What is frozen shoulder and how physiotherapy helps in reducing pain
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"frozen shoulder" OR "adhesive capsulitis" AND physiotherapy
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Frozen Shoulder (Adhesive Capsulitis)
What Is Frozen Shoulder?
Frozen shoulder, formally called adhesive capsulitis, is a condition characterized by pain and progressive loss of both active and passive glenohumeral (shoulder joint) movement in all planes. The term was coined by Neviaser to describe a contracted, thickened joint capsule drawn tightly around the humeral head, with relative absence of synovial fluid and chronic inflammatory changes in the capsule's subsynovial layer.
The underlying pathology involves synovial inflammation followed by reactive capsular fibrosis - specifically, a dense matrix of type III collagen containing fibroblasts and myofibroblasts (resembling Dupuytren disease histologically). The essential lesion involves the coracohumeral ligament (CHL) and the rotator interval capsule. Alarmins (endogenous molecules released after tissue injury) are significantly elevated in frozen shoulder capsules, and HMGB1 expression correlates directly with pain severity. Neoangiogenesis and neuroinnervation of the capsule also contribute to the often severe pain.
- Campbell's Operative Orthopaedics 15th Ed 2026, p. 2838
- Miller's Review of Orthopaedics 9th Ed
Who Gets It?
| Risk Factor | Detail |
|---|---|
| Age | 40-70 years most commonly affected |
| Sex | ~70% of patients are women; most common in women in their 50s |
| Diabetes mellitus | Insulin-dependent patients ~5x more likely; bilateral in 50% of diabetic cases |
| Immobilization | Prolonged immobility is the most significant contributing factor |
| Other associations | Thyroid disease, cervical disc disease, stroke, MI, autoimmune disease, trauma, chest/breast surgery |
| Hyperlipidemia | Proposed as an additional risk factor |
The condition rarely recurs in the same shoulder. Between 20-30% of patients develop it in the opposite shoulder later.
- Campbell's Operative Orthopaedics 15th Ed 2026, p. 2838
Stages of Adhesive Capsulitis
The disease progresses through distinct stages (arthroscopically described):
| Stage | Description |
|---|---|
| 1 - Pre-adhesive | Fibrinous inflammatory synovitis; pain is the dominant symptom; patient restricts movement |
| 2 - Acute adhesive synovitis | Synovium proliferates; early adhesion formation, notably in the inferior capsular fold |
| 3 - Maturation | Less synovitis, more fibrosis; axillary fold obliterated; stiffness dominant |
| 4 - Chronic | Fully mature adhesions; motion severely reduced; pain only at end ranges |
| 5 - Thawing | Gradual spontaneous improvement in motion |
Clinically, internal and external rotation are lost first, followed by flexion. Patients typically can internally rotate only to the sacrum, with ~50% loss of external rotation and less than 90° abduction. The pathognomonic sign is loss of active external rotation. Active and passive ROM are equivalently reduced - this distinguishes it from rotator cuff tears.
The natural course lasts 12-18 months, though approximately 10% of patients have long-term residual problems. Duration is often considerably longer in diabetics.
- Campbell's Operative Orthopaedics 15th Ed 2026, p. 2839-2840
- Goldman-Cecil Medicine, p. 2777
How Physiotherapy Reduces Pain and Restores Function
Approximately 90% of frozen shoulder cases respond to nonoperative management including physical therapy, corticosteroid injections, and NSAIDs.
Goldman-Cecil Medicine, p. 2777 | Miller's Review of Orthopaedics 9th Ed
Physiotherapy Modalities
1. Ice / Heat Therapy
Applied around the shoulder to reduce local inflammation and pain before or after exercise, improving tolerance for movement.
2. Ultrasound Therapy
Therapeutic ultrasound delivers deep thermal and non-thermal effects to the capsule and periarticular tissues, increasing tissue extensibility and reducing pain.
3. Transcutaneous Electrical Nerve Stimulation (TENS)
TENS modulates pain signals through gate-control mechanisms and is used to provide pain relief both during and between sessions, facilitating exercise tolerance.
4. Range of Motion Exercises - Staged Progression
The most important physiotherapy component. The progression is:
- Pendulum (Codman) exercises - gravity-assisted swinging to decompress the joint and begin gentle capsular stretching
- Finger wall climbing - progressive shoulder elevation with the fingers "walking" up the wall
- Passive stretching - therapist-assisted end-range mobilization
- Active-assisted ROM - patient uses the other arm (e.g., pulley exercises) to assist movement
- Active ROM and strengthening - once pain and stiffness permit
Abduction is initially avoided to prevent subacromial impingement until joint motion becomes suppler.
Goldman-Cecil Medicine, p. 2777
5. Joint Mobilization Techniques
Manual therapy techniques directed at the glenohumeral joint (Maitland grades, Kaltenborn techniques) to stretch the capsule, reduce stiffness, and improve end-range motion. A 2024 systematic review (PMID: 39420459) found that both muscle energy techniques and joint mobilization techniques significantly improved range of motion, pain, and functional ability in adults with frozen shoulder.
6. Mulligan's Mobilization with Movement (MWM)
A 2025 meta-analysis (PMID: 39189938) confirmed clinical significance of Mulligan's MWM for shoulder pathologies including frozen shoulder, improving pain and ROM.
7. End-Range Interventions
A 2024 meta-analysis (PMID: 37559358) on end-range mobilization techniques showed these are effective in managing primary adhesive capsulitis.
8. Extracorporeal Shockwave Therapy (ESWT)
Listed among treatments with reported efficacy in Campbell's 2026. Applied to the shoulder capsule to promote tissue remodeling and pain reduction.
9. Scapular Stabilization and Posture Correction
Addresses compensatory movement patterns and scapulothoracic dysfunction that develop as patients guard the shoulder.
10. Education and Activity Guidance
Patients who seek care earlier recover more quickly. Understanding the staged, self-limiting nature of the condition reduces anxiety-driven guarding, which worsens stiffness. Depression and anxiety adversely affect pain and function and may require separate attention.
Combined Approach: Physiotherapy + Injections
Physiotherapy works best alongside:
- Intraarticular corticosteroid injections (methylprednisolone acetate 40 mg/mL into glenohumeral joint and subacromial bursa) - reduce inflammation, allowing better exercise participation
- Distension arthrography/hydrodistension (20-30 mL of local anaesthetic injected to expand the capsule) - directly stretches adhesions and facilitates subsequent physiotherapy
Bailey and Love's 28th Ed, p. 552 | Campbell's 2026
When Surgery Is Considered
Patients in whom 12-16 weeks of nonsurgical treatment fails are offered:
- Manipulation under anesthesia (MUA) - closed stretching under general anaesthetic, followed by immediate physiotherapy to maintain gained motion
- Arthroscopic capsular release - effective for refractory cases; a 2024 meta-analysis (PMID: 38747000) compared this to MUA with similar outcomes
Failures after surgery are most often related to inability to maintain postoperative range of motion - underscoring that physiotherapy after any intervention remains the cornerstone of recovery.
Summary
| Physiotherapy Goal | Main Techniques |
|---|---|
| Pain relief | TENS, ice/heat, ultrasound |
| Capsular stretching | End-range mobilization, MWM, pendulum exercises |
| ROM restoration | Progressive active/passive exercises, joint mobilization |
| Function recovery | Strengthening, scapular stabilization, ADL training |
| Patient empowerment | Education, home exercise programs |
The key principle: early intervention and consistent physiotherapy are the most effective tools for shortening the painful and frozen phases of adhesive capsulitis.
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