Frozen Shoulder Explained: What’s Actually Happening in Your Shoulder?

Part 1: Understanding Your Frozen Shoulder

If you’re reading this, you’re likely all too familiar with the unique and profound frustration of a frozen shoulder. It defies common advice because the root cause isn’t a muscle tear or tendonitis—it’s a problem with the joint’s container itself. This condition follows a stubborn, predictable timeline, often leaving people stuck in a cycle of pain and stiffness with no clear path forward.

Pete’s story captures this perfectly:

“It’s not just pain; it’s like my shoulder has been unplugged. I can’t find a comfortable position to sleep, and the stiffness is worse in the morning. I tried stretching it out, but that just made the pain sharper for days. What on earth is going on in there?”

He’s asking the right question. That deep ache and profound stiffness aren’t random—they’re specific signs of a precise process unfolding inside the joint.

The Distinct Symptoms: More Than Just a “Bad Shoulder”

Frozen shoulder creates a specific pattern of symptoms that sets it apart. It often begins with a deep, throbbing night pain that regularly steals sleep. The stiffness feels fundamentally different from a sore muscle; it’s a hard, internal block that seems to come from within the joint itself.

Most tellingly, you’ll lose movement in a strict, predictable order known as the ‘Capsular Pattern’:

• Reaching for a seatbelt or behind you (external rotation) becomes difficult first.
• Lifting your arm out to the side (abduction) tightens up significantly.
• Reaching behind your back to tuck in a shirt (internal rotation) often becomes the most restricted movement of all.

This sequence is a clear signpost pointing to a problem within the joint capsule. You’ll typically feel a constant, dull background ache, punctuated by a sharp, catching pain if you accidentally move to your new, restricted limit—a hallmark of the condition.

The Root Cause: A Shrinking Container for Your Joint

All these symptoms point to one key structure: the glenohumeral joint capsule. Imagine a flexible, balloon-like sac that surrounds your shoulder joint, lined with a sensitive membrane that produces lubricating fluid. This sac is what allows your shoulder its incredible, wide range of motion.

In frozen shoulder, this capsule changes in two specific phases:

• Phase 1: Inflammation (Synovitis). The capsule’s inner lining becomes intensely inflamed—hot, swollen, and irritated. This is the direct source of your constant, deep pain.
• Phase 2: Scarring and Contraction. This inflammation triggers a faulty repair response. The body lays down thick, disorganised bands of scar tissue inside the capsule (adhesions), and the capsule tissue itself actively tightens and shrinks.

The result is capsular contracture. That pliable, spacious sac thickens and tightens into a restrictive, shrunken shell. This physical tightening creates the mechanical block causing your stiffness; your bones are literally running out of space to move. This is why forcing it doesn’t work—you’re pushing against a tightened, thickened structure.

The Three-Stage Timeline: Knowing Your Phase is Everything

This condition unfolds in a predictable cycle. Identifying your current stage isn’t just academic—it tells you exactly what to focus on and, critically, what to avoid. Getting this wrong is the most common reason for prolonged suffering.

Stage 1: Freezing (The Painful Phase)
This phase is dominated by aggressive inflammation. Pain is constant and often severe, especially at night. While stiffness increases rapidly, movement is limited primarily by pain and protective muscle spasm, not yet by permanent tightening.

• This stage typically lasts 2 to 9 months.
• The Goal: Reduce pain and inflammation. Success is measured by improved sleep and calming the ache, not by gaining range of motion. Pushing for movement here often backfires.

Stage 2: Frozen (The Stiff Phase)
The intense inflammation settles, leaving behind the densely scarred and maximally tightened capsule. Pain often reduces to a dull ache or stiffness, but the loss of movement becomes absolute and ‘locked’. The hard end-feel is unmistakable.

• This stage typically lasts 4 to 12 months.
• The Goal: Remodel the thickened tissue. The focus shifts entirely to patient, consistent, sustained stretching to gently encourage the capsule to lengthen. It’s a marathon, not a sprint.

