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Education · shoulder

Frozen Shoulder Info In-depth Evidence

Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed

Related shoulder topics. Capsular release .

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Video transcript

Frozen shoulder is a deep, aching pain that comes with stiffness, so the joint gradually becomes harder to move. It often starts for no clear reason, and is more common around middle age, and in people with diabetes. Reaching overhead or behind your back becomes difficult and sore. The pain is often worst at night, and can disturb your sleep. It tends to pass through phases, slowly freezing, staying frozen, then gradually thawing. Most frozen shoulders settle on their own, though it can be a slow journey over many months. The aim early on is to control the pain, and to keep as much movement as possible. Gentle stretching, guided by a physiotherapist, helps maintain range without flaring things up. Anti-inflammatory medication, and a cortisone injection into the joint, can be very helpful in the painful phase. With time and patience, the shoulder usually loosens and the pain fades. When a shoulder stays stiff and painful despite these measures, a keyhole operation can release it. A camera and small instruments are used through tiny incisions. The tight, inflamed capsule around the joint is carefully released, freeing the shoulder to move again. You go home the next day, with the arm resting in a sling. Movement is the key to recovery, so physiotherapy starts soon after surgery, to hold on to the range that has been gained. The sling is mainly for comfort in the first few days. Most people see their movement improve steadily over the following months. The shoulder can ache as it settles, which is a normal part of healing. Keeping up the exercises gives the best long-term result.

What you're feeling

Frozen shoulder usually starts as a deep, dull ache that builds over weeks rather than appearing overnight. For most people the pain is the worst part at first, and it is often worst at night. Lying on that side becomes impossible, and broken sleep is one of the most exhausting parts of the whole condition.

Then the shoulder starts to lock up. You reach for a seatbelt, or up to a high shelf, or back to a pocket, and the arm simply stops. What makes frozen shoulder different from most shoulder problems is that the stiffness is not just you guarding against pain — the shoulder genuinely will not move, even if someone else lifts your arm for you. Losing the ability to turn your hand outwards, as if opening a door or putting your arm into a sleeve, is the most characteristic sign of all.

Most people are between about 40 and 60. Some remember a minor knock beforehand; many have no explanation at all. It is more common if you have diabetes or a thyroid condition, and if you have had it in one shoulder, there is a modest chance of the other one following later.

What's actually happening

Your shoulder joint sits inside a sleeve of tough tissue called the capsule. Normally that sleeve is loose and stretchy, which is what allows the shoulder to move further than any other joint in the body. In frozen shoulder the capsule becomes inflamed and then thickens and contracts, so the sleeve shrinks. The space inside the joint can end up less than half its normal size.

Despite the older name "adhesive capsulitis", nothing is actually stuck together inside the joint. There are no glue-like adhesions. The tissue has tightened, which is a genuinely different problem, and it is why some surgeons argue the condition should simply be called a contracture — a tightening — of the shoulder.

Why it starts is still not properly understood, and it is honest to say so. There is good evidence that it is not purely a local problem with the shoulder. Studies of inherited risk show that type 1 diabetes genuinely causes frozen shoulder rather than just being associated with it, and that the link runs through blood sugar rather than through weight or mechanical load. The tissue changes look strikingly similar to Dupuytren's disease in the hand, which is why the two often turn up in the same person.

Being honest about how long it takes

You will very likely read that frozen shoulder is self-limiting and resolves completely in around eighteen months to two years. We want to be straight with you: that reassurance is more confident than the evidence supports.

The idea that the condition passes neatly through three stages — freezing, frozen, then thawing — comes from a small study published in 1975, in which patients had their arms rested in slings for up to nine months. Unsurprisingly, shoulders treated that way became stiff and then loosened again once movement was allowed. When researchers went back and reviewed all the available studies, they could find no good evidence that untreated shoulders reliably pass through those stages and end up normal. In fact, no study has ever shown people getting back to a measured, genuinely normal range of movement without treatment.

What the evidence does show is more useful, and it is this: most of the improvement you are going to get tends to happen early, and then progress slows and levels off. That plateau can be permanent. Depending on which study you read, somewhere between a third and a half of people still have some ache or stiffness several years later, though for most of them it is mild and does not stop them doing what they want to do.

None of that means you will not get better. Most people improve a great deal. It does mean that "just wait, it will sort itself out" is not a neutral piece of advice, and that there is a reasonable case for treating the pain actively rather than simply enduring it.

What we can do about it

At Mater Private Hospital Rockhampton, Dr Kieran Hirpara will talk you through the options based on which is bothering you more — the pain or the stiffness — rather than trying to slot you into a numbered stage.

A steroid injection into the joint is the single best-supported treatment for the painful phase. Across a very large body of research it is the one treatment that reliably produces a difference in pain and function that patients actually notice, and it works within the first few weeks. Its honest limitation is that the advantage fades by around four to six months. It buys you comfort, sleep, and the ability to work at the shoulder — it does not cure the tightness.

Exercises and physiotherapy are worth doing, with realistic expectations. A simple home exercise programme has measurable value. What may surprise you is that how hard you push does not appear to matter: studies comparing firm, end-of-range stretching against gentle, pain-free movement found no difference in the results at six and twelve months — and, reassuringly, no evidence that pushing harder does damage. So work within what you can tolerate. Fighting through severe pain has not been shown to speed anything up.

Hydrodilatation, where fluid is injected to stretch the capsule from the inside, is widely used and low-risk. The research on it is genuinely mixed: one large review found it helped pain a little but not movement, another found the reverse. It is a reasonable option, but we will not oversell it.

Manipulation under anaesthetic means moving the shoulder through its full range while you are asleep, to stretch the tight capsule. In the largest trial comparing the main treatments, this came out as the best value option overall.

Keyhole capsular release involves surgically dividing the tight capsule under direct vision, rather than stretching it until it tears. Its main advantage is that it tends to be the most durable: across the published surgical series recurrent stiffness after a release is uncommon, whereas after a manipulation a meaningful proportion of shoulders tighten up again and need a second procedure. In the large UK trial, people who had a release were the least likely of the three groups to need any further treatment. Because it is an operation it carries a little more risk than the alternatives and costs more, and you should expect to feel sorer in the first few weeks than someone who had a manipulation — that early difference evens out by around six months.

Worth knowing: in that trial, all three approaches ended up within a few points of each other at one year. That is genuinely good news, because it means the decision can be made on what suits you, your other health conditions and your circumstances, rather than on one option being clearly better.

How Dr Hirpara usually sequences this. You will not be told to put up with it for a fixed number of months before anything can be offered. In practice he will usually suggest a steroid injection first, because for a lot of people that takes enough of the pain away to get on with life while the shoulder settles. If the injection does not give you adequate relief, he is happy to offer a capsular release from that point — he does not require you to have struggled on for nine or twelve months first. Given how shaky the "it always resolves on its own" reassurance turns out to be, there is little sense in spending a year in pain to find out which way yours will go.

What to expect

If you have an injection, expect the pain to ease over the first week or two. Use that window to keep the shoulder moving.

If you have a manipulation or a capsular release, most of the range you are going to regain comes back quickly — usually within the first four to six weeks — and there is generally little further change after about three months. Getting moving early matters, and physiotherapy normally starts within a day or two of the procedure. Most people are back to office-type work within one to three weeks.

If you have diabetes, it is fair to expect a slower and slightly less complete recovery than average, and worth knowing that a steroid injection can unsettle your blood sugars for a few days. Tell us if your control is difficult, because it changes what we recommend.

