All about frozen shoulder and the role of physical therapy in it

Frozen shoulder (scientific name: Adhesive Capsulitis) is one of those conditions that can significantly disrupt daily life: constant pain, stiffness, and limitation of shoulder movement so that picking up a shirt, combing hair, or putting an object on a shelf doesn't seem simple. This condition usually begins gradually, and sometimes the patient initially only experiences pain at night or difficulty in raising the arm, but over time, the active and passive range of motion of the shoulder decreases, and daily activities are disrupted due to joint pain and stiffness.

One of the important features of frozen shoulder (in English: Frozen Shoulder) is its stage course: the painful stage which is often associated with inflammation and severe pain, the "freezing" stage in which movement limitation prevails, and the "liberation/healing" stage in which the range of motion gradually returns over months to years. This length of treatment and fluctuating symptoms make patients feel hopeless; But the hopeful thing is that most patients with conservative treatment—especially targeted physical therapy programs—can find pain relief and improved quality of shoulder function.

In the rest of this article, we describe not only the definition and mechanism of the disease, but also the factors that increase the risk of developing it, how to accurately diagnose it clinically and with imaging, and all the current treatment options from home care to injections and specialized interventions. The important and most used part of this article is dedicated to physical therapy: therapeutic goals of physical therapy, valid techniques (range of motion exercises, manual therapy, physical modalities) and a practical home program that the patient can implement under the supervision of the therapist.

If you or someone around you is experiencing shoulder pain and limitation, this article is designed to serve as both a scientific and understandable guide and a practical reference to discuss with your doctor or physical therapist. At the end of each section, safety tips and times to see a doctor immediately are mentioned so that your treatment path is clear and safe. The ultimate goal is to help you find a logical and effective way to restore movement and relieve shoulder pain by providing detailed information, recognized clinical evidence, and physical therapy applications.

What is frozen shoulder? Reasons and risk factors

Frozen shoulder or Adhesive Capsulitis is a common but at the same time complicated disorder of the shoulder joint that causes pain, stiffness and progressive movement limitation. In this condition, the joint capsule — which is the soft and flexible tissue surrounding the shoulder joint — becomes inflamed, thickened, and sticky. These structural changes cause the range of motion of the shoulder to gradually decrease, and even in some simple daily movements, it creates limitations and discomfort.

In primary frozen shoulder, the exact cause is not known and it usually starts gradually without obvious damage. But in the secondary type, a specific underlying factor or event, such as shoulder injury, surgery, or long-term immobility, is the cause. For example, if a person cannot use his shoulder for a while after breaking his arm or heart surgery, the possibility of capsule adhesion and onset of symptoms increases.

One of the most important risk factors for frozen shoulder is the following:

1. Diabetes: Diabetic patients suffer from frozen shoulder between 2 and 4 times more often than healthy people, and their recovery process is usually longer.
2. Hormonal disorders: thyroid problems (hypoactivity or hyperactivity) and hormonal changes during menopause play an important role in increasing the risk.
3. Systemic diseases: Cardiovascular diseases, Parkinson's and some autoimmune diseases are associated with an increase in the prevalence of this disorder.
4. Age and gender: the highest incidence is between the ages of 40 and 60, and it is slightly more common in women than in men.
5. Prolonged immobility: after a fracture, injury, or even fear of movement due to pain, can cause stiffness and the onset of disease.

One of the important points about this disease is its staged nature; This means that the symptoms change over time and each treatment stage has its own approach. Knowing the risk factors and starting treatment in the early stages increases the chances of faster and more complete recovery. Also, patients with underlying conditions such as diabetes or thyroid problems should be under more careful control to prevent disease progression.

Frozen shoulder, contrary to its name, has nothing to do with cold, and "frozen" is actually a metaphorical description of extreme stiffness and limitation of the joint. Being aware of this point and understanding the reasons for its occurrence can help the patient and the therapist to have a proper plan for physical therapy and prevent the exacerbation of symptoms in the very early stages.

Illness stages and normal course of frozen shoulder

Frozen shoulder usually has a gradual process and is classically divided into three or four distinct stages. Knowing these stages is very important not only for the patient, but also for the doctor and physiotherapist, because the treatment approach is different in each phase.

1. Pre-Freezing / Painful Phase

At this stage, the patient usually experiences sudden or gradual pain in the shoulder. The pain is often worse at night and may disturb sleep. Simple movements like combing your hair or picking up your bag from a chair can be annoying. This phase usually lasts between a few weeks and three months.

