Dr. Yi-Cheng Wu
中文

Shoulder Pain in Middle Age: Understanding Frozen Shoulder, from Symptoms to Treatment

By Dr. Yi-Cheng Wu · Reviewed June 21, 2026

Frozen shoulder is pain and restricted mobility caused by fibrosis and adhesion of the shoulder joint capsule. It is more common in middle-aged women and people with diabetes. It typically evolves naturally through three stages and may last several years, and treatment centers on rehabilitation, injections, and manual therapy.

Frozen shoulder (adhesive capsulitis) is a condition in which the shoulder joint capsule thickens, becomes fibrotic, and adheres to the humeral head, causing shoulder pain and restricted mobility. It typically occurs around age 55, is slightly more common in women (about 1.4:1), has a prevalence of about 3% in the general population, and reaches 10-20% in people with diabetes. The course is usually divided into three stages — freezing/painful, frozen/stiff, and thawing — with an average of more than 30 months from onset to marked improvement, and most cases gradually improve. Common management includes rehabilitation exercises, manual therapy, anti-inflammatory painkillers, and corticosteroid injections. Whether a particular treatment is suitable still depends on your condition and a physician's assessment.

Adhesive capsulitis, commonly called frozen shoulder, is caused by thickening and fibrosis of the shoulder joint capsule and its adhesion to the humeral head. The main symptom is painful restriction of shoulder range of motion (ROM).

The term “frozen shoulder” was first proposed by Codman in 1934. In 1872, the same condition had already been described by Duplay as “periarthritis.” In 1945, Naviesar coined the term “adhesive capsulitis.”

  • It is divided into two types: primary (no obvious triggering event, slow onset) and secondary (associated with trauma, immobility, or an underlying systemic disease).
  • After a period of worsening symptoms, frozen shoulder often improves, but full recovery can take up to 3 years. Rehabilitation, injection treatment, and manual therapy are commonly recommended to help reduce the freezing process, and may also help ease discomfort and support recovery.

Epidemiology

  • Slightly more common in women than men, at a ratio of about 1.4:1.
  • The average age of onset is about 55, and it is rare under age 40.
  • 15% of patients develop bilateral disease.
  • The prevalence in the general population is 3%, and 10-20% in people with diabetes. People with diabetes and frozen shoulder tend to have more severe stiffness before the “thawing” stage, and it persists for longer.

Etiology and Pathophysiology

  • The exact pathophysiology is not fully understood. Research suggests that the pain arises from synovitis, while capsular fibrosis restricts the range of motion.

  • The clinical course can be divided into three stages:

  • Freezing/Painful stage: progressive pain (6 weeks to 9 months). Pain and stiffness appear around the shoulder with no history of injury. The persistent pain worsens at night and responds poorly to non-steroidal anti-inflammatory drugs.

  • Frozen/Stiff stage: reduced range of motion affecting daily life (4 to 12 months or longer). The pain gradually eases, but the stiffness remains. Pain is felt only with extreme movements, scapular and humeral motion is markedly reduced, and external rotation range is almost completely lost.

  • Thawing stage: motion gradually returns (12 to 42 months). The range of motion progressively improves. The average time from the onset of inflammation to maximal improvement is more than 30 months.

  • It may be primary, with no specific cause, or secondary — caused by injury to the shoulder, cervical radiculopathy, brachial plexopathy, or rotator cuff tendinitis.

  • Possibly related conditions include hypothyroidism, hyperthyroidism, Parkinson’s disease, and autoimmune-related causes (microvascular disease leading to abnormal collagen repair).

Risk Factors

  • Prolonged shoulder immobilization increases the risk 5- to 9-fold.
  • Diabetes: 10-20% prevalence.
  • Thyroid disease.
  • Stroke.
  • Female sex.

History

  • Symptoms include progressive shoulder pain over weeks to months.
  • Any shoulder movement, whether active or passive, worsens the pain. Night pain is worse and may disturb sleep.
  • The pain often appears not only in the deltoid region but may also radiate to the upper arm and neck.
  • Common functional problems include difficulty dressing, combing hair, and reaching into a back pocket to get a wallet.

Physical Exam

  • The typical presentation is reduced shoulder range of motion with pain, and a lack of arm swing when walking.
  • It usually affects the non-dominant shoulder first.
  • In the early stage, pain only at the end of the range of motion may be the only finding.
  • The most obvious restriction initially is usually seen in external rotation; in later stages all ranges of motion are typically restricted.
  • Restriction of movement usually occurs in the following order: external rotation, then abduction, then internal rotation, then forward flexion.

Differential Diagnosis

  • Rotator cuff tear.
  • Osteoarthritis of the glenohumeral or acromioclavicular joint.
  • Biceps tendinitis.
  • Cervical radiculopathy.
  • Gout.

Diagnostic Tests

  • X-ray: to rule out osteoarthritis, posterior dislocation, and calcific tendinitis.
  • Ultrasound: offers dynamic capability with multiple scanning planes, and depends on the clinician’s expertise and skill.
  • MRI: used to assess other pathologies, including the labrum.