Recovery is measured in months, not weeks, whichever route you take. The most useful thing you can do is keep using the arm within comfortable limits and keep your sleep protected.

When to see someone

See your GP if shoulder pain is waking you at night or has not settled with a few weeks of rest, and ask specifically about frozen shoulder if the shoulder is becoming genuinely hard to move rather than just sore.

Ask for a specialist review sooner if you cannot turn your hand outwards, if you have diabetes, if the shoulder is affecting your work or driving, or if the pain is severe enough to stop you sleeping. There is no advantage in waiting a long time before getting the pain assessed.

Seek prompt medical attention if the shoulder becomes hot, red and swollen, if you feel unwell or feverish with it, if there is significant weakness or numbness in the arm, or if the pain started with a fall or an injury. Those features point away from frozen shoulder and towards something that needs looking at more urgently.

Advanced reading: the deeper science (optional)

This section goes a step further than you need for your own treatment decisions. It is here because frozen shoulder is one of the conditions where what patients get told and what the research actually shows have drifted apart, and some people would rather see the reasoning than be asked to take it on trust.

What is actually going wrong in the joint

The capsule is a sleeve of collagen around the joint. In frozen shoulder it becomes inflamed and then fibrotic — cells called fibroblasts multiply and lay down dense new collagen, and some of them convert into myofibroblasts, which can actively contract. That is the key difference from ordinary scarring: the tissue does not just thicken, it pulls tight. The joint volume can drop from a normal 10–15 mL to 3–4 mL.

The same cell behaviour occurs in Dupuytren's disease in the hand, which is why the two conditions turn up in the same people, and why one shoulder surgeon has argued the condition should simply be renamed a contracture of the shoulder rather than a "capsulitis" [1]. Despite the old name "adhesive capsulitis", surgeons looking inside the joint find no adhesions at all.

Why the "three stages" story is on shakier ground than it sounds

You will read everywhere that frozen shoulder passes through freezing, frozen and thawing phases. That model was proposed in 1975. When researchers went back and traced where it came from, they found the author had mixed up the references for two different earlier papers, and — more importantly — that his patients had their arms rested in slings for up to nine months. A shoulder immobilised that long becomes stiff, and loosens once you let it move. The "stages" may partly describe the treatment rather than the disease.

A systematic review that set out to test the model could find no evidence for it, and found the opposite of what it predicts: most improvement happens early and then slows, rather than building to a late thawing [2]. Nor can clinicians reliably agree which stage a given shoulder is in — the people who wrote the standard definition admitted in print that the data to confirm it "are not available".

The recovery statistic, and why it has two very different answers

The often-quoted figure is that 94% of people recover without treatment. That comes from a real study, but it counts only the patients who went untreated and came back for follow-up. Most of the original group either chose treatment or dropped out. Counting everyone, the same data gives roughly 26% [3]. "Recovered" also meant within 10 degrees of the other shoulder — and in some of those patients the other shoulder had been frozen too.

The largest long-term follow-up found 41% still had symptoms an average of four years on, and — the part worth knowing — that improvement largely stops after about three years rather than continuing indefinitely [4].

It is a whole-body condition, not just a shoulder one

A large genetic study found five regions of DNA associated with frozen shoulder and, using a technique that can separate cause from coincidence, showed that type 1 diabetes genuinely causes it rather than merely accompanying it. Being overweight did not — once diabetes was accounted for, the weight association disappeared. That points to blood sugar rather than mechanical load as the driver [5].

What the physiotherapy evidence actually says

This is the part most worth knowing if you are having, or delivering, physiotherapy. A Cochrane review pooled 32 trials and 1,836 people [6]. Three findings stand out.

Against a steroid injection, hands-on physiotherapy comes off worse early on. In the head-to-head trial, six weeks of passive mobilisation and supervised exercise produced 26 points less pain improvement and 25 points less function improvement at seven weeks than a single injection. Judged on whether people felt much improved or recovered, it was 46% for physiotherapy against 77% for the injection — roughly one extra person helped for every four injected instead. By six to twelve months the gap had closed and the difference no longer mattered.

How hard you push, how often, and which technique is used appear not to matter. A 100-patient trial compared firm end-of-range mobilisation against gentle pain-free mobilisation and found no significant difference on any of seventeen outcomes at six or twelve months — pain, night pain, function, every plane of movement, quality of life. A 120-patient trial varying the frequency of end-range mobilisation (more than twice weekly, weekly, less than weekly) found differences in abduction of under eight degrees, all statistically indistinguishable from zero. Head-to-head comparisons of technique — anterior versus posterior glide, PNF versus conventional exercise, dumbbells versus bare-handed — were almost all non-significant. Reassuringly, there was also no sign that working at end range does harm.

The biggest structural gap: no trial has ever compared manual therapy plus exercise against no treatment at all. So while we can say physiotherapy is not clearly better than an injection, and that the details of how it is delivered do not seem to change much, nobody has actually shown how much of the improvement would have happened anyway.

Two useful caveats. The one genuinely high-quality trial in the review looked at physiotherapy after a joint distension, and found it made no difference to pain, function or quality of life — but it did improve how many people rated themselves recovered, and added about 13 degrees of abduction at six weeks, which had faded by six months. And in the big UK trial, the physiotherapy arm was described as including hands-on stretching into the stiff range, yet its own records show manual mobilisation was used in only 11–27% of patients and supervised stretching in a single one. What was actually delivered — and performed as well as surgery at a year — was education, an injection, gentle supervised movement and a home programme.

How long until it feels better, and does the type of release matter

Timing. After a release, the median patient crosses the "this is a real improvement" threshold at about one month, and the "my shoulder is acceptable to me" threshold at about four months [14]. Time off work runs to a median of eight weeks, though the spread is wide — a quarter are back by four weeks, three quarters by thirteen [15].

Manipulation gets movement back faster. That is the honest trade-off against the durability advantage above: manipulation restores range sooner, and release does not really catch up until around the six-month mark, after which the two are indistinguishable on every pooled measure. One small comparison even found manipulation alone finished with the best external rotation [16].

How much capsule to divide is a genuine question, and the answer is "less than you might think". A review pooling 18 studies, 629 patients and 811 shoulders compared three techniques: releasing the front and underside of the capsule only, adding the back of it, or going the whole way round. Its conclusion was that less extensive releases gave better function and pain scores, that adding a posterior release buys early internal rotation which does not last (though it does give a lasting flexion gain), and that a full 360-degree release "may not provide any further benefit". Complication rates did not differ between the three [17]. Two randomised trials of the posterior extension found the same pattern — faster early recovery, no difference by six months. So a bigger operation is not automatically a better one.

Doing both together is not the answer. In the only three-way comparison, adding a manipulation to a release produced the highest rate of losing external rotation — 18%, against 7% for manipulation alone and 2% for release alone [16].

What the biggest treatment trial actually found

A UK trial randomised just over 500 people to structured physiotherapy with an injection, manipulation under anaesthetic, or keyhole surgery. At one year all three landed within a few points of each other — less than the difference a patient would notice [7]. That is genuinely useful news: it means the choice can be made on what suits you and your circumstances, rather than one option being plainly better.

Where the three do differ is in how often people need something else afterwards. In that trial, further treatment was needed by 4% after a release, 7% after a manipulation and 15% after physiotherapy [7]. Manipulation came out best on cost per unit of benefit; release cost the most and generated most of the trial's serious complications, though those were rare in absolute terms.

Manipulation or release — the recurrence question

This is where the two operations genuinely separate, and it is the reason a surgeon may steer you towards a release even though the headline outcome scores look the same.