Treatment goal at this stage: reduce inflammation and pain using methods such as warm compresses, physiotherapy modalities (such as ultrasound or TENS) and mild exercises without aggravating symptoms.

2. Freezing Phase

This period is where movement limitation begins noticeably. The patient notices that he can no longer raise his arm or reach behind his back. The pain is still there and any sudden or wide movement can aggravate it. This stage can last for several months to about 9 months.

Treatment goal at this stage: maintaining range of motion with controlled exercises and gradual increase of motion, without excessive pressure on the joint.

3. Frozen Phase

During this period, the pain usually subsides, but the shoulder becomes very stiff and limited. The patient may be able to perform light daily activities, but movements such as raising an arm above the head or zipping the back of a garment become difficult or impossible. This stage may take between a few months and a year.

Treatment goal at this stage: focus on increasing the flexibility of the joint capsule and improving the range of motion with stretching exercises and specialized manual therapy.

4. Thawing / Recovery Phase

At this stage, the movement of the shoulder gradually returns and the pain decreases significantly. The length of this phase can be several months to more than a year. Applying strengthening and stretching exercises in this period can accelerate the process of full return of performance.

Treatment goal at this stage: restore muscle strength and full function of the shoulder with a comprehensive rehabilitation program.

Why is knowing these steps important?

Because therapeutic interventions should be selected according to the phase of the disease. For example, intense stretching during the painful phase may worsen symptoms, while during the healing phase, the same stretches can be very helpful.

When should we see a doctor or physiotherapist for frozen shoulder?

Frozen shoulder is one of the diseases that usually starts slowly and at first it may be confused with simple problems like fatigue or muscle strain. However, its symptoms worsen over time and can reach a point where even the simplest movements become difficult. Early recognition of these symptoms is the key to preventing the progression of the disease and starting treatment on time. When is it necessary to see a doctor?

• Sudden severe shoulder pain with inability to move the arm
• Presence of fever or symptoms of systemic inflammation
• Weakness or numbness in the arm or hand which can be a sign of a nerve problem
• History of injury or severe trauma to the shoulder before the onset of symptoms
• Diagnosis and early treatment can shorten the healing process and prevent the disease from entering more severe stages.

Common symptoms of frozen shoulder

1. Persistent shoulder pain
   • The pain is usually felt in the front and outer part of the shoulder.
   • This pain is often worse at night and may cause frequent awakenings.
   • Moving the hand, even for simple tasks, can aggravate the pain.
2. Limited active and passive range of motion In many shoulder problems, the patient may not be able to move the arm, but the doctor or physical therapist can. In frozen shoulder, even the movement of the shoulder by the doctor is limited. The movements of raising the hand, taking it behind the head or pulling it to the side are clearly reduced.
3. Decreased ability to perform daily activities such as combing hair, putting on a shirt or taking things from the top shelf of the cabinet becomes difficult or impossible. Patients often feel that their shoulder is "locked" or "dry".

Methods for diagnosing frozen shoulder

• Detailed history: Your doctor will ask you about when the pain started, how it progressed, and what activities have been problematic.
• Physical examination: active and passive range of motion of the shoulder is checked to determine the degree of limitation.
• Imaging: In most cases, the diagnosis is made with history and clinical examination. But to rule out other problems such as rotator cuff tears, arthritis or inflammation of the tendons, a simple photo, ultrasound or MRI may be requested.

Treatment options for frozen shoulder — from conservative approach to advanced interventions

Frozen shoulder usually heals gradually, but this process can take months or even years. The choice of treatment method should be based on the stage of the disease, the severity of the symptoms and the individual needs of the patient. In the following, we review the main treatment options in order from the simplest to the most advanced.

