Frozen Shoulder
There are generally three stages of frozen shoulder.
The painful freezing stage lasts six weeks to nine months; the frozen stage where pain improves but there is stiffness last about four to six months, and the final thawing stage where the shoulder recovers. This can last 6 six months to two years.
Orthopaedic surgeon Gosford Dr Phil Markham frequently provides consults on frozen shoulder and operates in Gosford, Sydney and Wollongong.
The capsular inflammation, thickening and adhesions prevent movement and the shoulder develops painful stiffness.
Frozen shoulder, sometimes called adhesive capsulitis or “fifties shoulder”, is a painful and disabling shoulder condition that disrupts sleep and causes pain ranging from mild to excruciating.
Frustratingly, a frozen shoulder also causes stiffness and difficulty doing everyday tasks like putting on a bra, putting on a coat, or reaching overhead or across your chest.
Over time, the ability to move your shoulder is so reduced it literally becomes “frozen”.
- Pain, often dull or aching within the shoulder joint, which can worsen with activity
- Pain on movement involving lifting the arm, reaching, or rotating can provoke a sharp, acute pain
- Pain may also radiate down the arm or up to the neck
- Pain often develops slowly over weeks or months
- Stiffness, particularly when doing everyday tasks such as putting on a bra or coat, or reaching overhead
- Limited range of motion and difficulty moving the shoulder in various directions, such as lifting, reaching, rotating the arms outwards, or reaching behind the back
“First is the painful or ‘freezing’ stage, which lasts six weeks to nine months.
“Then there is the ‘frozen’ stage, where the pain improves but there is still stiffness. This often lasts for about four to six months.”
By the final ‘thawing’ stage, he says the pain improves significantly and range of movement starts to recover, often taking up to two years.
“The good news is that the vast majority of people with frozen shoulder will recover, although some may have a long-term slightly reduced range of movement.”
“People often first notice frozen shoulder through a gradually worsening inability to do everyday tasks.”
These tasks include:
- Difficulty putting on shirts or coats
- Women may notice pain when putting their hands behind their back to fasten a bra, and often opt for front-fastening bras
- Combing hair
- Driving
- Picking up objects above shoulder height or reaching overhead to change a light bulb
- Household chores like vacuuming or sweeping, or carrying grocery bags
“Frozen shoulder is known as somewhat of a mysterious ailment in medicine, sometimes idiopathic, meaning there is no identifiable underlying cause,” says Dr Markham.
“It also tends to affect a certain age group — the 40–60 group — and is significantly more common in women than men.”
However, there are identifiable risk factors:
For instance, people with diabetes have a higher risk of frozen shoulder.
“It’s thought that collagen, which is a constituent of all tendons, bones and cartilage, becomes “sticky” if sugar molecules attach, causing stiffness and adhesions or scarring, a process known as glycosylation.*¹”
Other risk factors and comorbidities for frozen shoulder include:
- Recent traumatic injury
- Previous rotator cuff injuries
- Smoking
- Dupuytren’s syndrome
- Autoimmune conditions such as rheumatoid arthritis or lupus
- Thyroid disease (especially hypothyroidism)
- Nephrolithiasis (kidney stones)
- Tumours/ Cancer
- Parkinson’s disease
- Chronic regional pain syndrome
While frozen shoulder affects 2–5% of the population generally, about 85%*² of people with frozen shoulder will have one comorbidity, while 37.5% have three.*²
Increasingly, menopause is also linked to joint pain*³ in women as a result of fluctuating oestrogen levels.
Frozen shoulder is a considerable complaint in this cohort, who also commonly experience neck pain, knee pain, and hand pain.
“Rarely, bilateral frozen shoulder can occur at the same time, but most commonly the first shoulder has recovered, or almost recovered, when the next episode starts,” says Dr Markham.
“It is particularly beneficial for patients with severe arthritis AND rotator cuff tears, as a procedure that effectively treats both conditions,” says Dr Philip Markham.
Currently reverse shoulders make up over 80% of all new total shoulder replacements implanted in Australia and represent 70.9% of all existing total shoulder replacements.
In patients with Type 1 diabetes, the rate increases to 59% of patients who develop frozen shoulder, with about 73% of this group developing it in both shoulders,*⁵ according to a 2017 report in the Archives of Physical Medicine and Rehabilitation.
The good news, however, is that frozen shoulder, whilst debilitating, always eventually thaws, most often without surgical treatment.
“Initial treatments include ice or heat packs, cortisone, physiotherapy, as well as over-the-counter pain relief and anti-inflammatory medications,” says Dr Markham.