A manipulation stretches the capsule until it tears, and the tear does not always go where you would choose. In the largest series — 792 shoulders followed for 17 years — a second manipulation was needed in 17.8%, and in people with type 1 diabetes that rose to 37.9% [9]. The longest follow-up, at an average of 13 years, found 19.2% had needed a repeat manipulation and 31.3% described a recurrence at some point [10]. Two things soften that: nearly all recurrences happen in the first year (after five years the rate is under 2%), and a repeat manipulation works about as well as the first [9][10].

A release divides the capsule deliberately, under vision. Reoperation is markedly less common: a series followed for a mean of five years reported no reoperations in 32 patients, with a single recurrence in someone who did not complete their rehabilitation [11]. The meta-analysis pooling eight studies and 768 patients found no significant difference between the two operations for pain, function or movement, but did note the manipulation group needed more additional injections, concluding that over a longer follow-up "the MUA group may experience more recurrences" [8].

Two honest caveats. First, the big manipulation-recurrence studies largely come from one surgeon's practice, so they are not independent confirmations of each other. Second, release is not a full restoration either: one series measuring against the patient's own opposite shoulder found people sitting at about 77–79% of the good side two to six years later [12], and in a cohort that excluded diabetics, while almost everyone improved by a meaningful amount, 11–22% still did not consider their shoulder acceptable at six months [13].

So the honest summary is this: for getting the shoulder moving and comfortable, the two are about equivalent, and manipulation is the cheaper way there. For staying that way, the evidence favours release. That difference matters most if you have diabetes, if the shoulder is very stiff, or if you have already had a manipulation that did not hold.

Reviewed by Hand-authored 2026-07-30 — pending clinical review · 30 July 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

References
  1. Bunker T. Time for a new name for frozen shoulder — contracture of the shoulder. Shoulder Elbow. 2009;1(1):4-9.
  2. Wong CK, Levine WN, Deo K, Kesting RS, Mercer EA, Schram GA, et al. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy. 2017;103(1):40-7.
  3. Vastamäki H, Kettunen J, Vastamäki M. The natural history of idiopathic frozen shoulder: a 2- to 27-year followup study. Clin Orthop Relat Res. 2012;470(4):1133-43.
  4. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg. 2008;17(2):231-6.
  5. Green HD, Jones A, Evans JP, Wood AR, Beaumont RN, Tyrrell J, et al. A genome-wide association study identifies 5 loci associated with frozen shoulder and implicates diabetes as a causal risk factor. PLoS Genet. 2021;17(6):e1009577.
  6. Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;2014(8):CD011275.
  7. Brealey S, Northgraves M, Kottam L, Keding A, Corbacho B, Goodchild L, et al. Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT. Health Technol Assess. 2020;24(71):1-162.
  8. Zhao Y, Yang T, Feng C, Li L, Pang L, Zhao S. Arthroscopic capsular release versus manipulation under anesthesia for refractory frozen shoulder: a systematic review with meta-analysis. Orthop Surg. 2024;16(7):1517-29.
  9. Woods DA, Loganathan K. Recurrence of frozen shoulder after manipulation under anaesthetic (MUA). Bone Joint J. 2017;99-B(6):812-7.
  10. Fairclough A, Waters C, Davies T, Ali A, Woods D. Long-term recurrence of frozen shoulder after manipulation under anaesthesia. Shoulder Elbow. 2023;15(2):173-80.
  11. Ranalletta M, Rossi LA, Zaidenberg EE, Bertona A, Tanoira I, Maignon GD, et al. Midterm outcomes after arthroscopic anteroinferior capsular release for the treatment of idiopathic adhesive capsulitis. Arthroscopy. 2017;33(3):503-8.
  12. Mardani-Kivi M, Hashemi-Motlagh K, Darabipour Z. Arthroscopic capsular release of frozen shoulder: mid-term results. Clin Shoulder Elb. 2021;24(3):172-7.
  13. Pasqualini I, Tanoira I, Hurley ET, Ranalletta M, Rossi LA. Arthroscopic capsular release achieves clinically significant outcomes in patients with adhesive capsulitis. Arthroscopy. 2024;40(4):1081-8.
  14. Pasqualini I, Rossi LA, Oyem PC, Tanoira I, Ranalletta M. Time required to achieve clinically significant outcomes after arthroscopic capsular release. Orthop J Sports Med. 2024;12(11):23259671241275653.
  15. Sedlinsch A, Berndt T, Rühmann O, Lerch S. Convalescence after arthroscopic capsular release in frozen shoulder. J Orthop. 2020;20:374-9.
  16. Schoch B, Huttman D, Syed UA, et al. Surgical treatment of adhesive capsulitis: a comparison of manipulation, capsular release and both. Cureus. 2020;12(7):e9032.
  17. Sivasubramanian H, Chua CXK, Lim SY, Manohara R, Ng ZWD, Prem Kumar V, et al. Arthroscopic capsular release to treat idiopathic frozen shoulder: how much release is needed? Orthop Traumatol Surg Res. 2021;107(1):102766.
Evidence & references

Overview

  • Frozen shoulder management guidelines provide evidence-based guidance and identify key areas for future research [2].
  • Magnetic resonance imaging findings in frozen shoulder should not replace clinical judgments regarding prognosis and treatment decisions [7].
  • Clinicians should monitor frozen shoulder patients with diabetes more closely and offer further treatment if pain or lack of function persist long-term [8].
  • Different treatment strategies for frozen shoulder may be appropriate depending on the location [9].
  • A strict definition of recalcitrant idiopathic frozen shoulder is needed to prevent unnecessary interventions, as current data should not be interpreted as a plea for surgery in patients with a mean symptom duration of 4 months [10].
  • The variety of participants, methods, interventions, and outcomes across trials provides limited new evidence to inform the non-surgical management and treatment of frozen shoulder [14].
  • Patients with a poor outcome or recurrent symptoms after manipulation under anaesthetic (MUA) should be offered a further MUA, with an expectation of a good outcome and a low complication rate [17].
  • Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder and is not associated with inferior clinical outcomes compared with late surgical intervention [19].
  • There is insufficient evidence to reliably recommend a single treatment approach for frozen shoulder [32].
  • Further treatment was indicated in 41% of patients who could not tolerate more than 20 mL of injection during hydrodilatation [34].
  • Recurrence of frozen shoulder was more common in primary (33%) versus secondary (16%) cases [34].
  • Arthroscopic capsular release is a suitable option for refractory primary frozen shoulder syndrome, leading to faster and long-lasting recovery [35].
  • Manipulation under anaesthetic (MUA) and arthroscopic capsular release (ACR) are both good treatment options for primary frozen shoulder [70].
  • MUA is simpler but carries risks of serious complications, whereas ACR may be safer if performed by experienced surgeons and is convenient for patients with combined rotator cuff tears [70].

