Frozen shoulder, what to expect over the months

Written by the SOS Clinic physiotherapy team.

A frozen shoulder can be one of the most painful and frustrating shoulder problems. It often starts without an injury. Over weeks the shoulder becomes more painful and then very stiff. Simple tasks like doing up a bra, reaching a top shelf or putting on a jacket become hard.

The most common question is how long it will last. The answer varies a lot from person to person. This article explains how frozen shoulder usually changes over time, what the evidence says, and how physiotherapy can help along the way.

What is a frozen shoulder?

The shoulder joint is wrapped in a soft lining called the capsule. In a frozen shoulder, the capsule becomes inflamed, then thick and tight. This causes pain and a loss of movement in every direction, especially turning the arm outwards.

It is most common between the ages of 40 and 60, and more common in women. People with diabetes are much more likely to develop it. One review found that people with diabetes were about five times more likely to have a frozen shoulder than people without diabetes.¹ Thyroid problems and a recent period of keeping the arm still can also play a part.

The SOS Clinic page on frozen shoulder explains the condition in more detail.

The three phases, and why they are only a rough guide

Frozen shoulder is often described in three phases. These are useful for understanding the condition, but they overlap, and not everyone goes through them in the same way or at the same pace.

• Freezing, the painful phase. Pain builds, often worse at night and with sudden movements. Movement starts to reduce.
• Frozen, the stiff phase. Pain may begin to ease, but the shoulder is very stiff. Daily tasks can be hard.
• Thawing, the recovery phase. Movement slowly returns and pain keeps settling.

The whole process is often described as lasting from many months to a couple of years. These timeframes come from older descriptions and are only a rough guide. Some people recover sooner. Others still have some stiffness or pain years later.

A systematic review looked for evidence that frozen shoulder always passes through these phases and fully recovers on its own. It found that people who had no treatment did improve, but often not completely. Most of the improvement happened early in the course.² A later review suggested that describing frozen shoulder as a three phase condition that always settles by itself can be confusing for patients.³

So it helps to expect slow progress over months, and to know that recovery is not the same for everyone.

What the UK FROST trial found

The UK FROST trial included 503 adults with frozen shoulder who had been referred to hospital.⁴ They were split into three groups.

• Early structured physiotherapy. Hands-on mobilisation and a graded home exercise program, along with a steroid injection.
• Manipulation under anaesthesia. The surgeon moved the shoulder to stretch the tight capsule while the person was asleep, followed by physiotherapy.
• Arthroscopic capsular release. A keyhole operation to cut the tight part of the capsule, followed by physiotherapy.

At one year, all three groups had improved. The differences in shoulder pain and function between the groups were small, and none of the three treatments was clearly better than the others. Keyhole release had more serious side effects.⁴

The physiotherapy group in this trial also had a steroid injection. SOS Clinic does not give injections. The trial is described here only to show how the treatments compared.

How physiotherapy can help in each phase

Physiotherapy helps you manage pain, keep as much movement as possible and get back to your usual activities as the shoulder recovers. No treatment has been shown to switch the condition off.

• When pain is high. The focus is on easing pain and sleep. Gentle movement within comfort, heat, and advice on positions for sleeping and working all help. Forcing painful stretches at this stage often makes things worse.
• When stiffness is the main problem. Stretches and hands-on mobilisation can be gradually increased as pain allows. Your physiotherapist will help you find the right amount.
• As movement returns. Strength work for the shoulder and shoulder blade helps you use the arm with confidence again for work, sport and daily tasks.

Your physiotherapist will check your movement at each visit so you can see change that is often slow from day to day.

If stiffness does not improve, surgical options may be discussed. Read about shoulder arthroscopy with Prof Phong Tran. After any procedure, follow your surgeon’s advice on rehabilitation and timelines.

How SOS Clinic can help

The physiotherapists at SOS Clinic in East Melbourne assess your shoulder movement and strength and explain what is likely happening. You leave your first visit with a plan suited to the phase your shoulder is in.

Myotherapy can ease tight, sore muscles in the neck, upper back and shoulder, which often work harder when the shoulder is stiff.

If you have diabetes, your GP may want to check your blood sugar control, as frozen shoulder is more common in people with diabetes.

The clinic team can also arrange a review with Prof Phong Tran, an orthopaedic surgeon who works from the same clinic, if your shoulder is not improving.

When to get help sooner

See a doctor promptly if your shoulder became stiff after a fall or injury, if it is hot, red and swollen with a fever, or if you have arm weakness, numbness or pain that spreads down the arm. Shoulder or arm pain with chest pain or shortness of breath needs urgent care, so call 000. During opening hours, contact the clinic. After hours and on weekends, go to your nearest emergency department.

Book a shoulder physiotherapy assessment at SOS Clinic

Frequently asked questions

Will my frozen shoulder go away on its own?

Most frozen shoulders improve a lot over time. Research shows that full recovery without any treatment is not certain, and some people keep some stiffness. Treatment aims to help you through it with less pain and better movement.

Should I keep moving my shoulder even if it hurts?

Gentle movement within comfort is helpful. Hard, painful stretching in the early painful phase often makes pain worse. Your physiotherapist can guide how much to do.

Can I get a frozen shoulder in my other shoulder?

It can happen, though it does not happen to everyone. It is more common in people with diabetes.

Why is it so painful at night?

Lying on the shoulder and staying still for long periods can both increase pain. A pillow under or in front of the arm can help you find a more comfortable position.

Do I need surgery?

Most people do not. In the UK FROST trial, physiotherapy and surgery gave similar results at one year. Surgery may be considered if stiffness stays severe despite treatment.

References

1. 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.
2. Wong CK, Levine WN, Deo K, Kesting RS, Mercer EA, Schram GA, Strang BL. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy. 2017;103(1):40-7.
3. Abrassart S, Kolo F, Piotton S, Chih-Hao Chiu J, Stirling P, Hoffmeyer P, Lädermann A. ‘Frozen shoulder’ is ill-defined. How can it be described better? EFORT Open Rev. 2020;5(5):273-9.
4. Rangan A, Brealey SD, Keding A, Corbacho B, Northgraves M, Kottam L, Goodchild L, Srikesavan C, Rex S, Charalambous CP, Hanchard N, Armstrong A, Brooksbank A, Carr A, Cooper C, Dias JJ, Donnelly I, Hewitt C, Lamb SE, McDaid C, Richardson G, Rodgers S, Sharp E, Spencer S, Torgerson D, Toye F. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. Lancet. 2020;396(10256):977-89.