Frozen Shoulder (Adhesive Capsulitis)

What is a frozen shoulder?

In frozen shoulder, the inner lining of the joint first becomes inflamed (synovialitis), then the capsule of the shoulder joint thickens and shrinks. As a result, the capsule “sticks” to a certain extent, the joint space becomes smaller, and movements become painful and increasingly restricted. External rotation is usually most affected, later also abduction and internal rotation.

A distinction is made between a primary (idiopathic) form with no apparent cause and a secondary form following injuries, operations or long-term immobilization. Diabetics and people with thyroid or metabolic diseases are more commonly affected.

Anatomy briefly explained

The shoulder joint (glenohumeral joint) connects the head of the humerus with the flat socket of the shoulder blade (glenoid). It is stabilized by the joint capsule, ligaments and the rotator cuff. The following are particularly relevant for frozen shoulder:

• Joint capsule with armpit skin fold (axillary recess): shrinks and thickens.
• Rotator interval and coracohumeral ligament: often thickened, painful.
• Synovial membrane: becomes inflamed in the early phase.

Important: In contrast to osteoarthritis, the cartilage in frozen shoulder is often inconspicuous. The problem lies primarily in inflammation and shrinkage of the capsule.

Causes and risk factors

• Primary form: without a clear trigger, probably multifactorial (inflammation, fibrosis).
• Secondary form: after shoulder injuries, operations, prolonged wearing of a sling or after immobilization.
• Concomitant diseases: diabetes mellitus (frequent, often prolonged course), thyroid diseases, heart/lung diseases, hormonal factors.
• Other risk factors: previous frozen shoulder on the opposite side, prolonged immobilization, certain metabolic and autoimmune diseases.

Bilateral courses are possible: For some of those affected, the frozen shoulder also occurs on the other shoulder with a time delay.

Symptoms and stages

A progression of stages is typical. The duration varies from person to person; the phases can merge into one another.

• Everyday obstacles: putting on jacket, fastening bra, washing/combing hair, reaching back pocket.
• Night/rest pain with sleep disorders.
• Evenly restricted active and passive movement (difference to many tendon tears).

Diagnosis: This is how we proceed

Diagnosis is primarily clinical: anamnesis, examination of mobility in all planes and pain provocation tests. A global, pain-related and capsular limitation - especially external rotation - is typical, both active and passive.

• Sonography: assessment of the rotator cuff, biceps tendon, bursa; Exclusion of other causes.
• X-ray: Rule out osteoarthritis, calcium deposits, bony causes.
• MRI (if necessary): shows partially thickened coracohumeral ligament, edema in the rotator interval, inflamed axillary recess; helpful if the findings are unclear or before planning an operation.

Differential diagnoses: Rotator cuff tear, impingement/subacromial syndrome, shoulder joint arthrosis (omarthrosis), AC joint arthrosis, labral lesions (e.g. SLAP), instability consequences (Bankart/Hill-Sachs lesion), synovitis of other origins.

Warning signs (red flags) such as fever, severe redness/warmth, trauma with persistent inability to move or neurological deficits should be examined by a doctor immediately.

Conservative therapy – first and specifically

Treatment depends on the stage, pain and everyday situation. Basic principle: mobilize in a way that adapts to pain – as much movement as possible, as little irritation as necessary. Aggressive “stretching” can worsen the inflammation.

• Education: Understanding stages and realistic expectations reduce stress and protective posture.
• Medication: anti-inflammatory painkillers (e.g. NSAIDs) or paracetamol for a limited time - always consider individually; Pay attention to stomach/cardiovascular risks.
• Physiotherapy: gentle, guided mobilization, capsular stretching in the pain-free area, joint techniques, posture and scapula setting.
• Self-exercises: short, regular sessions (5-10 minutes, 3-5 times/day) are often more effective than infrequent, intensive stretching.
• Warmth/cold: depending on the stage; Cold often helps in the pain phase, and later heat before stretching.
• Sleep management: side position with pillow support, supine position with forearm support; Pain therapy at night.
• Everyday life: temporarily reduce heavy overhead loads, but maintain everyday activity.

