4 Stages of Frozen Shoulder

The 4 Stages of Frozen Shoulder (Adhesive Capsulitis) Explained

Introduction

Frozen shoulder, medically known as adhesive capsulitis, is a condition characterized by pain, stiffness, and limited mobility of the shoulder joint. It typically develops gradually and progresses through a series of stages before recovery begins. Understanding these stages is crucial for diagnosis, treatment planning, and patient education.

This article will take you through the 4 stages of frozen shoulder, highlighting the duration, clinical features, and management strategies for each stage.

Stage 1: Pre-Freezing (Painful Stage)

Duration: 0–3 months

The first stage is often referred to as the painful stage, as discomfort dominates more than stiffness.

  • Symptoms:

    • Sudden or gradual onset of shoulder pain, often without a clear cause.

    • Pain worsens at night, especially when lying on the affected side.

    • Discomfort during overhead and behind-the-back movements.

  • Clinical findings:

    • Minimal restriction of motion initially.

    • Inflammation of the joint capsule begins.

Management:

  • Pain control through NSAIDs, heat therapy, and gentle range-of-motion exercises.

  • Corticosteroid injections may help reduce inflammation.

  • Patient education about activity modification.

Stage 2: Freezing Stage

Duration: 3–9 months

In this stage, both pain and stiffness increase significantly.

  • Symptoms:

    • Persistent pain that continues with daily activities.

    • Stiffness becomes more noticeable, especially in external rotation.

    • Loss of both active and passive range of motion.

  • Clinical findings:

    • Shoulder movements are painful and restricted in all planes.

    • Daily tasks like combing hair, dressing, or reaching behind become difficult.

Management:

  • Combination of pain management and physiotherapy.

  • Stretching and mobility exercises to maintain joint function.

  • Avoid aggressive strengthening, as it may worsen symptoms.

Stage 3: Frozen Stage (Adhesive Stage)

Duration: 9–15 months

This is the stage where stiffness dominates, while pain gradually decreases.

  • Symptoms:

    • Pain may reduce significantly compared to earlier stages.

    • Severe restriction of movement persists, often described as the shoulder being "locked."

    • Functional limitations such as reaching overhead or behind the back.

  • Clinical findings:

    • Thickening and tightening of the joint capsule.

    • Adhesions form inside the capsule, reducing mobility.

Management:

  • Focus on gentle stretching and mobilization to improve range.

  • Heat therapy before exercise to improve flexibility.

  • Strengthening exercises introduced cautiously as stiffness improves.

Stage 4: Thawing Stage (Recovery Stage)

Duration: 15–24 months (sometimes longer)

This is the stage of gradual recovery where mobility begins to return.

  • Symptoms:

    • Pain continues to decrease.

    • Range of motion improves slowly over months.

    • Function gradually returns, although some patients may not regain full motion.

  • Clinical findings:

    • Shoulder joint capsule remodels and softens.

    • Stiffness progressively reduces.

Management:

  • Continued physiotherapy focusing on stretching and strengthening.

  • Functional training to restore activities of daily living.

  • In some resistant cases, manipulation under anesthesia (MUA) or arthroscopic capsular release may be considered.

Summary Table of 4 Stages

Stage Duration Main Features Pain Stiffness
Stage 1: Pre-Freezing 0–3 months Inflammation, painful movements High Mild
Stage 2: Freezing 3–9 months Pain + increasing stiffness High Moderate to severe
Stage 3: Frozen 9–15 months Severe stiffness, less pain Moderate/low Severe
Stage 4: Thawing 15–24 months Gradual recovery of motion Low Improving

Conclusion

Frozen shoulder is a self-limiting condition, but it can last for up to 2 years or more if untreated. Early recognition of the 4 stages allows healthcare professionals to implement appropriate management strategies and improve patient outcomes.

With a combination of pain relief, physiotherapy, and patient education, most individuals can regain near-normal shoulder mobility and function.

Frequently Asked Questions (FAQ)

1. How long does frozen shoulder last?
Frozen shoulder typically lasts 1–2 years, but in some cases, stiffness can persist for longer.

2. Can frozen shoulder heal on its own?
Yes, frozen shoulder is often self-limiting, but physiotherapy can speed up recovery and prevent long-term stiffness.

3. Is exercise safe during frozen shoulder?
Yes, but exercises must be gentle and guided by a physiotherapist. Aggressive movements can worsen symptoms.

4. Who is most at risk of frozen shoulder?
People with diabetes, thyroid disorders, and prolonged shoulder immobility (e.g., after surgery or fracture) are at higher risk.

References

  1. Neviaser AS, Hannafin JA. Adhesive Capsulitis: A Review of Current Treatment. Am J Sports Med. 2010.

  2. Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg. 2011.

  3. Physiopedia. Frozen Shoulder (Adhesive Capsulitis). Available from: https://www.physio-pedia.com


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