Stage 3: Thawing (The Gradual Return)
The body begins to slowly break down the disorganised scar tissue. Movement returns in frustrating fits and starts. This phase is defined by the ‘Boom-Bust’ cycle: a ‘good day’ with more movement leads to overactivity, which then triggers a painful inflammatory flare-up that sets you back.

• This stage can last 12 to 42 months.
• The Goal: Rebuild strength and control. The focus is on intelligent pacing—increasing activity by tiny, careful margins—to navigate the return of movement without triggering debilitating setbacks. It’s about rebuilding trust in the joint.

Why Does This Happen? Key Risk Factors

While a specific trigger isn’t always found, several factors significantly increase the risk. Knowing these can help you and your clinician build a fuller picture.

• Diabetes is the strongest link. Prolonged high blood sugar can affect the collagen in the capsule, making careful glycaemic control an important part of the recovery conversation.
• Other Systemic Factors: Thyroid disorders, past cardiac surgery, Parkinson’s disease, and certain autoimmune conditions are also associated. It’s a condition that often interacts with other systemic health issues.
• Previous Immobilisation: Keeping the shoulder still after a fracture, rotator cuff surgery, or even a stroke can sometimes precede it.
• Age and Gender: It most commonly occurs in people aged 40 to 60. It is also more frequently diagnosed in women, which is thought to be related to a complex interplay of hormonal influences on connective tissue and immune response over a lifetime, though research into the precise mechanisms is on going.

In summary, frozen shoulder is a capsular contracture. This explains the unique pain, the strict loss of movement, and the long, stage-driven timeline. You can’t rush this process, but you can guide it effectively by matching your actions to the stage you’re in. The following sections will show you exactly how to do that, turning understanding into a practical, day-by-day plan.

Part 2: Your Stage-by-Stage Recovery Plan

Understanding the ‘why’ is essential, but the pressing question is: what do you actually do each day? The answer isn’t a single exercise, but a precise strategy that changes based on whether you’re in the painful Freezing, stiff Frozen, or erratic Thawing stage. Applying the wrong approach for your phase is the most common reason for a prolonged recovery.

First, Regain Daily Control

Before targeting your specific stage, master these fundamentals. Getting control of daily symptoms builds the stability all other progress relies upon.

1. Prioritise Sleep
Night pain is often worsened by lying in a position that strains the inflamed front of the capsule. If you sleep on your back, place a firm pillow under your entire forearm, from elbow to wrist, to support the arm in a gentle “thumbs-up” position. This simple propping reduces overnight strain on the sensitive joint.

2. Use Temperature Strategically
The rule is simple and non-negotiable: use ice for pain, heat for stiffness.

• Ice (Cryotherapy): Apply a cold pack (wrapped in a thin cloth) to the front of your shoulder for 15 minutes after activity or at the end of a painful day. This directly calms inflammatory pain signals.
• Heat (Thermotherapy): Use a warm wheat bag for 15-20 minutes before gentle movement or stretching. This improves blood flow and tissue pliability. Never apply heat to a joint that feels actively hot or throbbing.

3. Maintain Gentle, Pain-Free Movement
The goal here is circulation, not stretching. The pendulum exercise is ideal: lean forward, supporting yourself with your good arm on a table, and let the painful arm hang straight down. Gently shift your weight to create small, pain-free circles or side-to-side motions for 30-60 seconds, several times daily.

Considering a Supportive Brace
Managing symptoms throughout the day, not just during exercise sessions, is a key challenge. It’s worth understanding the clinical rationale for why a simple, adaptable support can be a useful part of your toolkit.

The right support isn’t about immobilisation; it’s about aiding your management. It can provide subtle sensory feedback that improves your awareness of the shoulder’s position (proprioception), which helps calm the subconscious muscle tightening that exacerbates pain. For the stiff ‘Frozen’ stage, maintaining gentle warmth around the joint can aid tissue pliability prior to stretching. Perhaps most practically, a well-designed support offers a simple way to manage cold therapy, securing a cold pack in the correct position for effective icing after activity.

