Shoulder capsulitis (frozen shoulder)

Frozen shoulder causes pain and makes it difficult to move the shoulder. This stiffness can interfere with sleep, getting dressed, and daily activities. Treatment aims to relieve pain and restore range of motion, with a progression tailored to your shoulder, particularly through physical therapy for frozen shoulder. Our guide to physical therapy for frozen shoulder explains the treatment plan.

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.

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.

• 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. ³
• 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. ^{4, 5}

In a series of five patients scheduled to undergo capsular release, the researchers measured passive abduction and external rotation before and after general anesthesia—medication that completely puts a person to sleep. A case series reports the findings observed in only a few individuals, without a comparison group. The capsule is the tissue sheath surrounding the joint, and a capsular release is a surgical procedure that cuts through it to facilitate movement. Abduction is the movement that moves the arm out to the side, and external rotation turns the forearm outward, with the elbow toward the body. Measuring the range of motion—that is, the extent of possible movement—during general anesthesia allows researchers to determine how far the shoulder moves when the muscles are no longer resisting. ⁶ Abduction increased in all five patients, and external rotation increased in three of them, suggesting that protective muscle contraction contributes to the limitation of movement only in certain cases. ⁶ Protective muscle contraction refers to muscles that tighten around the shoulder on their own, without the person’s conscious control. Five people constitute too small a sample size to determine how often this contraction accounts for the loss of movement or to quantify its extent. This small sample size does not allow for an estimate of this contribution in any specific individual.

To understand where the capsule is located in the shoulder, see our page on shoulder anatomy.

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.

Pain, Sleep, and Tolerance for Movement

Pain may be present at rest, at night, or during certain movements, while range of motion becomes more limited. A cross-sectional study—which assesses each person at a single point in time—compared 343 people with various shoulder conditions. The group with frozen shoulder slept less well. However, there was no clear difference in average pain intensity among the compared diagnoses. ⁸ These signs warrant an evaluation, but they do not by themselves confirm frozen shoulder. A systematic review of physical examination tests concludes that there are not yet universal clinical criteria for frozen shoulder. In other words, there is no universally accepted checklist of signs to look for. Some tests showed promising results in early studies, but no sufficiently validated set of tests could confirm the diagnosis on its own. ⁹

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. ¹⁰ This is an association based on frequency, not a definitive cause or a prediction for any individual. Depending on your medical history, it may be advisable 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. Review articles 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. ^{3, 11}

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?

La physiothérapie utilise des exercices, de l’éducation et des techniques manuelles pour travailler la mobilité de l’épaule et faciliter les activités. Les mobilisations articulaires sont des techniques manuelles où le physiothérapeute guide le mouvement de l’articulation. Le physiothérapeute vous apprend aussi à adapter vos exercices (notre page sur la progression des exercices en réadaptation) aux réactions de l’épaule et à vos activités. En clinique, ces options font partie des soins courants et le choix dépend du stade des symptômes.¹ Une revue Cochrane de 2014 décrit toutefois des résultats variables selon les programmes et les comparaisons. Dans deux essais, un programme combinant Manual therapy, exercices et électrothérapie (des soins réalisés avec des appareils) n’apportait pas de bénéfice supplémentaire jugé important lorsqu’il était ajouté à une infiltration de cortisone. Cette comparaison précise ne résume pas tous les soins de physiothérapie.¹² Une infiltration peut être discutée tôt avec un médecin lorsque pertinente; elle peut aussi compléter la physiothérapie.

Our physical therapy guide for frozen shoulder describes how the treatment plan is adjusted when pain or stiffness is the predominant symptom.

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 Cochrane review evaluated manual therapy and exercises for frozen shoulder. Its 32 trials compared a wide variety of interventions, with data that were often limited or imprecise, which restricted the scope of 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 were no clear differences in pain or daily functioning compared with the sham treatment. ¹² Injections, exercises, manual therapy, and patient 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.

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

In a cohort—that is, a group of people followed over time—the follow-up period 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 period, 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, including pain and difficulty performing daily activities. This average of 4.4 years refers to the duration of follow-up, not an individual recovery time. ¹⁷

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

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.

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. ¹⁸

Our physical therapy guide for frozen shoulder includes examples of exercises you can do at home and tips for managing nighttime pain.

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 at a private clinic without a doctor's prescription. However, your insurance provider may require a prescription in order to reimburse the costs. ¹⁹

Public network access rules may also require a reference.

