2023 review describes capsulitis as a condition characterized by severe pain and a progressive limitation of both active and passive range of motion in the shoulder.⁴
• Stiffness Followed by a Return of Movement The pain may subside while stiffness remains significant. Movement may then gradually return. These phases overlap, and recovery is not always complete.

Capsulitis may be accompanied by actual stiffness. The precise mechanisms linking changes in the capsule, symptoms, and disease progression have not been fully established. Studies primarily describe changes in the front of the capsule and in the surrounding tissues. They observe signs of inflammation and fibrosis—an accumulation of fibrous tissue that can thicken the capsule. These observations are not sufficient to determine what triggers capsulitis in each individual.^{5, 6}

What are the symptoms of frozen shoulder and how can you recognize it?

Capsulitis causes shoulder pain and difficulty moving the arm, even when someone is helping you. The pain may be more severe at night or when you try to raise your arm.⁷

Difficulty rotating the arm outward, with the elbow close to the body, is a common symptom. The healthcare professional checks several movements before confirming the diagnosis.¹

Everyday activities become challenging, such as putting on a coat, fastening a bra, washing your back, styling your hair, or reaching for the seatbelt.

What causes frozen shoulder and who is at risk?

The exact cause of capsulitis is often unknown, but diabetes and thyroid disorders are associated with a higher risk.¹

Significant stiffness can also develop after an injury, surgery, or a period of shoulder immobilization. These situations require an evaluation to determine the cause and tailor treatment accordingly.⁷

A meta-analysis, which combines the results of several studies, estimates that capsulitis is about five times more common in people with diabetes than in those without diabetes.⁸ This is an association in terms of frequency, not a definitive cause or a prediction for any individual. Depending on your medical history, it may be helpful to discuss this with a doctor.

Tell the healthcare professional if you have diabetes or a thyroid disorder. A doctor can determine whether tests are necessary to screen for or monitor these health issues.

How is frozen shoulder diagnosed?

The healthcare professional diagnoses capsulitis based on your symptom history and the limited range of motion in the shoulder observed during the physical exam. The healthcare professional assesses active and passive range of motion, pain, and function. Imaging may be ordered if it would help rule out other possible causes. Reviews note that the signs of frozen shoulder resemble those of other shoulder conditions, and that imaging is primarily used to confirm the clinical impression and rule out damage to the joint or the rotator cuff—a group of muscles and tendons that help move and stabilize the shoulder.^{4, 9}

The gradual onset of pain and stiffness can guide the evaluation. Comparing active and passive range of motion helps the healthcare professional consider capsulitis and other causes of shoulder pain, including rotator cuff tendinopathy, a painful condition affecting the tendons of this muscle group.

An X-ray can help identify osteoarthritis or another bone-related cause. Magnetic resonance imaging (MRI), which shows soft tissues such as muscles and tendons, is not necessary in all cases to diagnose frozen shoulder.

How does physiotherapy treat frozen shoulder?

Physical therapy uses exercises, education, and manual techniques to improve shoulder mobility and make daily activities easier. Joint mobilization is a manual technique in which the physical therapist guides the movement of the joint. The physical therapist will also teach you how to adapt your exercises based on how your shoulder responds and your daily activities. In a clinical setting, these options are part of standard care, and the choice depends on the stage of your symptoms.¹ However, a 2014 Cochrane review describes variable results depending on the programs and comparisons. In two trials, a program combining manual therapy, exercises, and electrotherapy (treatment using devices) did not provide any additional benefit considered significant when added to a cortisone injection. This specific comparison does not summarize all physical therapy treatments.¹⁰ A cortisone injection can be discussed early on with a doctor when appropriate; it can also complement physical therapy.