Injection treatment (if appropriate): Ultrasound-guided intra-articular cortisone injections can temporarily reduce pain and inflammation in the early phase. Hydrodilatation (capsule distension with saline/anesthetic and, if necessary, cortisone) can also carefully stretch the capsule. We discuss selection and timing individually.

• If you have diabetes, blood sugar control around cortisone injections is particularly important.
• Oral cortisone treatments are considered in individual cases; Benefits and risks are carefully weighed.
• A suprascapular nerve block can temporarily relieve pain and make physical therapy easier.

Examples of self-exercises (pain-adapted):

Regenerative and interventional procedures

If the symptoms are persistent or if pain blocks therapy, additional procedures may be useful. These do not replace active rehabilitation, but rather create a window for movement.

• Hydrodilatation: careful capsular expansion with fluid under imaging; The goal is to reduce pain and increase mobility.
• Ultrasound-controlled injections: targeted into the shoulder joint, possibly also into the biceps tendon, depending on the findings.
• Nerve blocks: e.g. B. suprascapular nerve for short-term analgesia; v. a. to support physiotherapy.

We provide transparent information about benefits, risks and alternatives. Not every method is suitable for every phase.

Operational options – when do they make sense?

An operation is rarely necessary immediately. It is considered if, despite consistent conservative therapy, significant, everyday-relevant stiffness with pain persists over several months.

• Arthroscopic capsule release: targeted loosening/splitting of the thickened capsule and the rotator interval.
• Manipulation under anesthesia (MUA): careful stretching under anesthesia; is now used selectively and cautiously.

Important: Every operation requires immediate, structured follow-up treatment with physiotherapy to stabilize the result. Risks such as bleeding, infection, nerve or capsular ligament injuries are discussed beforehand.

Prognosis and course

The natural course often extends over 12 to 24 months, in individual cases longer. Many patients achieve good fitness for everyday use, even if there may be some residual stiffness - especially in external rotation.

• Early pain relief and adapted movement help to avoid rest patterns.
• In the case of diabetes or thyroid disease, the course is often more protracted.
• Some develop symptoms on the other side over time - regular, gentle mobility can help.

Everyday life, work and sport

The aim is to make everyday life as active as possible - without overstimulating the shoulder. Painful end positions should be temporarily avoided, but pain-free movement windows should be consistently used.

• Office/Desk: Mouse and keyboard close to the body; forearm rest; regular micro-breaks with short mobilization exercises.
• Craft/Overhead: Reduce heavy overhead work; carry loads close to your body; Use aids.
• Sport: Start with walking, upright bike, cross trainer; later targeted shoulder and back strengthening, no jerky end positions.
• Sleep: Pillow as arm support, lying on your healthy side; relaxing heat application before bedtime, if tolerated.

Prevention and self-help

• After injury/surgery: as early as possible, guided, pain-adapted-moderate mobilization.
• Optimize metabolism: good blood sugar control in diabetes; Get thyroid function looked after.
• Maintain regular shoulder mobility: gentle stretching and mobility routines without provoking pain.
• If stiffness increases, seek medical advice early so that therapy can be initiated quickly.

Treatment in our practice in Hamburg

We accompany you through the phases of frozen shoulder in a structured manner - with clear information, pain-sensitive mobilization and targeted interventions when they make sense. Our location: Dorotheenstraße 48, 22301 Hamburg.

• Careful diagnosis: clinical examination, ultrasound, if necessary X-ray/MRI.
• Therapy plan according to stage: combination of self-exercises, physiotherapy and pain management.
• Ultrasound-guided injections and hydrodilation when appropriate.
• Close coordination with physiotherapy partners in Hamburg-Winterhude and the surrounding area.
• If stiffness has been treated: information about surgical options and structured aftercare.

We make no promises of healing. Our goal is to reduce pain, gradually improve mobility and realistically achieve your everyday goals.

When should I seek medical advice?

• Nighttime pain and increasing shoulder stiffness over several weeks.
• Acute trauma with persistent inability to function of the arm.
• Fever, significant redness/warmth or rapid swelling of the joint.
• Tingling, sensory disturbances or signs of paralysis in the arm/hand.
• Pre-existing diabetes with poor blood sugar control and severe shoulder pain.