Anatomy & Pathophysiology

  • Primary (idiopathic) frozen shoulder consists of three phases: pain, stiffness, and thawing [3].
  • Secondary frozen shoulders may not exhibit all three phases and may not follow the exact chronology of primary frozen shoulder [3].
  • The pain phase of primary frozen shoulder involves a gradual onset of diffuse shoulder pain that is progressive over weeks to months [3].
  • Pain in the initial phase is usually worse at night and exacerbated by lying on the affected side [3].
  • Reduced arm use due to pain leads to stiffness [3].
  • The stiffness phase begins when patients restrict movement to seek pain relief and usually lasts 4 to 12 months [3].
  • During the stiffness phase, patients experience difficulty with activities of daily living, such as men accessing back pockets or women fastening brassieres [3].
  • A dull ache is present nearly all time during the stiffness phase, especially at night, often accompanied by sharp pain during range of motion at or near new endpoints [3].
  • The thawing phase lasts for weeks or months, during which motion increases and pain diminishes [3].
  • Without treatment, motion return in the thawing phase is gradual and may never objectively return to normal, although most patients subjectively feel near normal [3].
  • Frozen shoulder is characterized by progressive pain and stiffness that usually resolves spontaneously after about 18 months [4].
  • Histological features of frozen shoulder are reminiscent of Dupuytren’s disease, with active fibroblastic and myofibroblastic proliferation in the rotator interval, anterior capsule, and coracohumeral ligament [4].
  • Conditions particularly associated with frozen shoulder include diabetes, Dupuytren’s disease, hyperlipidaemia, hyperthyroidism, cardiac disease, and hemiplegia [4].
  • The etiology of frozen shoulder is still not known and understanding of the pathogenesis is limited [15].
  • Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity [12].
  • The pathophysiology of frozen shoulder is complex, involving various pathophysiologic mechanisms [62].
  • A systematic review summarizes the tissue pathophysiology of primary frozen shoulder [25].
  • Primary frozen shoulder is defined by total elevation restricted to 135° or less [20].
  • In primary frozen shoulder, motion restriction is localized to the humero-scapular joint [20].
  • Primary frozen shoulder excludes cases with post-traumatic conditions, rheumatoid arthritis, osteoarthritis, hemiplegia, or other obvious changes explaining the range of motion decrease [20].
  • Secondary frozen shoulder involves decreased range of motion following a traumatic lesion, including soft tissue injury, intra- and juxtaarticular fractures, and other upper limb fractures [20].
  • Symptomatic subjects with frozen shoulder demonstrate substantial kinematic deficits during humeral range of motion [44].
  • Patients with frozen shoulder present with altered shoulder muscle activity and kinematics [78].
  • Pathomechanics of frozen shoulder are characterized by glenohumeral motion limitations, high tension in the anteroinferior glenohumeral capsule, and altered scapular motion [75].
  • The scapulohumeral rhythm (SHR) of the affected shoulder is inversely related to the severity of limitation of shoulder range of motion, suggesting a compensatory pattern [80].
  • The anatomical structure of passive shoulder restraints has no impact on the difference in passive joint position sense values between external and internal rotation in frozen shoulder [59].
  • The thickness of the inferior glenohumeral joint capsule in the 80° scapular plane elevated arm position is a highly reliable and valid method for assessment [79].
  • Imaging is an essential tool for evaluation of patients with shoulder pain to understand the extent of injury [37].
  • X-rays in frozen shoulder are normal, and their main role is to exclude other causes of pain and stiffness [4].
  • Post-traumatic stiffness may persist for some months after severe shoulder injury but is maximal at the start and gradually lessens, unlike the pattern of frozen shoulder [4].
  • Disuse stiffness can occur if the arm is nursed overcautiously, such as following a wrist fracture, but lacks the characteristic pain pattern of frozen shoulder [4].
  • Complex regional pain syndrome may follow acute trauma or be seen in patients with myocardial infarction or stroke, presenting features similar to frozen shoulder [4].
  • Rheumatoid arthritis and osteoarthritis can affect the shoulder and develop bilaterally, with diagnosis usually obvious on X-ray [4].
  • Shoulder stiffness is a typical outcome after bone or soft tissue injuries around the shoulder, including contusions, subluxations, dislocations, acromioclavicular joint injuries, clavicle and scapula fractures, and proximal humerus fractures in the elderly [61].
  • Repetitive, low-level trauma can cause localized contractures leading to motion loss in specific patterns [61].
  • Isolated posterior capsular contracture is the most commonly described localized contracture causing motion loss [61].
  • Surgical procedures such as anterior or posterior capsulorrhaphy, inferior capsular shift, and rotator cuff surgery can result in limitation of motion [61].

Classification

  • Frozen shoulder is a specific, painful, and debilitating condition affecting patients mainly in middle age [6].
  • Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity [12].
  • Most patients clinically diagnosed with primary frozen shoulder had undiagnosed systemic abnormalities and/or intra-articular pathologies [5].
  • Different treatment strategies for frozen shoulder may be appropriate depending on the location [9].
  • 18F-FDG PET/CT is clinically relevant in diagnostically challenging cases, such as distinguishing the first phase of frozen shoulder from subacromial impingement [11].
  • Health professionals manage frozen shoulders differently for different phases of the condition [16].
  • Primary frozen shoulders are defined by total elevation restricted to 135° or less [20].
  • In primary frozen shoulder, the restriction of motion is localized to the humero-scapular joint [20].
  • Primary frozen shoulder is diagnosed when no findings in case history, clinical examination, or radiological examination explain the decrease in range of motion [20].
  • Cases with post-traumatic conditions, rheumatoid arthritis, osteoarthritis, hemiplegia, and other obvious changes are excluded from primary frozen shoulder classification [20].
  • Secondary frozen shoulder is characterized by decreased range of motion following a traumatic lesion [20].
  • Associated injuries in secondary frozen shoulder include soft tissue injury to the shoulder region, intra- and juxtaarticular fractures, and other fractures of the upper limb [20].
  • Frozen shoulder is classified into three consecutive stages according to Reeves [20].
  • Stage 1 of frozen shoulder is characterized by pain [20].
  • Stage 1 of frozen shoulder has a duration of 10 to 36 weeks [20].
  • In Stage 1 of frozen shoulder, there is no difference between men and women, no difference between affected dominant and nondominant shoulders, and no correlation with age [20].
  • In the early stages of frozen shoulder, there is a full range of movement under anesthesia [20].
  • Classification of frozen shoulder was found to be controversial [38].
  • There are lower rates of agreement among Japan Shoulder Society (JSS) members than American Shoulder and Elbow Surgeons (ASES) members for the definition of primary frozen shoulder [43].
  • There are lower rates of agreement among JSS members than ASES members for the classification of primary and secondary frozen shoulder [43].
  • There are lower rates of agreement among JSS members than ASES members for the divisions of secondary frozen shoulder [43].
  • There is disagreement among shoulder specialists regarding terminology for frozen shoulder [57].