1. Patient education and modification of activities (Self-Management)
   • The first step is to make the patient aware of the nature of the disease and change his lifestyle.
   • Avoid sudden or heavy movements that put pressure on the shoulder.
   • Using the arm in a pain-free range of motion to prevent aggravation of dryness.
   • Teaching the correct techniques of doing daily tasks to reduce pressure on the shoulder joint.
2. Anti-inflammatory drugs and painkillers In the painful stages of the disease, the use of drugs such as ibuprofen or naproxen (with doctor's prescription) can temporarily reduce inflammation and pain. These drugs are mostly used to control symptoms and do not speed up the healing process alone.
3. Intra-articular corticosteroid injection.Steroid injection in the shoulder, especially in the early stages, can quickly reduce pain and improve range of motion. The effects are usually short-term (a few weeks to a few months). The best results are achieved when the injections are combined with a regular physical therapy program.
4. Hydrolysis or Hydrodilatation This method involves injecting a sterile liquid under pressure into the shoulder joint to stretch and open the joint capsule. It is usually done for patients who have not improved with simpler treatments. It can improve the range of motion faster.
5. Specialized physical therapy. The physical therapist helps reduce pain and restore movement by using gradual stretching exercises, strengthening the muscles around the shoulder, and manual techniques. The intensity and type of exercises are adjusted depending on the stage of the disease. Combining physiotherapy with other methods, especially steroid injection, has better results in the short term.
6. Surgery and advanced interventions When non-surgical treatments fail (usually after 6 to 12 months), surgery is considered:
   • Manipulation Under Anesthesia: moving the shoulder under anesthesia to break adhesions.
   • Arthroscopy (Capsular Release): Cutting the joint capsule to release movement.

Important point

There is no "one size fits all". The treatment plan should be personalized and designed considering the stage of the disease and the patient's goals. In many cases, a combination of methods gives the best results.

The role of physiotherapy in treating and preventing the return of frozen shoulder

Physiotherapy is one of the main pillars of frozen shoulder treatment and is not only effective in speeding up the healing process, but can also minimize the possibility of symptoms returning. The main feature of physical therapy is that instead of focusing only on pain relief, it works on restoring the joint's full function and preventing re-drying.

1. Restoration of range of motion (ROM): One of the key goals in treating frozen shoulder is to gradually restore range of motion. Physiotherapist using:

• gentle stretching exercises (such as stretching with a towel or pendulum movement)
• Manual Mobilization

Increases shoulder range of motion gradually to release joint capsule adhesions, without damaging the tissue.

2. Pain and inflammation reduction: In the early stages when pain is predominant, the physiotherapist uses auxiliary methods to reduce inflammation:

• Cold Therapy to reduce acute pain and inflammation
• ultrasound therapy or TENS for pain relief
• Calmation techniques and breathing control to reduce muscle tension

These measures not only control the pain, but also allow the patient to enter the phase of active exercises sooner.

3. Strengthening of supporting muscles: Weakness of the muscles around the shoulder, such as the rotator cuff muscles and scapular muscles, can cause instability and return of movement limitation. Physiotherapist with a phased program:

• First, it activates the muscles in the pain-free range.
• Then he adds light resistance exercises.

This process stabilizes the shoulder and protects it from re-injury.

4. Posture and ergonomics training: Many patients with frozen shoulder will change their body position due to pain (such as raising the shoulder or bending forward). These changes can cause secondary problems. Physiotherapist with:

• Teaching correct body posture
• Improve the way you do everyday things (like using a mouse or picking up objects)

It helps reduce the pressure on the shoulder and speed up the healing process.

5. Prevention of return of symptoms: After partial recovery, the patient usually receives special home exercises to maintain shoulder motion. Continuation of these exercises - even in the absence of pain - plays a key role in preventing dryness from returning.

Physiotherapy in frozen shoulder is not only an auxiliary treatment; Rather, it is a comprehensive and active approach that helps the patient not only to get rid of the pain, but also to restore the full function of the shoulder and prevent the problem from returning.

Key and safe exercises for frozen shoulder patients

Exercises for frozen shoulder should be staged, safe and without excessive strain. Their main goal is to reduce joint stiffness, improve range of motion, and strengthen supporting muscles, without aggravating inflammation or pain. In the following, I will explain the exercises based on the stages of the disease so that you can know what movement to do, when and why.

🔹 First stage (pre-freezing/painful)

Type of movementHow to performNumberPurposeReason for doingPandoli exercise (Codman's Exercise) Stand, bend the body slightly forward, the affected arm hangs freely. Slowly make a small circular movement (clockwise and counter-clockwise). 3 times a day, 30-60 seconds each time. Control pain and prevent progression This movement puts a little pressure on the joint capsule and improves blood flow. Stretching movement with the help of the healthy hand While sitting or standing, with the healthy hand, raise the affected arm slightly from the front or side. Only as far as the pain allows.

🔹 The second stage (freezing)

Type of movementHow to do itNumberPurposeReason to doStretching with a towel on the back of Kamrik Hold the towel behind the body, the healthy hand from above and the affected hand from below. Slowly pull the towel up so that the affected shoulder is slightly stretched. 10 repetitions, 2 times a day. Increasing the range of motion without inciting inflammation helps to return the internal rotation and movements behind the head. Wall stretching Stand facing the wall, walk up slowly with the tips of the fingers. Go to the highest point without pain, hold for 5 seconds, slowly return.