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. ²⁰

Other symptoms also require urgent care:

• Shoulder pain accompanied by chest pain, shortness of breath, sweating, or discomfort
• Shoulder pain accompanied by redness or marked localized warmth
• New weakness in the arm, or a pale or bluish hand
• Pain or stiffness in multiple joints, accompanied by fever, severe fatigue, or unexplained weight loss

Une douleur thoracique soudaine qui persiste, qui se propage au bras ou qui s’accompagne de sueurs, de nausées ou d’essoufflement demande d’appeler le 911. Ne patientez pas pour une séance de physiothérapie²¹. Pour les autres alertes, consultez aussi les signes urgents de douleur à l’épaule²⁰.

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

1. Pandey V, Madi S. Clinical Guidelines in the Management of Frozen Shoulder: An Update! Indian J Orthop. 2021;55(2):299-309.↩ Back to text: 1st, 2nd, 3rd, 4th, 5th mentions
2. Fields BKK, Skalski MR, Patel DB, White EA, Tomasian A, Gross JS, et al. Adhesive capsulitis: review of imaging findings, pathophysiology, clinical presentation, and treatment options. Skeletal Radiol. 2019;48(8):1171-1184.↩ Back to text
3. Picasso R, Pistoia F, Zaottini F, Marcenaro G, Miguel-Pérez M, Tagliafico AS, et al. Adhesive Capsulitis of the Shoulder: Current Concepts on the Diagnostic Work-Up and Evidence-Based Protocol for Radiological Evaluation. Diagnostics (Basel). 2023;13(22).↩ Back to text: 1st, 2nd mentions
4. Ryan V, Brown H, Minns Lowe CJ, Lewis JS. The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review. BMC Musculoskelet Disord. 2016;17(1):340.↩ Back to text
5. Jump CM, Duke K, Malik RA, Charalambous CP. Frozen Shoulder: A Systematic Review of Cellular, Molecular, and Metabolic Findings. JBJS Rev. 2021;9(1):e19.00153.↩ Back to text
6. Hollmann L, Halaki M, Kamper SJ, Haber M, Ginn KA. Does muscle guarding play a role in range of motion loss in patients with frozen shoulder? Musculoskelet Sci Pract. 2018;37:64-68.↩ Back to text: 1st, 2nd mentions
7. Frozen Shoulder - Adhesive Capsulitis - OrthoInfo - AAOS.↩ Back to text: 1st, 2nd mentions
8. Mulligan EP, Brunette M, Shirley Z, Khazzam M. Sleep quality and nocturnal pain in patients with shoulder disorders. J Shoulder Elbow Surg. 2015;24(9):1452-7.↩ Back to text
9. Schiltz M, Goudman L, Moens M, Nijs J, Hatem SM. The diagnostic value of physical examination tests in adhesive capsulitis: a systematic review. Eur J Phys Rehabil Med. 2023;59(6):724-730.↩ Back to text
10. Zreik NH, Malik RA, Charalambous CP. Adhesive capsulitis of the shoulder and diabetes: a meta-analysis of prevalence. Muscles Ligaments Tendons J. 2016;6(1):26-34.↩ Back to text
11. Zappia M, Di Pietto F, Aliprandi A, Pozza S, De Petro P, Muda A, et al. Multi-modal imaging of adhesive capsulitis of the shoulder. Insights Imaging. 2016;7(3):365-71.↩ Back to text
12. Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;2014(8):CD011275.↩ Back to text: 1st, 2nd mentions
13. Zhao Y, Yang T, Feng C, Li L, Pang L, Zhao S. Arthroscopic Capsular Release Versus Manipulation under Anesthesia for Refractory Frozen Shoulder: A Systematic Review with Meta-Analysis. Orthop Surg. 2024;16(7):1517-1529.↩ Back to text
14. Song A, Higgins LD, Newman J, Jain NB. Glenohumeral corticosteroid injections in adhesive capsulitis: a systematic search and review. PM R. 2014;6(12):1143-56.↩ Back to text
15. Koh KH. Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials. Singapore Med J. 2016;57(12):646-657.↩ Back to text
16. Carette S, Moffet H, Tardif J, Bessette L, Morin F, Frémont P, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum. 2003;48(3):829-38.↩ Back to text
17. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg. 2008;17(2):231-6.↩ Back to text
18. Kelley MJ, Shaffer MA, Kuhn JE, Michener LA, Seitz AL, Uhl TL, et al. Shoulder pain and mobility deficits: adhesive capsulitis. J Orthop Sports Phys Ther. 2013;43(5):A1-31.↩ Back to text
19. OPPQ. Comment ça fonctionne?↩ Back to text
20. nhs.uk. Shoulder pain. 2017.↩ Back to text: 1st, 2nd mentions
21. National Health Service (NHS), Royaume-Uni. Chest pain.↩ Back to text

Nos physiothérapeutes ont défini la stratégie de recherche, le plan et le contenu clinique de cet article. Un outil d’IA a soutenu la recherche documentaire et la révision du texte pour assurer une cohérence du contenu et du style d’écriture.