Clinical Presentation

  • Frozen shoulder is a specific, painful, and debilitating condition that primarily affects patients in middle age [6].
  • Frozen shoulder is a common disease that causes significant morbidity [21].
  • Frozen shoulder is characterized by severe shoulder pain and functional restriction [24].
  • Frozen shoulder has considerable economic impact [28].
  • Frozen shoulder typically involves substantial pain, movement restriction, and considerable morbidity [12].
  • Frozen shoulder affects approximately 4% of the general population [24].
  • Frozen shoulder affects up to 59% of patients with diabetes mellitus [24].
  • The disease duration of frozen shoulder varies between 1 and 3 years [24].
  • The clinical course of primary (idiopathic) frozen shoulder consists of three phases: pain, stiffness, and thawing [3].
  • Secondary frozen shoulders may not exhibit all three phases and may not follow the exact chronology of primary frozen shoulder [3].
  • Primary frozen shoulder is characterized by progressive pain and stiffness which usually resolves spontaneously after about 18 months [4].
  • In Phase I (Pain), patients experience a gradual onset of diffuse shoulder pain that is progressive over weeks to months [3].
  • The pain in Phase I is usually worse at night and exacerbated by lying on the affected side [3].
  • In Phase II (Stiffness), patients restrict movement to seek pain relief, leading to stiffness that usually lasts 4 to 12 months [3].
  • During Phase II, patients have difficulty with activities of daily living, such as men reaching back pockets or women fastening brassieres [3].
  • In Phase II, a dull ache is present nearly all the time, especially at night, often accompanied by sharp pain during range of motion at or near new endpoints [3].
  • In Phase III (Thawing), motion increases and pain diminishes over weeks or months [3].
  • Without treatment, motion return in Phase III is gradual and may never objectively return to normal, though patients often subjectively feel near normal [3].
  • The natural history of frozen shoulder involves pain that increases in severity, prevents sleeping on the affected side, and subsides after several months [4].
  • As pain subsides in frozen shoulder, stiffness becomes more prominent and persists for another 6–12 months if untreated [4].
  • Movement is gradually regained in frozen shoulder but may not return to normal [4].
  • Patients with frozen shoulder are typically aged 40–60 years [4].
  • Patients with frozen shoulder may give a history of trauma, often trivial, followed by pain [4].
  • Physical examination of frozen shoulder usually reveals slight muscle wasting and tenderness [4].
  • Movements in frozen shoulder are always limited, and the shoulder may be extremely stiff in severe cases [4].
  • X-rays in frozen shoulder are normal; their main role is to exclude other causes of pain and stiffness [4].
  • Post-traumatic stiffness is characterized by stiffness without much pain that is maximal at the start and gradually lessens, unlike the pattern of frozen shoulder [4].
  • Disuse stiffness occurs if the arm is nursed overcautiously and lacks the characteristic pain pattern of frozen shoulder [4].
  • Complex regional pain syndrome may follow acute trauma or occur in patients with myocardial infarction or stroke, presenting features similar to frozen shoulder [4].
  • Rheumatoid arthritis and osteoarthritis can affect the shoulder bilaterally and are usually obvious on X-ray [4].
  • Primary frozen shoulder is defined by total elevation restricted to 135° or less [20].
  • In primary frozen shoulder, motion restriction is localized to the humero-scapular joint [20].
  • Primary frozen shoulder excludes cases with post-traumatic conditions, rheumatoid arthritis, osteoarthritis, hemiplegia, or other obvious changes in history or examination [20].
  • Secondary frozen shoulder involves decreased range of motion following a traumatic lesion, such as soft tissue injury or fractures of the upper limb [20].
  • Stage 1 (pain) of frozen shoulder lasts 10 to 36 weeks [20].
  • In Stage 1 of frozen shoulder, there is no difference in presentation between men and women, affected dominant and nondominant shoulders, or correlation with age [20].
  • In the early stages of frozen shoulder, there is a full range of movement under anesthesia [20].
  • Frozen shoulder following COVID-19 vaccination may present with clinical features similar to idiopathic frozen shoulder [39].
  • Frozen shoulder can occur after COVID-19 vaccination [41].
  • Frozen shoulder is particularly associated with diabetes, Dupuytren’s disease, hyperlipidaemia, hyperthyroidism, cardiac disease, and hemiplegia [4].
  • Most patients clinically diagnosed with primary frozen shoulder had undiagnosed systemic abnormalities and/or intra-articular pathologies [5].
  • MR findings in frozen shoulder should not replace clinical judgments regarding further prognosis and treatment decisions [7].
  • 18F-FDG PET/CT is clinically relevant in diagnostically challenging cases, such as distinguishing the first phase of frozen shoulder from subacromial impingement [11].
  • Unusual stiffness and pain in the shoulder of a young female patient suggests a wide range of disease entities, including infection [23].
  • Misdiagnosing shoulder tumors as frozen shoulder syndrome is likely to cause a significant delay in making a correct diagnosis [40].
  • A detailed clinical history and examination is critical in the assessment of a painful, stiff shoulder to avoid misdiagnosis of conditions like malignant shoulder girdle tumours [1].

Investigations

  • A detailed clinical history and examination is critical in the assessment of a painful, stiff shoulder [1].
  • Frozen shoulder is a specific, painful and debilitating condition affecting patients mainly in middle age [6].
  • The term frozen shoulder should be reserved for a well-defined disorder characterized by progressive pain and stiffness which usually resolves spontaneously after about 18 months [4].
  • The histological features of frozen shoulder are reminiscent of Dupuytren’s disease, with active fibroblastic and myofibroblastic proliferation in the rotator interval, anterior capsule and coracohumeral ligament [4].
  • Conditions particularly associated with frozen shoulder include diabetes, Dupuytren’s disease, hyperlipidaemia, hyperthyroidism, cardiac disease, and hemiplegia [4].
  • Patients with frozen shoulder are typically aged 40–60 years [4].
  • Patients may give a history of trauma, often trivial, followed by pain that gradually increases in severity and often prevents sleeping on the affected side [4].
  • Pain begins to subside after several months, but stiffness becomes more problematic; untreated stiffness persists for another 6–12 months before movement is gradually regained, which may not return to normal [4].
  • Clinical examination usually reveals slight muscle wasting and tenderness, with always limited movements and extreme stiffness in severe cases [4].
  • X-rays are normal in frozen shoulder, and their main role is to exclude other causes of pain and stiffness [4].
  • Post-traumatic stiffness may persist for some months after severe shoulder injury but is maximal at the start and gradually lessens, unlike the pattern of frozen shoulder [4].
  • Disuse stiffness may occur if the arm is nursed overcautiously, such as following a wrist fracture, and lacks the characteristic pain pattern of frozen shoulder [4].
  • Complex regional pain syndrome may follow acute trauma or be seen in patients with myocardial infarction or stroke, and its features can be similar to those of frozen shoulder [4].
  • Both rheumatoid arthritis and osteoarthritis can affect the shoulder, with diagnosis usually obvious on X-ray, and rheumatoid arthritis may present with characteristic generalized symptoms and signs [4].
  • Most patients clinically diagnosed with primary frozen shoulder had undiagnosed systemic abnormalities and/or intra-articular pathologies [5].
  • MR findings in frozen shoulder should not replace clinical judgments regarding further prognosis and treatment decisions [7].
  • 18F-FDG PET/CT is clinically relevant in diagnostically challenging cases, such as distinguishing the first phase of frozen shoulder from subacromial impingement [11].
  • Unusual stiffness and pain in the shoulder of a young female patient suggests a wide range of disease entities, from simple frozen shoulder to infection [23].
  • Routine use of shoulder MRI scans in patients with frozen shoulder but without suspicion of additional pathology may not be indicated [31].
  • Imaging is an essential tool for evaluation of patients with shoulder pain, and understanding the extent of an injury with imaging is key to successful management [37].
  • Physicians should re-examine frozen shoulder patients with repeated plain radiographs and further imaging, especially MRI, if conservative therapy fails [56].
  • MR arthrography reveals characteristic findings in patients with frozen shoulder [58].
  • T2 signal hyperintensity and axillary capsule thickening are characteristic of the early stages of frozen shoulder, although MRI alone cannot completely define the disease stage [71].
  • The burning sign is an abnormal finding that appears in dynamic MRI of severe frozen shoulder [73].
  • Dynamic MRI semiquantitatively demonstrated a reduction in abnormal blood flow and improvement in clinical results after manipulation under cervical nerve root block (MUC) in patients with frozen shoulder [77].
  • Clinical improvement in patients with frozen shoulder was associated with a decrease in the coefficient of enhancement (CE) in the glenohumeral synovium following intraarticular injections of hyaluronate [81].
  • There may be a causal relationship between hypothyroidism and frozen shoulder [85].
  • Patients who underwent image-guided (ultrasound) injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection compared to blind injections [86].
  • MR imaging of patients with severe frozen shoulder after MUC showed 29 capsule tears, 4 labrum tears, and 15 bone bruises of the humeral head [87].

