Why shoulder stiffness and pain shouldn’t be ignored
Shoulder pain is common, but when pain is accompanied by a progressive loss of movement, especially without a clear injury, it may point towards a condition known as adhesive capsulitis, more commonly referred to as frozen shoulder.
Frozen shoulder can be frustrating, painful, and slow to resolve. Many people feel unsure about what is happening, how long it will last, and whether movement will make things worse. Understanding the condition — and what evidence-based care looks like — is a key step towards recovery.
What is adhesive capsulitis?
Adhesive capsulitis is a condition characterised by pain and significant restriction of both active and passive shoulder movement, caused by inflammation and thickening of the joint capsule surrounding the shoulder (Glenohumeral joint) (Lewis, 2015).
Unlike many shoulder conditions, frozen shoulder:
- Is not caused by muscle weakness alone
- Limits movement even when someone else moves your arm
- Develops gradually, often without a clear traumatic event
The condition is generally self-limiting, but without appropriate management it can persist for months to years, significantly affecting daily activities, sleep, work, and sport (Brue, Valentin, Forssblad, Werner, Mikkelsen and Cerulli, 2007).
Who is most at risk?
Adhesive capsulitis most commonly affects adults between 40 and 60 years of age, and is slightly more common in women (Hand, Clipsham, Rees and Carr, 2008).
Risk factors include:
- Diabetes (type 1 and type 2)
- Thyroid disorders
- Prolonged shoulder immobilisation
- Previous shoulder injury or surgery
- Cardiovascular disease
It can affect one shoulder, and in a smaller proportion of cases, the opposite shoulder may be affected later on.
The stages of frozen shoulder
Frozen shoulder typically progresses through three overlapping stages:
1. Painful (Freezing) Phase
- Increasing shoulder pain
- Pain worse at night
- Gradual loss of movement
This stage can last 2–9 months.
2. Stiff (Frozen) Phase
- Pain may reduce
- Stiffness becomes the dominant problem
- Difficulty with dressing, reaching overhead, or behind the back
This stage can last 4–12 months.
3. Recovery (Thawing) Phase
- Gradual improvement in range of movement
- Reduced pain
- Slow return of function
Recovery may take 6–24 months, depending on individual factors and management.
Common symptoms to watch for
- Persistent shoulder pain without a clear cause
- Marked stiffness, particularly with external rotation and elevation
- Difficulty with daily tasks such as dressing or washing hair
- Sleep disturbance due to shoulder pain
- Limited movement even when assisted
If these symptoms are present, a physiotherapy assessment is recommended to confirm the diagnosis and rule out other shoulder conditions.
How physiotherapists assess frozen shoulder
A physiotherapy assessment focuses on identifying whether symptoms fit the pattern of adhesive capsulitis or another shoulder pathology.
This typically includes:
- A detailed history (onset, progression, night pain, medical conditions)
- Assessment of active and passive shoulder range of movement
- Strength testing where appropriate
- Functional assessment of daily activities
- Screening for red flags or conditions requiring onward referral
Imaging (such as ultrasound or MRI) is not routinely required to diagnose frozen shoulder but may be used to exclude other causes of shoulder pain when clinically indicated (Lewis, 2015).
Treatment options: what does physiotherapy involve?
Management of adhesive capsulitis depends on the stage of the condition, symptom severity, and individual goals.
Physiotherapy may include:
- Education and reassurance about the condition’s natural course
- Pain management strategies
- Stage-appropriate mobility exercises
- Progressive strengthening as movement improves
- Manual therapy to support symptom relief and movement where appropriate
- Load and activity modification
Exercise intensity and stretching must be carefully dosed — overly aggressive treatment, particularly in the painful phase, can worsen symptoms rather than speed recovery (Kelley, Shaffer, Kuhn, Michener, Seitz, Uhl and Godges, 2013).
Other treatments and when they are considered
In some cases, physiotherapy may be combined with:
- Corticosteroid injections (particularly in the early painful stage)
- Hydrodilatation
- Pain-modifying medications (via GP or consultant)
Evidence suggests that early injection combined with physiotherapy may provide short-term pain relief and improved function for some patients (Challoumas, Biddle, McLean and Millar, 2020).
Red flags and when referral is required
Further investigation or referral may be required if:
- Pain is severe and unrelenting without stiffness
- There is unexplained weight loss or systemic illness
- Neurological symptoms are present
- There is a history of significant trauma
- Symptoms are rapidly worsening or atypical
A physiotherapist is trained to recognise these signs and refer appropriately.
What is the outlook?
While frozen shoulder can be slow to resolve, most people regain good functional movement over time. Structured physiotherapy, appropriate pain management, and realistic expectations are key to navigating recovery effectively.
Early assessment helps avoid unnecessary fear, inappropriate loading, or prolonged disability.
Takeaway: patience, structure, and the right support
Adhesive capsulitis is not something you can “push through”, but it is something you can recover from with the right guidance. Understanding the stage you’re in and following an evidence-based plan can make a significant difference to both comfort and confidence.
If you’re ready for evidence-based, structured, and personalised care, our physiotherapy team is here to help you understand your shoulder pain and guide your recovery at every stage. Book an appointment or get in touch — your shoulder deserves the right rehab.
Written by Stuart Williams | Physiotherapist | Vestibular Specialist | Running Expert
References
Brue, S., Valentin, A., Forssblad, M., Werner, S., Mikkelsen, C. and Cerulli, G. (2007) ‘Idiopathic adhesive capsulitis of the shoulder: A review’, Knee Surgery, Sports Traumatology, Arthroscopy, 15(8), pp. 1048–1054. https://doi.org/10.1007/s00167-007-0348-2
Challoumas, D., Biddle, M., McLean, M. and Millar, N.L. (2020) ‘Comparison of treatments for frozen shoulder: A systematic review and meta-analysis’, JAMA Network Open, 3(12), e2029581. https://doi.org/10.1001/jamanetworkopen.2020.29581
Hand, C., Clipsham, K., Rees, J.L. and Carr, A.J. (2008) ‘Long-term outcome of frozen shoulder’, Journal of Shoulder and Elbow Surgery, 17(2), pp. 231–236. https://doi.org/10.1016/j.jse.2007.05.009
Kelley, M.J., Shaffer, M.A., Kuhn, J.E., Michener, L.A., Seitz, A.L., Uhl, T.L. and Godges, J.J. (2013) ‘Shoulder pain and mobility deficits: Adhesive capsulitis’, Journal of Orthopaedic & Sports Physical Therapy, 43(5), pp. A1–A31. https://doi.org/10.2519/jospt.2013.0302
Lewis, J. (2015) ‘Frozen shoulder contracture syndrome – Aetiology, diagnosis and management’, Manual Therapy, 20(1), pp. 2–9. https://doi.org/10.1016/j.math.2014.07.006