• When pain is predominant, assisted movements and gentle mobilization allow for exercise within a tolerable range. Sharp pain or prolonged worsening of symptoms after a session warrants reducing the intensity and revising the exercises. A cortisone injection can be discussed with a doctor when appropriate. A Cochrane review of 49 trials on joint contractures—that is, persistent limitations in joint movement—in people with neurological or other conditions did not show any significant improvement in mobility with the stretching exercises studied for less than seven months. This finding, which applies to several types of contractures, does not replace studies specific to frozen shoulder.¹¹
• When stiffness is the predominant symptom, exercises are designed to gradually restore the arm’s range of motion in elevation and rotation. The physical therapist may increase the range of guided movements depending on the shoulder’s tolerance. Distension arthrography—an injection of fluid into the joint—may be considered when significant limitations persist despite the treatments already tried. In a trial involving 60 participants, adding a progressive stretching device to physical therapy resulted in a greater gain in range of motion than physical therapy alone after four weeks, with a difference still observed at the 12-month follow-up.¹² A single trial of this size is not sufficient to establish the effectiveness of all progressive stretching devices.
• As you resume your activities, the exercises will help you re-learn the movements you've been missing, such as reaching for a shelf or carrying an object. The intensity and number of repetitions of these movements will increase based on your ability.

Surgery may be considered when significant limitations persist despite appropriate management; the decision is made on a case-by-case basis. In patients whose capsulitis does not respond to non-surgical treatment, a systematic review with meta-analysis found comparable outcomes between arthroscopic capsular release—a procedure performed through small incisions using a camera—and shoulder mobilization under anesthesia, with a higher rate of serious complications following arthroscopic surgery.¹³

To learn more, consult our complete guide to physiotherapy for shoulder pain.

A cortisone injection can be discussed with your doctor as part of the treatment for capsulitis, especially for short-term relief when pain is the predominant symptom: reviews report improvements in pain or range of motion in the first few weeks, with short-term benefits lasting up to twelve weeks, while long-term outcomes are similar to those of a placebo or other treatments.^{14, 15} Exercises and other treatment options are tailored based on symptoms, function, and the observed response.

Does physical therapy work for frozen shoulder?

Physical therapy can speed up the recovery of movement when used in conjunction with an injection, but the results depend on the program and the timing of follow-up care. In a trial involving 93 people, adding supervised sessions to an injection led to faster improvements in mobility. All groups also received home exercises; after one year, their results were similar.¹⁶

A study compared a low-intensity approach with intensive physical therapy in people with frozen shoulder. After 24 months, in the low-intensity group—which performed exercises without exceeding the pain threshold—89% had regained normal or near-normal shoulder function, compared with 63% in the intensive group.¹⁷ This result comes from a single comparative study and does not mean that all intensive physical therapy is harmful.

A Cochrane review evaluated manual therapy and exercises for frozen shoulder. Its 32 trials compared a wide variety of interventions, with data that were often weak or imprecise, which limited the comparisons; the data did not allow for a clear determination of which exercise or manual technique was preferable. After joint distension, one trial in this review showed that more participants rated the treatment as successful and reported better lateral arm movement after six weeks of manual therapy and exercises. However, there was no clear difference in pain or daily functioning compared with the sham treatment.¹⁰ Injections, exercises, manual therapy, and education can be considered based on symptoms, function, and the observed response.

A comprehensive assessment helps you choose which movements to focus on and track your progress in the activities that matter to you.

Capsulitis can last a long time, but its duration varies from person to person. Clinical reviews generally estimate that gradual recovery takes between 12 and 18 months, while noting that the duration of each stage is not consistent.¹ A cohort followed for an average of 4.4 years shows that some shoulders recover almost completely, while others continue to experience symptoms.¹⁸

How long does it take to recover from frozen shoulder, and what are the chances of a full recovery?

Recovery from capsulitis often takes several months and can extend over a few years; a full recovery is not guaranteed. Treatments can alter this course. The trial involving the suprascapular nerve block, described above, involved individuals who were already receiving an injection and physical therapy; therefore, the timeframes reported do not reflect the course of capsulitis without treatment.³

This recovery process can be frustrating when it interferes with sleep or daily activities. Treatment can focus first on these practical challenges, without waiting for full range of motion to return.