Treatment

Non-Operative Management

  • Treatment for frozen shoulder aims to improve pain and function through a shared decision-making process, utilizing a step-up approach from conservative measures to invasive treatments if symptoms persist [28].
  • Health professionals manage frozen shoulders differently depending on the phase of the condition [16].
  • There is insufficient evidence to reliably recommend a single treatment approach for frozen shoulder [32].
  • There is limited evidence of the effectiveness of different forms of treatment used for frozen shoulder, with many studies carrying a moderate to high risk of bias and omitting details of symptom duration or condition phase [74].
  • The variety of participants, methods, interventions, and outcomes across trials provides limited new evidence to inform non-surgical management [14].
  • Conservative treatment is effective for the treatment of frozen shoulder regardless of the severity of symptoms [45].
  • Intra-articular steroid injection is effective and safe for frozen shoulder, relieving pain, improving functional performance, and increasing range of motion [48].
  • Multisite corticosteroid injection therapy is more effective than single intra-articular injection in terms of pain relief, restoration of motion, and functional status for primary frozen shoulder [46].
  • Both multisite and single glenohumeral injections of corticosteroid are effective in patients with primary frozen shoulder [49].
  • Ultrasound-guided administration of corticosteroid injections into the glenohumeral joint increases the likelihood of successful injection but does not improve clinical outcomes at 12 weeks compared with blind administration [52].
  • Ultrasound-guided multisite injection is a nonsurgical treatment technique for frozen shoulder that emphasizes correct injection sites [72].
  • Hydrodilatation has emerged as a potential nonsurgical option in the management of frozen shoulder, but its role has yet to be fully clarified [60].
  • Management of frozen shoulder stage II to III using hydrodistension and a guided exercise programme by physiotherapists in primary care is an effective non-operative treatment strategy [66].
  • Further treatment was indicated in 41% of patients who could not tolerate more than 20 mL of injection during hydrodilatation [34].
  • Recurrence of frozen shoulder after hydrodilatation was more common in primary (33%) versus secondary (16%) frozen shoulder [34].
  • A central nervous system-focused treatment approach is being evaluated in a randomized clinical trial to compare effectiveness against standard medical and physical therapy care [42].
  • The comparative effectiveness of low-level laser therapy versus muscle energy technique is being evaluated in a randomized controlled trial to determine the optimal treatment approach for frozen shoulder related to diabetes [47].

Operative and Procedural Management

  • Secondary frozen shoulder may be more recalcitrant to conventional conservative treatment [64].
  • The study on arthroscopic capsular release timing adds information for shared decision-making but should not be a plea for surgery for patients with a mean duration of symptoms of 4 months; a strict definition of recalcitrant idiopathic frozen shoulder is needed to prevent unnecessary interventions [10].
  • The arthroscopic 360° release is an effective and safe treatment modality for severe or recalcitrant frozen shoulder [53].
  • A combination of limited capsular release and manipulation under anaesthesia (MUA) for primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function, and range of motion [55].
  • The mid-term outcomes of transcatheter arterial micro embolization (TAME) for frozen shoulders resistant to conservative treatments are encouraging and warrant further evaluation [50].
  • Manipulation under anesthesia versus physiotherapy treatment in stage two of a frozen shoulder is being evaluated in a randomized controlled trial to provide evidence on the best treatment strategy [51].
  • Different treatment strategies for frozen shoulder may be appropriate depending on the location of pathology [9].

Complications

  • Frozen shoulder is a painful and debilitating condition [6].
  • Frozen shoulder causes significant morbidity [21].
  • The natural history of primary frozen shoulder consists of three phases: pain, stiffness, and thawing [3].
  • Primary frozen shoulder usually resolves spontaneously after about 18 months [4].
  • Without treatment, motion return in primary frozen shoulder is gradual and may never objectively return to normal [3].
  • In the long term, 41% of patients with frozen shoulder report some ongoing symptoms [30].
  • Postoperative frozen shoulder is a serious complication after shoulder surgery with an incidence of 11% [54].
  • Preoperative frozen shoulder negatively affects functional outcomes, including range of motion, at 6 months and 1 year postoperatively following arthroscopic rotator cuff repair [33].
  • Preoperative frozen shoulder positively affects rotator cuff healing [33].
  • Patients with diabetes should be monitored more closely for frozen shoulder, as they may experience persistent pain or lack of function long-term [8].
  • An age between 46 and 60 years is a statistically significant risk factor for developing frozen shoulder after simple arthroscopic shoulder procedures [29].
  • A previous history of contralateral frozen shoulder is a statistically significant risk factor for developing frozen shoulder after simple arthroscopic shoulder procedures [29].
  • Most patients clinically diagnosed with primary frozen shoulder have undiagnosed systemic abnormalities and/or intra-articular pathologies [5].
  • Recurrence of frozen shoulder after manipulation under anaesthetic (MUA) can occur, but late recurrence is uncommon [22].
  • Patients with poor outcomes or recurrent symptoms after MUA can be offered a further MUA with an expectation of good outcome and low complication rate [17].

Recovery

  • Primary (idiopathic) frozen shoulder consists of three phases: Pain, Stiffness, and Thawing [3].
  • Secondary frozen shoulders may not exhibit all three phases and may not follow the exact chronology of primary frozen shoulder [3].
  • Phase I (Pain) involves a gradual onset of diffuse shoulder pain that is progressive over weeks to months [3].
  • Pain in Phase I is usually worse at night and exacerbated by lying on the affected side [3].
  • Phase II (Stiffness) usually lasts 4 to 12 months [3].
  • During Phase II, patients restrict movement to seek pain relief, leading to difficulty with activities of daily living such as reaching back pockets or fastening brassieres [3].
  • Phase II is accompanied by a dull ache present nearly all the time, especially at night, and sharp pain during range of motion at or near new endpoints [3].
  • Phase III (Thawing) lasts for weeks or months, during which motion increases and pain diminishes [3].
  • Without treatment, motion return in Phase III is gradual in most patients [3].
  • Objective motion may never return to normal, although most patients subjectively feel near normal due to compensation or adjustment in activities of daily living [3].
  • Frozen shoulder affects approximately 4% of the general population and up to 59% in patients with diabetes mellitus [24].
  • The disease duration of frozen shoulder varies between 1 and 3 years [24].
  • In the long term, 59% of patients with frozen shoulder have normal or near normal shoulders [30].
  • In the long term, 41% of patients with frozen shoulder report some ongoing symptoms [30].
  • 94% of patients with spontaneous frozen shoulder recover to normal levels of function and motion without treatment [69].
  • Idiopathic frozen shoulder is a self-limiting condition in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms [88].
  • Idiopathic frozen shoulder is a self-limiting condition in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms [89].
  • Long-term outcome after manipulation under anaesthetic (MUA) for frozen shoulder is favourable with late recurrence being uncommon [22].
  • Patients with poor outcome or recurrent symptoms after MUA should be offered a further MUA with the expectation of a good outcome and a low complication rate [17].
  • Arthroscopic capsular release leads to a faster and long-lasting recovery in patients with refractory primary frozen shoulder syndrome [35].
  • The long-term results of arthroscopic capsular release in frozen shoulder were confirmed in 255 patients [36].
  • MUA in stage 2 frozen shoulder results in a faster recovery of range of motion and improved functional outcome compared to physiotherapy alone in the short term [68].
  • MUA in stage 2 frozen shoulder can be considered safe compared to physiotherapy alone in the short term [68].
  • Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder [19].
  • Early surgical intervention is not associated with inferior clinical outcomes when compared with late surgical intervention [19].
  • Timing has a significant influence on the outcome of manipulation for frozen shoulders [90].
  • Diabetes is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
  • Male sex is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
  • Simultaneous bilateral involvement is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
  • Subsequent bilateral involvement is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
  • A longer duration of symptoms recorded at the first visit is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
  • Clinicians should monitor frozen shoulder patients with diabetes more closely and offer further treatment if pain or lack of function persist long-term [8].
  • Preoperative frozen shoulder negatively affected most functional outcomes, including range of motion, at 6 months and 1 year postoperatively after arthroscopic rotator cuff repair [33].
  • Preoperative frozen shoulder positively affected rotator cuff healing after arthroscopic rotator cuff repair [33].

