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Frozen Shoulder | Symptoms, Stages & Treatment with Physiotherapy

Posted on Oct 28 2020
Posted by: Dr. Firdaus Shaikh (PT) & Dr. Nikita Vaidya (PT)

Frozen shoulder, also known as adhesive capsulitis is characterized by significant restriction of shoulder movements that occurs in the absence of a known intrinsic shoulder disorder. It is one of the most common musculoskeletal disorders encountered in Indian population with a prevalence of almost 50% older patients with diabetes and 2-10% in non-diabetics.

The restriction may or may not be associated with pain depending on the stage of the condition.

In this blog post, we’ve provided an overview of Frozen shoulder- Its symptoms, stages, causes, and management. We’ve also provided an insight into how we, at AquaCentric manage Frozen shoulder with our unique tailor-made Aquatic and land therapy programs.

What are the Symptoms?
Stiffness often associated with insidious onset of pain which might be worst at night or early morning is the characteristic symptom of Frozen Shoulder.

In the initial stages, patients might complain only of pain around the shoulder. It is difficult to take hand behind the back, hand behind the neck or do overhead activities. As the condition progresses, there is reduction of pain and increase in the stiffness around the shoulder causing a gradual restriction of doing overhead, behind the neck or behind the back movements. Patients commonly complain of difficulty in taking things from overhead shelves, difficulty in combing hair, difficulty in wearing a bra, driving.

It is a progressive and at times self-resolving condition. However, it might take anytime between 12-24 months to get resolved and if not taken seriously might lead to a lot of restrictions in your daily activities thus reducing the quality of life.

Stages of Frozen Shoulder
The symptoms are usually classified in three stages.

• Freezing: This stage is characterized by a gradual onset of diffuse, severe shoulder pain that typically worsens at night. It could last anywhere between about 2–9 months.
• Frozen: The pain begins to subside during the frozen stage with a significant gradual loss of overall shoulder movements Duration is about 4–12 months.
• Thawing: By this stage the pain has substantially reduced and the movements become a lot easier making this stage much better tolerated by patients in-spite of it lasting the longest for about 5-26 months.

Causes of Frozen shoulder
The actual cause of adhesive capsulitis is yet unknown. However, if one has a hormonal imbalance, diabetes, or a weakened immune system, they may be prone to joint inflammation and developing a frozen shoulder. The International Diabetes Federation has claimed that approximately 50% of people suffering from shoulder pain and stiffness have diabetes and vice versa diabetes
The Other possible causes include:
• Reactions after an injury or surgery
• Pain from other conditions, such as arthritis, a rotator cuff tear, bursitis, or tendinitis, that has caused a person to stop moving the shoulder
• Immobilization of the arm, such as in a sling, after surgery or fracture
Often, however, there is no clear reason why adhesive capsulitis develops.

Physiotherapy for Frozen Shoulder:
Physiotherapy is the most common treatment for frozen shoulder. The two major goals of physiotherapy are providing pain relief and regaining the lost movements thereby improving the functional range and improving the quality of life.
Management is highly dependent on the physical examination, patient concerns and the current stage.

AquaCentric Approach to Management (A window to what we do)
AquaCentric Therapy believes in providing a holistic approach in rehabilitation. A thorough physical examination is conducted on day 1 of patient visit. The assessment helps the therapist in determining the severity and categorizing the condition into one of its three stages. As the clinical presentation of each stage is different, the management would also differ on the basis of the stages.
Based on the assessment, a unique tailor-made treatment strategy is formulated.
Aquatic therapy is used in conjunction with land & outdoor -based programs to further enhance restoration of motion, reduce muscle spasm and aid in enhancing dynamic movements to enhance tissue healing and functional recovery.
Our Centre is equipped with advanced land therapy equipment like the MI7 multi resistance training station, Pilates reformer for enhancing core stability along with restoring upper body range and strength along with other equipment like TRX bands, Resistance tubes and loops and weighted battle ropes to enhance muscle endurance for advanced rehabilitation at later stages.

Strengthening the shoulder flexors using the pilates reformer for controlled resistance along with core stability.



Endurance training of the shoulder muscles using battle ropes.


Strengthening different shoulder muscles using the multi- functional resistance station


• Aquatic therapy, previously known as hydrotherapy is a specialized form of rehabilitation, where in physiotherapy interventions are performed in water, utilizing the physical properties of water to aid in the rehabilitation process.
• The unique properties of water, including buoyancy, viscosity and hydrostatic pressure, allow for patients to perform therapeutic exercises with much ease and far lesser pain.
• This allows the patient to start rehabilitation and movement-based interventions that would otherwise be extremely painful at a much earlier stage in the rehabilitation process.

4 Beneficial effects of Aquatic therapy in shoulder cases:

Our pools are heated to a therapeutic warm temperature.
The Warmth of the water helps in reducing pain, reducing the surrounding muscle tension and in reducing the overall stiffness around the joint. This is typically helpful in the freezing stage where the pain is severe and usually in tolerable.
The Drag force of water helps in creating a natural resistance on the moving body segment and can also be used to facilitate movements.
It helps to restore the mobility of joints, strength and flexibility of the muscles
The effects of hydrostatic pressure help in reducing the swelling around the joint. The pressure exerted also helps in improving muscle blood flow that may aid in tissue healing and extensibility.

Aquatic Therapy Equipment used to enhance shoulder function:
Usage of multiple equipments can be used either to assist or resist the muscles depending upon the requirement.
The power of assistance or resistance of the equipment depends on the buoyancy of the object used.
The various equipment used in Aquatic Rehabilitation are noodles, snorkels, flippers, therapeutic barbells, kickboard, resistance bands, floats, paddles etc. can be used in various combinations to obtain the desirable resistance or assistance.

Assisted shoulder movements using the resistance of water and a floating ball


Resistance plate that provides resistance as it cuts through the water during various shoulder motions


Strengthening shoulder flexors using an aquatic dumbbell. Patient is held prone with the help of a floatation belt and a snorkel is worn to help him breathe easily underwater.


Specialized training in advanced pool to further enhance shoulder function and strength along with core stability. Used mainly for athletes and fitness enthusiasts.



Return to work/ Return to sports!
It is extremely important to understand the fact that all the effects of your rehabilitation must be translated into expected function.
After achieving the set goals, there should be a focus on therapy that enhances return to sports or return to function for the patient. This includes a good amount of outdoor training, work conditioning and work hardening.

The circle of rehabilitation can only be completed when you successfully make your patient return to their previous functional level!

1. Armstrong A. Diagnosis and clinical assessment of a stiff shoulder. Shoulder & elbow. 2015 Apr;7(2):128-34.
2. Vaishya R, Agarwal AK, Vijay V. Adhesive capsulitis: Current practice guidelines. Apollo Medicine. 2016 Sep 1;13(3):198-202.
3 Hanchard NC, Goodchild L, Thompson J, O’brien T, Davison D, Richardson C. Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder: quick reference summary. Physiotherapy. 2012 Jun 1;98(2):117-20.