Cause of disease

There are two categories of frozen shoulder, namely primary and secondary frozen shoulder (Kelley et al., 2009). In the case of a primary frozen shoulder, the mechanism of origin is still unclear, but there is usually a case of overburdening or incorrect movement of the shoulder. This can lead to capsular damage, to which our body will react with capsular inflammation. Because of the pain caused by the inflammation, the patient will move his shoulder less, which will lead to a thickening and a decreased elasticity of the capsule. In case of a secondary frozen shoulder there is an underlying disorder that makes one more likely to develop this pathology. These include Diabetes Mellitus, Parkinson's disease, thyroid problems or Dupuytren's disease, but it can also be a fracture of the shoulder or shoulder surgery.

Evolution of the clinical picture

The course of a frozen shoulder is characterised by three major phases (Challoumas et al., 2020). These phases run into each other and during each phase specific characteristics are present.

The first phase is called the "freezing phase" and here the pain is dominant. In this phase, the patient will gradually start to experience pain in the shoulder. This pain will become worse during the night or with sudden extreme movements. The first phase can last between two and nine months.

The second phase is called the "frozen phase". In the transition from the first to the second phase, the pain will start to decrease and there will be a progressive restriction of movement in the shoulder joint. Pain will still occur at the extreme of the range of motion. This phase can last anywhere from four months to a year.

The last phase is also called the "thawing phase". During this phase, the patient will gradually regain full range of motion in the shoulder. This period can last from five months to even six years (Challoumas et al., 2020).


Pain in the shoulder is an important symptom that is mainly present at the beginning. This pain will become worse during the night and with extreme movements. The pain is located around the shoulder and can radiate down the side of the upper arm.


Movement limitations will mainly occur when rotating the upper arm. External (turning the shoulder outwards) and internal rotation (turning the shoulder inwards) are painful and limited, as are abduction movements (raising the arm sideways).


In principle, there are no neurological symptoms.


In principle, there are no symptoms at the level of the muscles.

Other symptoms

Because of the movement restriction, daily functioning will be disturbed. Putting clothes on or off, washing your hair or other actions that require a lot of mobility of the shoulder are difficult or impossible.

Rol of physical therapy and your physiotherapist

The physiotherapist plays an important role in the diagnosis and the entire treatment process.

Physiotherapeutic examination

After the interview, the physiotherapist will examine the active mobility (the patient performs the movement himself) and the passive mobility (the physiotherapist performs the movement of the neck for the patient) of the shoulder. In addition, the physiotherapist will also examine whether the symptoms can possibly come from the neck. Since a frozen shoulder is a disorder of the shoulder joint, the active and passive mobility of the shoulder joint must be approximately equally restricted. If this is not the case, there is another cause for the limitation. The physiotherapist will examine whether the limitation shows a capsular pattern. This is a characteristic sequence of movement restrictions in the joint due to irritation of the capsule.

Physiotherapeutic treatment

Conservative (i.e., without medication or interventions) treatment with physical therapy is the first choice for treating frozen shoulder. The aim of the treatment is to reduce pain, restore range of motion and improve the functionality of the shoulder (Chan et al., 2017). The physiotherapist must assess how prevalent the pain is and the extent to which the individual responds to treatment. This is important to determine what treatment options are available. After all, with a frozen shoulder all treatments and therapies must be carried out within the pain limit. The goal is to avoid irritation of the capsule.

Manual physiotherapy

The physiotherapist can improve the mobility of the capsule by means of mobilisations and passive stretching.

Pain control

This is important in the first phase of the pathology. The doctor can prescribe non-steroidal anti-inflammatory drugs during this phase. These will help to reduce the pain and, moreover, this medication will have a better effect when it is combined with physical therapy. Besides anti-inflammatories, a corticosteroid injection is also an option during this acute phase. This will also help to reduce the pain (Challoumas et al., 2020), but it is very important to continue physical therapy afterwards. When the pain decreases, it is easier for the physiotherapist to make faster progress. It is important in the early stages that the patient tries to avoid movements that provoke pain. These are overhand activities, but also quick unexpected movements.

Exercise therapy

Exercises for a frozen shoulder are aimed at regaining the mobility of the shoulder joint (Chan et al., 2017). Dexterity and stretching exercises can help to regain normal functionality of the capsule. These exercises should be done within the pain threshold. If the patient experiences too much pain, this will adversely affect the further progression of the treatment. Next, pendulum exercises are good for the shoulder joint. The idea is that the patient lets his/her arm hang down and makes a quiet relaxing movement. As the patient has less pain or reacts less to the treatment, the exercises can become more extensive and heavy. The patient will also receive an exercise programme for at home. The intention is to carry out this programme several times a day so that the mobility gained is not lost.

Rehabilitation pathway

Within each rehabilitation, we always distinguish between short-term and long-term goals. Depending on the type of pathology, this will differ.

Korte termijn

De verwachting is dat door het aanpassen van de activiteiten en behandeling de pijn vermindert. Hierdoor kan een verdere toename van de bewegingsbeperking vermeden worden. Dagelijkse activiteiten aanpassen om pijn te vermijden.

Lange termijn

Wanneer de bewegingsbeperking stabiliseert kan men traag een herstel van het volledige bewegingsbereik en functionaliteit van de schouder verwachten. Dit is een proces dat sterk van patiënt(e) tot patiënt(e) kan verschillen.

Multidisciplinary pathway

The patient's general practitioner plays an important role in the treatment of frozen shoulder. They will refer the patient to the physiotherapist and, in consultation with the physiotherapist, will decide on the steps to be taken so that the patient can receive the best possible care. When the physiotherapist notices that the patient is experiencing excessive symptoms, he/she will inform the doctor to consider other pain medication in order for the physiotherapist treatment to be more effective. The orthopaedic surgeon will determine whether a corticosteroid injection is necessary and will monitor the patient's progress (Cho et al., 2019). It should also be considered whether modified work is necessary to avoid pain. Depending on the occupation, it may or may not be necessary to make significant adjustments to work.



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