Without treatment, a frozen shoulder can cause severe pain and profound stiffness for up to two years. Understand the three distinct stages of the condition , and learn how modern interventions like hydrodilatation and keyhole capsular release can fast-track your recovery.
Adhesive capsulitis, commonly known as frozen shoulder, is one of the most debilitating and misunderstood conditions in orthopaedics. Unlike a sudden injury or a tear, it is a slow, relentless process that stiffens the joint capsule until simple movements, like reaching for a seatbelt or brushing your hair, become impossible.
For many patients, the physical stiffness is secondary to the pain. The deep, aching "toothache" in the shoulder, particularly at night, can make sleep nearly impossible for months on end. The most common question I am asked in the clinic is simply: When will this end?
The natural history of the condition is long. Without treatment, a frozen shoulder typically runs a course of 18 to 24 months. While the condition is technically "self-limiting" (meaning it will eventually go away on its own), asking a patient to endure two years of pain and disability is often unacceptable. Here is a detailed look at why this happens, the stages you will go through, and how modern treatments can drastically shorten this timeline.
To understand the timeline, you must understand the pathology. Your shoulder joint is surrounded by a strong connective tissue called the joint capsule. In a healthy shoulder, this capsule is loose and flexible, allowing the ball (humeral head) to rotate freely within the socket (glenoid). In adhesive capsulitis, this capsule becomes inflamed and thickened. It contracts and tightens around the joint, physically restricting movement. We often describe it as the capsule shrinking to fit the ball too tightly, like a shirt that has shrunk in the wash. This is not a problem with the muscles or the bones; it is a problem with the container the joint sits in.
Frozen shoulder is unique because it follows a very specific pattern. The British Elbow & Shoulder Society (BESS) classifies the condition into three distinct phases:
1. Freezing (The Painful Phase) Duration: 2 to 9 months. This is arguably the most difficult phase for patients. The shoulder starts to ache, and the pain becomes severe. The hallmark sign is night pain, you may find it impossible to sleep on the affected side. You will notice a gradual loss of motion, but pain is the dominant symptom. Symptoms: Sharp pain at the extremes of movement, constant dull ache, disturbed sleep.
2. Frozen (The Stiff Phase) Duration: 4 to 12 months. In this phase, the acute inflammation begins to settle. The sharp pain may subside into a dull ache, but the stiffness becomes profound. The capsule has now thickened and scarred (fibrosis). The shoulder is physically stuck. Symptoms: Less pain at rest, but the arm feels "blocked." External rotation (moving your hand away from your stomach) is usually the first movement to be lost.
3. Thawing (The Recovery Phase) Duration: 5 to 24 months. The motion slowly returns as the capsule stretches out. This is a slow process, often taking over a year to return to "normal." Symptoms: Gradual improvement in range of motion and function.
Risk factors and causes
For the majority of patients, frozen shoulder is idiopathic, meaning it arises without a clear cause or injury. However, certain medical factors significantly increase your risk.
Diagnosing frozen shoulder is usually done via a clinical examination. The key sign is a loss of passive external rotation. If I try to rotate your arm outwards and it hits a hard stop, that is the hallmark of a tight capsule. We will often perform an X-ray to rule out arthritis, as osteoarthritis can also cause stiffness. In some cases, an MRI is useful to ensure there is no underlying rotator cuff tear hiding behind the stiffness.
The traditional advice from many GPs was to wait and see. However, modern shoulder practice has moved away from this passive approach. If you are struggling with sleep or work, we have effective interventions to speed up the process.
1. Physiotherapy In the early "freezing" phase, aggressive physiotherapy can actually make the pain worse. The shoulder is inflamed, and forcing it to move adds fuel to the fire. Physio is most effective in the later "thawing" stages to help regain strength.
2. Hydrodilatation This is a specialized injection procedure performed under ultrasound guidance. It bridges the gap between simple steroid injections and surgery. How it works: We inject a mixture of saline (salt water), local anaesthetic, and steroid into the shoulder joint. The goal is two-fold:
This is effectively a "liquid expansion" of the joint. For many patients, hydrodilatation provides rapid pain relief and can "break the cycle" of freezing, allowing them to sleep again.
3. Arthroscopic Capsular release (Keyhole Surgery) For stubborn cases, or for diabetic patients where injections have failed, surgery is the definitive solution. The Procedure: This is a minimally invasive (keyhole) day-case procedure. Through two tiny incisions (less than 1cm), we insert a camera and a radiofrequency probe. We then meticulously cut through the tight, scarred ligaments of the capsule. Think of it like cutting the tight rubber band that is holding the shoulder globally. Once the capsule is released, the shoulder is manipulated to ensure full range of motion is achieved while you are still asleep. The Recovery: The results are often dramatic. Patients typically wake up with near-full range of motion. The key to success is immediate physiotherapy, you must move the arm straight away to prevent the capsule from sticking down again. Most patients return to desk work within 2 weeks and driving within 3–4 weeks.
While frozen shoulder will eventually burn itself out, the wait and see approach is not for everyone. Two years is a long time to live with pain and restriction. If your shoulder is affecting your quality of life, you do not have to suffer in silence. Early intervention, whether through hydrodilatation or surgical release, can save you months of unnecessary disability. Is stiffness stopping your life? You do not have to wait two years for relief. Read more about [Frozen shoulder treatment] or [Book a Consultation] to discuss your options with Mr Baring.
