All About Frozen Shoulder

The puzzling, painful medical condition most often strikes women between the ages of 40 and 60.
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shoulder pain

There are a lot of great unknowns about frozen shoulder, including the answer to the most basic question of all: Why does it happen? If doctors puzzle over this (and they definitely do), imagine the frustration of being among the estimated 2 to 5% of the U.S. population affected by it, most of them never knowing why. When my own frozen shoulder saga began about a year ago, with a shooting pain in my upper arm that routinely woke me at 3 a.m., I racked my brain for a reason—and never found one. Was it the result of years of schlepping a heavy handbag over my left shoulder? I still don’t know. But now I know that not knowing is the norm.

Formally known as adhesive capsulitis, a reference to the thickening of the shoulder capsule and adhesions (bands of tissue) that develop, frozen shoulder is more than just painful: It is notoriously stubborn, sometimes taking up to two to three years to resolve. “It takes a long time, so there is a psychological aspect to that,” says orthopedic surgeon and sports medicine specialist Kent Sheridan, M.D., of Sutter Health Sacramento. Helping patients manage their frustration, he says, is part of the treatment process.

What else do we know—and not know—about frozen shoulder? Local experts shared these eight takeaways.

STIFFNESS AND LIMITED RANGE OF MOTION ARE THE HALLMARKS. At the apex of my frozen shoulder journey, my range of motion was so limited I could barely raise my arm out to my side. Apply deodorant, shave under my arm or slide my hand into my back pocket? Fuggedaboudit.

This is all classic frozen shoulder, confirms William Bragg, M.D., an orthopedic surgeon and shoulder surgery subspecialist for Dignity Health Mercy Medical Group in Sacramento. It’s kind of a double whammy, says Bragg, because frozen shoulder impacts not one but both types of range of motion: active, meaning the patient can’t fully raise the arm, and passive, meaning no one else can, either. “With frozen shoulder, when either the patient or  the doctor tries to move the arm, there’s a block,” he says. That’s different from something like a rotator cuff tear, in which only active range of motion is affected, explains Bragg—a differentiation that aids in diagnosis. A patient’s symptoms and exam findings are typically all that’s needed to diagnose a frozen shoulder, Bragg says, though an X-ray or MRI may be used to rule out other issues. Primary care doctors are “really great” at diagnosing frozen shoulder, according to Bragg—so that’s where a patient should start.

“HUH?” THAT IS THE QUESTION. Most patients who show up at his door haven’t a clue how their frozen shoulder happened, says Sheridan. “‘I woke up and my shoulder really started hurting, and it keeps getting worse’ or ‘I’m getting an ice cream headache in my shoulder’ are a couple of the common descriptions I hear,” he says. But it doesn’t always seem to come out of nowhere; often, Sheridan says, a minor precipitating trauma (bumping against a shelf, for example) is identified, hinting at the possible trigger. While studies suggest systemic inflammation and genetics also may play a role in the disease process, frozen shoulder is nonetheless considered idiopathic, according to Sheridan. “Exactly why it happens, we don’t know,” he says. “That’s frustrating to patients and to clinicians, too.” For that reason, he says, practitioners tend to focus on what to expect, the course of the disease (see item 4) and the timeline, instead of puzzling over causal factors.

WOMEN OF A CERTAIN AGE ARE HARDEST HIT. Scientists may not know why frozen shoulder hits, but they know who it most often strikes. Topping that list is women between the ages of 40 and 60, prompting this reporter to wonder if the shifting hormones of perimenopause and menopause play a role. “I’m sure there’s a link there,” Bragg says. “I would argue we don’t have the large-scale studies we need to answer that question.” Also at increased risk: People with endocrine disorders (diabetes, thyroid disease), Parkinson’s disease and cardiac disease. Immobilization of the shoulder, a common post-surgery or postinjury plight, can also set up the “freezing” process.

IT’S A THREE-ACT PLAY. Sheridan emphasizes the importance of understanding the disease’s three distinct stages: Stage 1, freezing, when pain and limited range of motion first appear; Stage 2, frozen, when stiffness worsens and pain may start to fade; and Stage 3, thawing, when the shoulder gradually improves. It’s during Stage 1, when pain peaks, that most people call their doctors, says Sheridan, who prefers to label the phases “painful, stiffness and resolution.” But diagnosis is easiest to establish in Stage 2, he says, when the shoulder becomes stiff. Duration of each stage is highly individual, but according to the American Academy of Orthopaedic Surgeons, average time frames look like this: Stage 1, six weeks to nine months; Stage 2, four to six months; and Stage 3, anywhere from five months to two years. Add it up, and you’ll see just how long this process can take.