Acute Treatment

  • Gentle stretching and range-of-motion exercises should begin as early as possible once symptoms start.

  • Manual therapy: begin with gentle range-of-motion exercises first, followed by scapulothoracic stabilization exercises, rotator cuff strengthening, and biceps strengthening.

  • Modality treatments include: ultrasound (using sound waves to heat the affected tissue), phonophoresis (using ultrasound waves to drive topical corticosteroid medication into the affected tissue), and iontophoresis (using electrical current to drive corticosteroid into the affected tissue).

  • First-choice medication: non-steroidal anti-inflammatory drugs (NSAIDs); other medication options include topical anesthetics and capsaicin.

  • Ice massage and oral and topical anti-inflammatory drugs can be used during acute symptom flares, especially when combined with rest.

See the AAOS patient handout

Medication and Injection Treatment

  • Corticosteroid injection has been associated with symptom relief in many patients in studies; whether it is suitable depends on your condition and a physician’s assessment.

  • Hydrodilatation of the shoulder joint: if symptoms are not relieved by other non-surgical methods, hydrodilatation may be recommended. This treatment involves gently injecting a large volume of sterile fluid into the shoulder joint to distend and stretch the joint capsule.

  • In this study, 93% of patients had symptom relief after the first hydrodilatation procedure; to get the most benefit from shoulder distension, it should be accompanied by an exercise program. Carrying out a home exercise program on one’s own after the procedure was shown to be as effective as a supervised physical therapy program. These are trial results and do not predict any individual’s outcome.

  • The physical distension produced by injecting 20-40 mL of fluid (saline, corticosteroid, and local anesthetic) into the shoulder capsule may lower the glycosaminoglycan concentration within the capsule, thereby reducing myofibroblast activity.

  • Suprascapular nerve block (SSNB): relieves pain arising from the sensory innervation of the subscapular bursa, the posterior shoulder capsule, and the acromioclavicular joint.

  • A dose that may be considered: 5 mL of 1% Lidocaine or 0.5% Bupivacaine/Levobupivacaine +/- Depomedrone.

  • Shockwave therapy: has a reasonable effect on improving pain around the shoulder, but more well-designed trials with long-term follow-up are needed.

  • PRP (platelet-rich plasma) treatment: related studies and systematic reviews began to appear after 2018-2019.

Surgery

  • Surgery is aimed at refractory cases in which conservative treatment has failed; it is usually performed during the “second stage: frozen.” Note that the failure rate is higher in people with diabetes.
  • The goal of surgery is to stretch and release the stiff joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

Follow-up

  • Patient monitoring: people with diabetes may have a short-term rise in blood sugar after receiving a corticosteroid injection.
  • Axillary nerve injury may occur after surgical capsular release.

Prognosis

  • About 70% of patients are symptom-free within one year of onset.
  • About 30% of patients have symptoms that persist for years; of these, 66% improve after extracorporeal shockwave therapy, and the remaining 10% with symptoms are considered for surgery.
  • Negative prognostic indicators include female sex, bilateral involvement, the dominant hand, and accompanying large or multiple calcifications. In these specific patients, more aggressive treatment early in the disease course may improve long-term outcomes.
  • After surgery, returning to daily activities takes 3 to 4 months, and full return to sports activity takes 6 to 18 months, which is longer than with conservative treatment.

References

Frequently asked questions

Who is more likely to develop frozen shoulder?

It occurs most often around an average age of 55 and is slightly more common in women (about 1.4:1), and is uncommon under age 40. In people with diabetes the prevalence reaches 10-20% and the stiffness is often more severe. Prolonged shoulder immobilization, thyroid disease, and stroke are also associated with increased risk.

Does frozen shoulder resolve on its own, and how long does it take?

The course is usually divided into three stages — freezing/painful, frozen/stiff, and thawing. Observational studies show that most cases gradually improve, but the average time from onset to marked improvement is more than 30 months, and full recovery may take longer. About 70% of patients have symptom relief within one year of onset.

What are the symptoms of frozen shoulder, and how does it affect daily life?

The main features are progressive shoulder pain and restricted mobility developing over weeks to months. Night pain is often more noticeable and may disturb sleep, and it commonly makes daily activities such as dressing, combing hair, and reaching into a back pocket difficult. The restriction of movement usually appears in the order of external rotation, abduction, internal rotation, and forward flexion.

How is frozen shoulder usually treated?

The foundation is early, gentle stretching and range-of-motion exercises, manual therapy, modality-based physical therapy, and anti-inflammatory painkillers. Corticosteroid injection, hydrodilatation of the shoulder joint, and shockwave therapy are also options that may be considered. Surgery is reserved for refractory cases in which conservative treatment has not worked. The exact approach depends on your condition and a physician's assessment.

This article is also available in the original Chinese, with the full reference list.

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