Key Evidence

  • [L4] A detailed clinical history and examination is critical in the assessment of a painful, stiff shoulder. [1] (10.1186/1477-7800-2-2)
  • [L1] This updated guideline provides evidence-based guidance for managing frozen shoulder and identifies key areas for future research. [2] (10.1177/17585732251335955)
  • [L4] Most patients clinically diagnosed with primary frozen shoulder had undiagnosed systemic abnormalities and/or intra-articular pathologies. [5] (10.5397/cise.2018.21.2.82)
  • [Paper] Frozen shoulder is a specific, painful and debilitating condition effecting patients mainly in middle age. [6] (10.1016/j.maturitas.2014.02.009)
  • [L4] MR findings in frozen shoulder should not replace clinical judgments regarding further prognosis and treatment decisions. [7] (10.1007/s00167-015-3887-y)
  • [L2] If high-quality studies can confirm the findings of this review, then clinicians should monitor frozen shoulder patients with diabetes more closely and offer further treatment if pain or lack of function persist long-term. [8] (10.1016/j.arrct.2021.100141)
  • [L5] Different treatment strategies for frozen shoulder may be appropriate, depending on the location. [9] (10.1016/j.jse.2018.03.010)
  • [L5] The study adds information for shared decision-making but should not be a plea for surgery for patients with a mean duration of symptoms of 4 months; a strict definition of recalcitrant idiopathic frozen shoulder is needed to prevent unnecessary interventions. [10] (10.1177/2325967120903710)
  • [L2] This is clinically relevant in diagnostically challenging cases, for instance in the first phase of frozen shoulder, which can be difficult to distinguish from subacromial impingement. [11] (10.1007/s00167-020-05937-2)
  • [L5] Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity. [12] (10.1016/j.math.2014.07.006)
  • [L1] The variety of participants included/excluded in trials and the variety of methods, interventions and outcomes used across the trials provided limited new evidence to inform the non-surgical management and treatment of people with frozen shoulder. [14] (10.2340/16501977-2578)
  • [L4] The etiology of frozen shoulder is still not known and our understanding of the pathogenesis is limited. [15] (10.3109/03009749009096786)
  • [L4] Health professionals manage frozen shoulders differently for different phases of the condition. [16] (10.1111/j.1758-5740.2010.00073.x)
  • [L4] Patients with a poor outcome or recurrent symptoms of a frozen shoulder after a MUA should be offered a further MUA with the expectation of a good outcome and a low complication rate. [17] (10.1302/0301-620x.99b6.bjj-2016-1133.r1)
  • [L3] Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder and is not associated with inferior clinical outcomes when compared with late surgical intervention. [19] (10.1016/j.jse.2020.07.023)
  • [L4] Frozen shoulder is a common disease which causes significant morbidity. [21] (10.5312/wjo.v6.i2.263)
  • [L3] Long-term outcome after MUA for frozen shoulder is favourable with late recurrence being uncommon. [22] (10.1177/17585732211070007)
  • [L5] Unusual stiffness and pain in the shoulder of a young female patients suggests a wide range of disease entities, from simple frozen shoulder to (albeit rarely) infection. [23] (10.1016/j.radcr.2020.08.006)
  • [L1] This systematic review presents a summary of what is currently known about the tissue pathophysiology of primary frozen shoulder. [25] (10.1186/s12891-016-1190-9)
  • [L4] Frozen shoulder is a painful and debilitating condition with considerable economic impact; treatment aims to improve pain and function through a shared decision-making process, with a step-up approach from conservative measures to invasive treatments if symptoms persist. [28] (10.1177/1758573215601779)
  • [L3] An age of between 46 and 60 years and a previous history of contralateral frozen shoulder were statistically significant risk factors. [29] (10.1302/0301-620x.97b7.35387)
  • [L3] In the long term, 59% of patients had normal or near normal shoulders and 41% reported some ongoing symptoms. [30] (10.1016/j.jse.2007.05.009)
  • [L4] Therefore, routine use of shoulder MRI scans in patients with FS but without suspicion of an additional pathology may not be indicated. [31] (10.1016/j.jseint.2022.05.009)
  • [L1] There is insufficient evidence to reliably recommend a treatment approach for frozen shoulder. [32] (10.1136/bmj.i4162)
  • [L3] Preoperative frozen shoulder positively affected rotator cuff healing but negatively affected most functional outcomes, including ROM, at 6 months and 1 year postoperatively. [33] (10.1177/2325967120934449)
  • [L4] Further treatment was indicated in 41% of patients who could not tolerate more than 20 mL of injection, and recurrence was more common in primary (33%) versus secondary (16%) frozen shoulder. [34] (10.1177/17585732221124914)
  • [Paper] In patients with refractory primary frozen shoulder syndrome, arthroscopic capsular release emerges as a suitable option that leads to a faster and long-lasting recovery. [35] (10.1016/j.eats.2015.06.004)
  • [L4] The long-term results of arthroscopic capsular release in frozen shoulder were confirmed in 255 patients. [36] (10.1186/s13018-018-0758-5)
  • [L4] Imaging is an essential tool for evaluation of patients with shoulder pain; understanding the extent of an injury with imaging is key to successful management. [37] (10.1016/j.csm.2013.03.009)
  • [L4] However, classification of frozen shoulder was found to be controversial. [38] (10.4055/cios.2020.12.1.60)
  • [L4] Frozen shoulder following COVID-19 vaccination may present with clinical features similar to those of idiopathic frozen shoulder. [39] (10.1016/j.xrrt.2023.09.013)
  • [L2] Misdiagnosing shoulder tumors as frozen shoulder syndrome is likely to cause a significant delay in making a correct diagnosis. [40] (10.1016/j.jse.2009.05.010)
  • [L4] Frozen shoulder can occur after COVID-19 vaccination, and musculoskeletal specialists should be aware of this diagnosis to identify and treat such patients early. [41] (10.1016/j.jseint.2022.02.013)
  • [Paper] The trial aims to compare the effectiveness of a CNS-directed treatment program versus standard medical and physical therapy care on outcomes in participants with frozen shoulder. [42] (10.1186/s13063-019-3585-z)
  • [L4] The survey shows lower rates of agreement among the JSS members than the ASES members for the definition of primary frozen shoulder, the classification of primary and secondary frozen shoulder, and the divisions of secondary frozen shoulder. [43] (10.1016/j.jos.2018.12.012)
  • [L4] Symptomatic subjects demonstrated substantial kinematic deficits during humeral range of motion. [44] (10.1016/s0003-9993(03)00359-9)
  • [L3] Conservative treatment is effective for the treatment of frozen shoulder. [45] (10.1016/j.asmr.2025.101149)
  • [Commentary] Multisite corticosteroid injection therapy is more effective in terms of pain relief, restoration of motion, and functional status than single intra-articular injection for the treatment of primary frozen shoulder. [46] (10.1016/j.arthro.2021.02.028)
  • [L2] The findings of the study may provide evidence on the efficacy of these interventions and most likely, the optimal treatment approach for frozen shoulder related to diabetes, which may guide clinical practice. [47] (10.1186/s13018-024-04735-7)