But most people aren’t willing to wait that long, as Bragg notes—and in his opinion, there’s no reason why they should. “I tell my patients that progress is going to be slow, and you’re going to be frustrated. But we’re not going to let it take two years.” In the great majority of cases, a frozen shoulder will resolve with nonsurgical methods (or even nontreatment), but if a patient hasn’t seen results somewhere between six months and a year, Bragg says, he may suggest a surgical intervention. “When a shoulder issue is having a significant impact on a person’s mental health, their ability to function in leisure activities, their ability to do their job and be productive in society—at some point, you don’t just say, ‘Let’s wait longer.’ You make the choice to try to help them with an intervention.” Deciding whether to pull that trigger can be tricky, Bragg says, and it’s also a last resort. But in stubborn cases, manipulation under anesthesia (which stretches the shoulder capsule) and arthroscopy are options.

PHYSICAL THERAPY IS KEY. To get the shoulder moving normally again, physical therapy and a whole lot of stretching are widely considered the most essential treatment tools. “I’m a little biased,” says Mark Eddy, owner and president of Campus Commons Physical Therapy in Sacramento. “But I believe physical therapy can help a lot of people with this problem.” A practicing physical therapist for more than 25 years, Eddy says he can usually find some reason behind a frozen shoulder if he asks enough questions. When working with client Jim Burk, the mild nature of the precipitating event took them both by surprise: After reaching behind his back to tie the strings of his apron, Burk felt a “twang” in his shoulder, and things got worse from there. “It was a very humbling experience,” says the 66-year-old Sacramentan. “I was used to going to the gym, lifting weights, staying in shape, and suddenly I was having trouble trying to raise my arm over my head.” After about seven months of twice-weekly therapy sessions and regular stretching at home, Burk says, “I was out of pain and had my arm movement back.”

Eddy cautions that not all therapy is created equal; what matters, he says, is approach. In treating frozen shoulder, Eddy says, he and his staff typically use a combination of range of-motion exercises, joint mobilization techniques and hands-on manual therapy, moving the shoulder in various directions “so that the shoulder, scapular region and the capsule itself frees up and gains mobility.” Early intervention, he stresses, is key. “I’ve found therapy is most useful early on,” says Eddy. “If you wait too long, you may be in a phase where it may not be beneficial.” Bragg agrees timing is everything, noting physical therapy can be counterproductive if shoulder pain isn’t under control—so the first step for most patients, he says, is anti-inflammatories.

TO GET THE SHOT, OR NOT? When frozen shoulder pain hits, most first reach for the Advil (or other NSAID of choice) and an ice pack. But to attack pain and inflammation more aggressively, a cortisone (steroid) injection, given directly into the shoulder joint, is commonly used. Should your primary care doctor do it? That is a matter of debate. Bragg, for one, recommends an image-guided injection, performed by a specialist, for best results.

Steroid use may not be for everyone. “Do you really want to put something into your body that could break down your tissues or have other harmful ramifications?” as Eddy asks. But most conventional clinicians agree that when used appropriately, the benefits outweigh the risks. The general rule of thumb? One shot, and one shot only. “Cortisone shots are overall safe and effective,” Sheridan says. “But multiple injections, particularly in a short period of time, may have deleterious effects on the soft tissues and the cartilage of the shoulder.” Timing, again, is key: According to the findings of a large-scale study published in December 2020 in JAMA Network Open, corticosteroid use in patients who have had frozen shoulder for less than a year is associated with better outcomes. Coupling the treatment with a home exercise program maximizes chances for recovery, the study says.

MULTIMODAL WORKS BEST. As the foregoing suggests, a multimodal approach is often the best way to beat frozen shoulder. In my own case, nonsteroidal anti-inflammatories and physical therapy got the engine started, but it was acupuncture that ultimately got me out of the woods. Jim Burk, who initially dodged the cortisone shot, made a different choice when he confronted a frozen shoulder in his other arm and says he’s glad he did. “It [the shot] was effective almost immediately,” says Burk, who paired it with the at-home exercises he’d learned the first time around. Burk’s “other arm” experience isn’t uncommon: A whopping 20 to 30% of frozen shoulder sufferers are estimated to experience an occurrence in the opposite arm, according to the American Physical Therapy Association.

PREVENTION MAY BE POSSIBLE. Or is it? Experts say there’s no surefire way to prevent a frozen shoulder. But keeping the shoulder moving might help, notes Bragg, directing his comment to those who have an injury or other shoulder issue, such as impingement. “Being immobile will just make you stiff and potentially lead to frozen shoulder,” he says. “You don’t want to turn one problem into two.”