In a cohort—that is, a group of people followed over time—the follow-up lasted an average of 4.4 years after the onset of symptoms, with durations ranging from 2 to 20 years depending on the individual. At the end of this follow-up, 59% of the shoulders were normal or nearly normal, and 41% still had symptoms. Of the 269 shoulders monitored, 35% still had mild to moderate symptoms, and 6% had severe symptoms involving pain and difficulty performing daily activities. This average of 4.4 years refers to the duration of follow-up, not an individual recovery time. ¹⁸

The follow-up focuses on pain, sleep, and the activities you are able to resume. If your progress is slower than expected, this may lead to a reassessment of the diagnosis or a discussion of other treatment options.

To better understand the causes of shoulder pain, consult our complete guide to shoulder pain.

What can be done at home to relieve frozen shoulder?

Gentle movements, appropriate exercises, and comfortable arm support can help manage frozen shoulder at home. The choice of movements depends mainly on your current pain and stiffness. Work with your physical therapist to determine the range of motion, number of repetitions, and frequency.¹⁹

• When pain is the predominant symptom
  • For a pendulum-like motion, rest your pain-free hand on a table. Lean forward and let your other arm swing gently while remaining relaxed.²⁰
  • To raise your arm with assistance, lie on your back. Use your other hand to support the painful arm and raise it only as far as you can comfortably tolerate, as inthe assisted shoulder mobility exercise.⁷
  • Avoid pushing yourself if you experience sharp pain. If the exercises cause your symptoms to worsen over time, reduce the range or number of movements and have your exercise program reviewed.
• When Stiffness Prevails
  • The physical therapist selects mobility and strengthening exercises, then increases their difficulty based on your tolerance.
  • To slide your hand toward the wall, place a towel under your hand on the affected side. Gently move toward the wall, letting your hand rise, then slowly lower it back down—a movement similar tothe shoulder flexion control exercise.²⁰
  • A rotation exercise can be done with a stick held in both hands. Keep the elbow close to your body and use your other hand to gently guide your hand outward.²⁰
• During the return to normal activities
  • Gradually reintroduce useful activities, such as combing your hair or placing a light object on a shelf. The movement should remain appropriate for your current abilities.
  • The physical therapist adjusts the resistance of the strengthening exercises as you regain your strength.
• Nighttime pain management
  • Try sleeping on your back or on the side that doesn't hurt if pressure on your shoulder makes the pain worse.
  • A pillow under your arm or in front of you can support your shoulder. Adjust its height for your comfort.
  • If pain regularly keeps you from sleeping, talk to a professional about your relief options.

If your symptoms change, if home exercises aren't helping, or if your activities remain very limited, a physical therapy evaluation can help you adjust your plan.

When should you consult a professional for your frozen shoulder?

You should see a doctor if shoulder pain and stiffness limit your movement, disrupt your sleep, or make it difficult to perform your daily activities.

In Quebec, you can see a physical therapist in a private practice without a doctor's prescription. However, your insurance provider may require a prescription to reimburse your costs.²¹

Seek urgent medical attention if you experience sudden or severe shoulder pain, or if you are unable to move your arm. A deformity of the arm or shoulder, significant swelling, loss of sensation, or persistent tingling also require urgent evaluation. The same applies if the arm or shoulder feels hot or cold to the touch. Also seek urgent medical attention if the pain begins after an injury, if both shoulders become very painful, or if you have a fever or feel generally unwell. These situations require medical care even if the other symptoms on the list are absent.²²

A physical therapist can assess the situation, propose a treatment plan, and work with a doctor when an injection, a medical evaluation, or another resource is appropriate.

Regular follow-up allows us to monitor improvements in mobility and the activities the patient has regained. Goals may change even if full recovery takes time.

References

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