🔹 third stage (freeze)

Type of movementHow to do itNumberPurposeReason for doingStick movement (Passive/Active Assisted) Hold a stick or cane with both hands. The healthy hand moves the affected hand forward or to the side. - 15 repetitions, 2 times a day. Restoring the movement and starting to strengthen the muscles helps to strengthen the rotator cuff muscles. Isometric exercises Light, gentle pressure on the wall without joint movement (for example, push against the wall with your elbow).

🔹 The fourth stage (Thawing)

Type of movementHow to performNumberPurposeReason for doingResistance exercises with elastic bands and movements of opening, closing and rotating the shoulder with a light elastic band. 3 sets of 10, 3-4 days a week. Full return of function and prevention of relapse. Daily functional exercises such as putting on a seat belt, removing dishes from the shelf, or opening the top door, to return movement coordination.

Safety tips

• Every movement should be done without severe pain.
• Sudden movements or excessive stretching are prohibited.
• Exercises should be done under the supervision of a physiotherapist or with detailed training.
• Golden tips for preventing frozen shoulder and maintaining shoulder health

Prevention of frozen shoulder

Frozen shoulder usually occurs in people whose shoulder has been unused for a period of time due to various reasons — such as prolonged immobility, injury, or underlying disease. By following a few simple but key points, you can prevent this problem to a large extent or even prevent its development in the early stages.

1. Maintaining daily mobility of the shoulder
   • Do a few minutes of light stretching every day such as raising your hands, rotating the shoulders and pendulum exercises
   • Even if the shoulder is injured, continue pain-free movements so that the joint capsule does not tighten.
   • Scientific note: long immobility increases the fibrosis tissue and decreases the flexibility of the capsule.
2. Management of underlying diseases
   • Diabetes, thyroid problems and cardiovascular diseases increase the risk of developing frozen shoulder.
   • blood sugar control and regular checkups can play a big role in prevention.
3. Early initiation of movements after injury or surgery
   • After any shoulder injury or surgery, consult your doctor or physiotherapist to begin gentle movements early.
   • Reason: even a few weeks of immobility can lead to the beginning of adhesions and limitations.
4. Improving the ergonomics of the working and sleeping environment
   • Using a chair and table with the right height, preventing the shoulders from bending forward.
   • When sleeping, if you sleep on a painful shoulder, place a small pillow under your arm to reduce pressure.
5. Warming up before activity and exercise
   • Before any heavy activity or exercise, warm up for 5-10 minutes.
   • This work increases blood flow and reduces the risk of sudden stretching of the joint capsule.
6. Refer to a specialist quickly in case of early symptoms
   • Do not ignore vague pain or slight restriction of movement.
   • Early intervention makes the treatment process much shorter and easier.

Frequently asked questions about frozen shoulder and the role of physical therapy

1. What is frozen shoulder and how is it different from tendonitis or rupture?

Frozen shoulder (Adhesive Capsulitis) means inflammation and stiffness of the capsule of the shoulder joint, which causes severe limitation of movement. In tendonitis or tears, the problem is in the tissues around the joint, and passive range of motion (when a doctor or other person moves the shoulder) is usually preserved, but in frozen shoulder, even this type of range of motion is limited.

2. Does frozen shoulder get better by itself?

In some people, yes; But this process may take 12 to 24 months and severely reduce the quality of life. With physiotherapy and auxiliary treatments, this time will be significantly shorter.

3. What is the role of physiotherapy in the treatment of frozen shoulder?

🔹Reducing pain with manual techniques and anti-inflammatory modalities (like ultrasound or TENS) 🔹Increasing the range of motion with stretching exercises and specialized maneuvers 🔹Teaching home exercises to prevent the return of limitations 🔹Improving the strength of shoulder muscles and shoulder girdle for better performance

4. Is exercise dangerous during frozen shoulder?

Heavy exercise or sudden movements may aggravate the pain, but gentle exercises guided by a physical therapist are very helpful and even necessary. The important thing is to choose the right exercises for the stage of the disease.

5. Who are most at risk of frozen shoulder?

🔹people over 40 years old 🔹women (especially in pre- and postmenopausal age) 🔹suffering from diabetes or thyroid disease 🔹those who have kept their shoulder still for a long time

6. Is it possible for the disease to return?

Yes, but it is rare. Following the exercise program and maintaining the mobility of the shoulder after treatment is the best way to prevent the recurrence of the disease.

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