Frozen Shoulder

Frozen shoulder passes through a painful phase, in which the shoulder hurts constantly and particularly at night, and a stiff phase, in which pain settles but movement is severely restricted in every direction.

The treatments are different, and applying the wrong one prolongs the condition. Aggressive stretching during the painful phase increases inflammation and makes the stiffness worse. This is why staging the diagnosis comes before treating it.

Restriction in every direction, including passive movement performed by someone else, distinguishes frozen shoulder from a rotator cuff problem, where some directions remain free. Night pain that wakes the person when lying on that side is characteristic.

It is more common in people with diabetes and thyroid disease, and in that group it tends to last longer.

Frozen shoulder resolves in most people, but slowly — often over a year or more 2. Treatment shortens that and limits how much range is lost in the meantime; it does not make it a short condition.

During the painful phase: pain control, gentle movement within the pain-free range, and injection where indicated. During the stiff phase: progressive mobilisation and stretching, which can be demanding and needs to be sustained.

Frozen shoulder occurs most often between forty and sixty, more frequently in women, and substantially more often in people with diabetes — where it also tends to be more stubborn and to last longer 2. Thyroid disease and a period of shoulder immobilisation after injury or surgery are the other common associations.

We check blood glucose in anyone presenting with it who has not been tested, because undiagnosed diabetes is found often enough to be worth looking for and because it changes what the programme should expect.

In the first phase the capsule is inflamed and the dominant problem is pain, including pain at night that wakes you. Aggressive stretching here increases inflammation and lengthens the whole course. This is the single most common treatment error in frozen shoulder.

What helps is pain control, gentle movement within a comfortable range to prevent additional stiffness, activity modification, and — where pain is severe — an intra-articular corticosteroid injection, which is most useful early rather than late.

Once pain settles and stiffness dominates, the priority reverses. Sustained, progressive stretching at end range, joint mobilisation and strengthening through the recovered range are what restore movement, and they need to be done regularly rather than intensively once a week.

Progress is measured in degrees of external rotation and elevation rather than in how the session felt, because this is a condition where subjective impressions mislead in both directions.

Hydrodilatation, manipulation under anaesthetic and arthroscopic capsular release exist for shoulders that remain severely restricted after an adequate course of rehabilitation. They are not first-line and they do not remove the need for the rehabilitation that follows them — the range gained under anaesthetic is lost within weeks without it.

If a procedure is being considered, the question worth asking is what the therapy plan for the following six weeks is. Without one, the procedure buys very little.