  • [L1] Intra-articular steroid injection is effective and safe for frozen shoulder, relieving pain, improving functional performance, and increasing range of motion. [48] (10.1177/0363546516669944)
  • [L1] Both treatments were effective in patients with primary frozen shoulder. [49] (10.1016/j.arthro.2021.01.069)
  • [Abstract] The mid-term outcomes of TAME for frozen shoulders that were resistant to conservative treatments are encouraging and warrant further evaluation. [50] (10.1016/j.jse.2016.11.031)
  • [L2] Successful completion of this trial will provide evidence on the best treatment strategy for patients with a stage two frozen shoulder. [51] (10.1186/s12891-017-1763-2)
  • [L1] In patients with frozen shoulder, US-guided administration of corticosteroid injections into the glenohumeral joint increased the likelihood of successful injection but did not improve clinical outcomes at 12 weeks compared with blind administration. [52] (10.2106/jbjs.21.01007)
  • [L4] The arthroscopic 360° release is an effective and safe treatment modality for severe or recalcitrant frozen shoulder. [53] (10.1016/j.jseint.2024.07.006)
  • [L2] Postoperative frozen shoulder is a serious complication after shoulder surgery, with an incidence of 11%. [54] (10.1007/s00402-016-2589-3)
  • [L4] A combination of limited capsular release and MUA for the treatment of primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function and range of motion. [55] (10.1177/1758573215578590)
  • [L4] Physicians should re-examine frozen shoulder patients with repeated plain radiographs and further imaging, especially MRI, if conservative therapy fails. [56] (10.1016/j.jse.2011.07.026)
  • [L4] This survey summarized the trend in prevalent practices regarding frozen shoulder among shoulder specialists and senior shoulder surgeons of SESI, revealing strong consensus on imaging and nonoperative management but disagreement on terminology and specific surgical complications. [57] (10.1177/23259671221118834)
  • [L4] MR arthrography reveals characteristic findings in patients with frozen shoulder. [58] (10.1148/radiol.2332031219)
  • [L3] The anatomical structure of passive shoulder restraints has no impact on the difference in passive joint position sense values between external and internal rotation. [59] (10.1186/s12891-016-0971-5)
  • [L5] Hydrodilatation has emerged as a potential nonsurgical option in the management of frozen shoulder, but its role has yet to be fully clarified. [60] (10.1302/2058-5241.2.160061)
  • [L5] This scoping review outlines the complexity of the pathophysiology of frozen shoulder and provides a comprehensive overview of pathophysiologic mechanisms. [62] (10.1186/s40634-020-00307-w)
  • [L4] Secondary frozen shoulder may be more recalcitrant to conventional conservative treatment. [64] (10.1016/j.jor.2015.01.030)
  • [L4] This service evaluation demonstrates that management of frozen shoulder stage II to III, as conducted by physiotherapists in a primary care setting utilizing hydrodistension and a guided exercise programme, represents an effective non-operative treatment strategy. [66] (10.1177/1758573217701063)
  • [L1] MUA in stage 2 frozen shoulder can be considered safe and results in a faster recovery of range of motion and improved functional outcome compared to physiotherapy alone in the short term. [68] (10.1016/j.jseint.2023.11.004)
  • [L4] We found 94% of patients with spontaneous frozen shoulder recovered to normal levels of function and motion without treatment. [69] (10.1007/s11999-011-2176-4)
  • [L5] MUA and ACR are good treatment options for primary frozen shoulder; MUA is simpler but carries risks of serious complications, while ACR may be safer if performed by experienced surgeons and is convenient for patients with combined rotator cuff tears. [70] (10.5397/cise.2020.00311)
  • [L5] T2 signal hyperintensity and axillary capsule thickening are characteristic of the early stages of frozen shoulder, although MRI alone cannot completely define the disease stage. [71] (10.1016/j.xrrt.2024.05.002)
  • [L5] This technique is presented for the nonsurgical treatment of frozen shoulder, emphasizing correct injection sites. [72] (10.1016/j.eats.2022.06.020)
  • [L4] The burning sign is an abnormal finding that appears in dynamic MRI of severe frozen shoulder. [73] (10.1016/j.jse.2016.06.003)
  • [L2] There is limited evidence of the effectiveness of different forms of treatment used for frozen shoulder, with many studies evaluating treatment effects carrying a moderate to high risk of bias and omitting details of the duration of symptoms or the phase of the condition. [74] (10.1111/j.1758-5740.2010.00067.x)
  • [L5] Pathomechanics of the frozen shoulder characterised by glenohumeral motion limitations should be considered complicated, as confirmed by high tension in the anteroinferior glenohumeral capsule and altered scapular motion. [75] (10.1016/j.jseint.2025.04.003)
  • [L4] Dynamic MRI semiquantitatively demonstrated a reduction in abnormal blood flow and improvement in clinical results after MUC in patients with frozen shoulder. [77] (10.1016/j.jseint.2021.12.007)
  • [L4] Patients with frozen shoulder presented with altered shoulder muscle activity and kinematics, and one-session of heat and manual muscle release showed beneficial effects on shoulder muscle performance, kinematics, mobility, and pain. [78] (10.1186/s12891-017-1867-8)
  • [L3] The thickness of the inferior glenohumeral joint capsule in the 80° scapular plane elevated arm position was shown to be a highly reliable and valid method. [79] (10.1016/j.jseint.2024.06.004)
  • [L4] SHR of the affected shoulder is inversely related to severity of limitation of shoulder range of motion, which suggests a compensatory pattern. [80] (10.1016/j.jbiomech.2007.09.004)
  • [L4] Clinical improvement in patients with frozen shoulder was associated with a decrease in the coefficient of enhancement (CE) in the glenohumeral synovium. [81] (10.1007/s00776-004-0766-7)
  • [L2] Diabetes, male sex, simultaneous bilateral involvement, subsequent bilateral involvement, and a longer duration of symptoms recorded at the first visit were identified as poor prognostic factors for the conservative treatment of frozen shoulder. [82] (10.1016/j.jos.2019.03.011)
  • [L2] Our MR analysis suggests that there may be a causal relationship between hypothyroidism and frozen shoulder. [85] (10.1186/s12891-024-07826-y)
  • [L1] Patients who underwent image-guided (ultrasound) injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection compared to blind injections. [86] (10.1186/1471-2474-12-137)
  • [L4] MR imaging of patients with severe frozen shoulder after MUC showed 29 capsule tears, 4 labrum tears, and 15 bone bruises of the humeral head. [87] (10.1016/j.jse.2015.06.019)
  • [L4] In the great majority of patients idiopathic frozen shoulder is a self-limiting condition, in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms. [88] (10.2106/00004623-197860040-00030)
  • [L4] In the great majority of patients idiopathic frozen shoulder is a self-limiting condition, in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms. [89] (10.2106/00004623-197860040-00029)
  • [L4] Timing has a significant influence on the outcome of manipulation for frozen shoulders. [90] (10.1016/j.jos.2020.11.002)

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