The ideal support is adaptable—offering more stabilisation during a flare-up, and lighter, sensory-focused wear as you improve. Its sole role is to complement your stage-specific exercise plan and professional guidance.

At NuovaHealth, we developed our shoulder support specifically to meet these clinical needs for frozen shoulder recovery. It’s designed to be that adaptable, therapeutic aid you can use throughout the different stages. You can learn more about how it works here.

Identify Your Stage: Your Strategy Depends On It

Your entire daily approach hinges on an honest assessment of your dominant symptoms.

• You are in the FREEZING stage if your main issue is constant or night-dominant PAIN. Stiffness is increasing, but movement is limited primarily by fear of sharp pain.
• You are in the FROZEN stage if your main issue is profound, ‘locked’ STIFFNESS. The severe pain has subsided to a dull ache, but you feel a firm, absolute block at the end of any movement.
• You are in the THAWING stage if you notice gradual, erratic improvements in movement, but suffer unpredictable flare-ups of pain after overdoing activity.

Managing the Freezing Stage: The Priority is Calm

In the Freezing stage, aggressive inflammation is the primary problem. Your core principle is to settle this down, not fight it. Forcing a stretch here is inflammatory and counterproductive.

Continue meticulously with sleep modification and proactive icing. Pendulum exercises are your primary movement. You may carefully ‘walk’ your fingers up a wall, but only to the point of a mild stretch, never a sharp pain. Success here is measured by reduced pain and improved sleep, not by gains in range of motion. The goal is purely to create calmer conditions for the shoulder to begin healing.

Managing the Frozen Stage: The Focus Shifts to Gentle Stretching

As pain recedes and stiffness becomes absolute, your focus must shift. The goal is to gently remodel the thickened, scarred capsule through low-load, prolonged stretching.

The cross-body stretch is a cornerstone. Find the point of a firm, definite pull—never a sharp pain—and hold it steadily for 45 to 60 seconds. This sustained, gentle tension encourages the collagen fibres to gradually lengthen. Consistency with this approach, ideally 2-3 times daily, is far more important than intensity. Progress is measured in millimetres over weeks.

Managing the Thawing Stage: Rebuilding Without Regret

In the Thawing stage, movement returns erratically. The core principle is to rebuild strength and confidence while avoiding the destructive ‘Boom-Bust’ cycle. This is the defining psychological and physical trap of this phase:

• The BOOM: You have your first truly ‘good’ day in months. Pain is low, stiffness feels lighter. Encouraged, you instinctively return to normal activity—perhaps gardening, reaching overhead, or a longer exercise session. It feels fine in the moment.
• The BUST: 12 to 48 hours later, your shoulder reacts with a vengeance. Sharp, inflammatory pain returns, stiffness ratchets back up, and you lose days or weeks of progress.

To navigate this, you must treat a ‘good day’ not as permission to overdo it, but as a baseline. Introduce gentle strengthening with resistance bands (focusing on rows and external rotations) at a very low intensity. Carefully resume light tasks, but work at about 70% of your perceived capacity. A flare-up isn’t a failure; it’s feedback to refine your pacing. When one occurs, revert immediately to your Freezing-stage protocols (ice, rest, pain-free pendulums) to reset.

This stage-by-stage plan is the fundamental part of your routine. By applying the correct strategy for your phase, you take direct control of your recovery process. To make it truly effective, you need to integrate this daily work with professional expertise and a long-term view—which is exactly what we’ll cover next.

Part 3: Working with Professionals and Your Long-Term Strategy

Frozen shoulder recovery takes time. This section focuses on the practicalities of that process: how to collaborate effectively with your healthcare team, how to handle inevitable setbacks with a clear plan, and what further options exist if progress stalls.

How to Work Effectively with Your Physio or GP

The most productive appointments happen when you combine your clinician’s expertise with your own detailed observations. Good preparation turns a general discussion into a targeted session that moves your recovery forward.