“The other thing I would say here is to use the shoulder as much as possible, without pushing the pain limits too much.
“This is best done with a physiotherapy plan. If you stop using the arm or immobilise it, this will cause the condition to be even more painful.”
He says exercises should not be painful and are not intended to increase the range of movement or push your body to its limit.
“In fact, too aggressive shoulder exercise can aggravate the condition and should be avoided.”
One good exercise for frozen shoulder is “walking the wall”:
- Stand facing a wall
- With your fingers, walk up the wall reaching as high as comfortable
- Hold for a moment and walk back down
- Repeat 5 times, a few times a day
“Another good exercise is holding a towel behind your back with one hand, then using the other hand to gently pull the towel upward, stretching the shoulder. Hold for 15 seconds and repeat two or three times.”
“The volume of fluid injected acts to stretch the joint capsule and breakdown adhesions in addition to reduce inflammation from the direct effect of the cortisone.
“However, cortisone should be used especially judiciously in people with diabetes, due to the fact that a side effect of cortisone includes raising blood sugar levels.
This needs to be discussed and monitored with your GP or specialist.
“While there isn’t an official strict limit on lifetime cortisone injections, 3 to 4 injections per year would be the maximum per joint.
Too much cortisone can lead to other side effects such as joint damage.”
“However, some patients are in so much pain in the initial freezing stage that they are unable to sleep or do their job, which is when we could consider joint hydrodilation.”
This is a procedure performed under radiological guidance to inject a large volume of fluid into the shoulder joint, distending the joint, stretching the capsule, and providing pain relief and improved motion.
“During the procedure the patient is given a local anaesthetic and the radiologist mixes up a cocktail of saline and steroids to stretch out the joint.
“This is followed up with extensive physiotherapy to break down the adhesions or scarring that has occurred on the shoulder joint,” says Dr Markham.
“Risks include adverse events from local anaesthesia, which patients are monitored for. The most common side effect is recurrent stiffness, which is usually prevented with physiotherapy.”
You can generally return to work within a week or two and drive within a week or two.
One study in the GP Journal of Family Practice found that 94% of patients in that study experienced immediate pain relief after hydrodilation, with effects often lasting up to 10 years. Remember though all results vary.
Occasionally patients can be managed with a surgical release that is performed arthroscopically, with a capsular release and shoulder manipulation under a general anaesthetic. The surgery is usually reserved for resistant cases of adhesive capsulitis that do not respond to other measures.
The diagnostic criteria has not changed for decades and is largely based on clinical examination, a normal x-ray, and a global loss of passive range of motion (ROM),” says Dr Markham.
“While a wait-and-see approach is the usual path, it is still important to rule out other causes of shoulder pain and stiffness, which can include trauma or fracture, rotator cuff tear, osteoarthritis or rarely a tumour.
“Not all cases of frozen shoulder require x-rays or MRIs; however, these tests may be recommended by your orthopaedic surgeon to rule out other conditions such as a torn rotator cuff or arthritis.
“More often than not, there are multiple conditions involved in shoulder pathology. It is quite common, for instance, to have a frozen shoulder with neck pain, or frozen shoulder with a rotator cuff tear.”
“However, this is an emerging area of medicine and we now have good evidence that hormone changes in perimenopause and menopause are linked to shoulder pain as well as joint pain in the knees, hands, and hips — this is known as menopause arthralgia.*⁶
At least one small study has found that women who receive HRT are less likely to develop frozen shoulder.”
This page was reviewed by Dr Philip Markham, June 2026
AHPRA Registration No. MED0001196569
*1 Diabetes UK – Frozen Shoulder
*2 Front Med 2021 – A Comprehensive View of Frozen Shoulder: A Mystery Syndrome
*3 Maturitas, 2010 -Menopausal Arthritis, Fact or Fiction
*4 The Journal of Clinical Orthopaedic Trauma, 2014 – Presentation of frozen shoulder in diabetic vs non-diabetic patient
*5 Archives of Physical Medicine and Rehabilitation – Very high presence of frozen shoulder in patients with Type 1 Diabetes >45 years’ duration: The Dialong Shoulder Study
*6 Maturitas, 2010 – Menopausal Arthritis, Fact or Fiction
Additional Source:
*7 Orthop J Sports Med, 2023 Jul 31 – Is Hormone Replacement Therapy Associated with Reduced Risk of Adhesive Capsulitis in Menopausal Women? A Single Centre Analysis
Adhering to post-operative instructions, attending your follow-up appointments and participating actively in rehabilitation treatment will help mitigate any potential side effects of shoulder surgery.