For a few days before your visit, make brief notes on what specifically affects your shoulder. For example: “The sharp catch happens when I reach for the car’s passenger seat,” or “Stiffness is worst for the first hour after I wake up.”

Bring focused questions that relate directly to your current stage. This helps your physio or GP tailor their advice precisely:

• If you’re in the Freezing Stage: “Can you help me identify the exact line between helpful movement and stretching too far?”
• If you’re in the Frozen Stage: “Could you watch me do my key stretch to check my technique and the level of tension I should be aiming for?”
• If you’re in the Thawing Stage: “What’s a safe, minimal starting point for strengthening that won’t trigger a flare-up?”

Your Personal Plan for Managing Setbacks

Flare-ups, particularly in the Thawing stage, aren’t a sign of failure—they’re a common part of the landscape. Having a pre-agreed plan removes the panic and guesswork when one occurs.

Follow these steps to reset and get back on track:

1. Identify the Likely Cause
Look back at the 24-48 hours before the flare. Did you try a new activity, hold a static position too long (like at a desk), or make an unguarded, sudden movement? Pinpointing the trigger is your best defence against the next one.

2. Activate Your Reset Protocol
For 2-3 days, consciously return to the basic principles of the Freezing stage:

• Rest from any movements that cause sharp pain.
• Ice the front of your shoulder for 15 minutes, several times a day.
• Move gently with pain-free pendulum exercises only.
• Pay attention to your sleeping posture with propping.

3. Resume Activity Cautiously
Once the sharp pain subsides to your usual background ache, restart activities at a markedly lower level. Begin at about half the intensity or duration that led to the flare, and increase only gradually over the following week.

The Long-Term View and Further Treatment Options

Full recovery from frozen shoulder typically takes 18 to 24 months. Your consistent, correct daily management is the most powerful factor in guiding this process positively and efficiently.

For the small percentage of people whose progress plateaus significantly despite dedicated, stage-specific physiotherapy, a specialist may discuss other interventions:

• Hydrodilatation: A procedure where a radiologist injects sterile fluid into the joint capsule under imaging guidance to gently stretch it.
• Manipulation Under Anaesthesia (MUA): A procedure where a surgeon moves the shoulder through its full range while the patient is sedated, to break down adhesions.
• Arthroscopic Capsular Release: Widely considered the most definitive surgical solution for resistant cases. It’s a keyhole surgery to precisely release the tightened capsule, and requires a committed, structured rehabilitation programme afterwards to maintain the gains.

Conclusion: From Frustration to a Clear Path

Frozen shoulder follows a stubborn but predictable path. While you can’t hurry the timeline, you can absolutely steer it. By understanding your stage—what’s actually happening inside the joint—you can apply the right daily management, use professional appointments strategically, and navigate setbacks without panic.

This knowledge turns frustration into a clear plan. It replaces the question, “What on earth is going on in there?” with the clarity and confidence to guide your shoulder steadily back to full, reliable use. You move from being a passive patient to an active manager of your own recovery.

Important Guidance

This guide is designed to inform and support your management of frozen shoulder after a professional diagnosis. It is not a substitute for personal medical advice.

1. The Necessity of Professional Diagnosis
Shoulder pain has many possible causes, including rotator cuff injuries, arthritis, and referred pain. The advice here is specific to adhesive capsulitis. You must obtain a formal diagnosis from your GP or a Chartered Physiotherapist before following these strategies.

2. A Note on Using a Support
A shoulder support is a management aid, not a treatment. If you choose to use one, such as the NuovaHealth support designed for this condition, it should only be used following a confirmed diagnosis. Ensure it is never worn so tightly as to restrict circulation or cause numbness. Its purpose is solely to support your prescribed exercise and management plan, not replace it.

3. Final Advice
Your healthcare team’s personalised guidance should always take priority. If you experience severe, unremitting pain, sudden weakness, loss of sensation, or any other acute concerning symptom, seek immediate medical attention.