The Three Phases of a Frozen Shoulder

Frozen shoulder, or adhesive capsulitis, is a condition that can be difficult to navigate, both for the client experiencing it and the therapist working to relieve it. When someone comes to us with frozen shoulder, they are often dealing with frustration, confusion, and, of course, pain. This condition, which impacts not only shoulder mobility but also quality of life, typically unfolds in three phases: freezing, frozen, and thawing. Each phase has unique characteristics, symptoms, and treatment approaches. With a well-rounded understanding of each stage and the best strategies for addressing them, we can help clients get through frozen shoulder as smoothly as possible.

Phase 1: The Freezing Phase

What It Is and How It Feels

The freezing phase marks the initial onset of pain and stiffness in the shoulder, often appearing with no clear cause. The pain might start as mild, something you’d easily dismiss, but gradually intensifies over a few days or weeks. Many clients report feeling that they’re unable to lift their arm without a sharp, sudden pain. Activities as basic as reaching for an object or putting on a coat become increasingly difficult. This phase can last anywhere from six weeks to nine months, depending on the individual and how soon they begin treatment.

Symptoms

Pain is the hallmark of this phase, and it often intensifies with movement. Many people experience a deep, throbbing ache or even sharp pain with certain motions, particularly overhead activities or reaching backward. Clients frequently report that the pain worsens at night, making it hard to sleep.

Therapeutic Treatments

During the freezing phase, the goal is to manage pain while encouraging gentle mobility without triggering more inflammation. Here are some of the most effective approaches for pain management and controlled movement:

Manual Therapy and Massage: Gentle manual therapy can be useful to prevent further stiffening of the joint. At this stage, massage focused on surrounding muscles, such as the deltoids, trapezius, and rotator cuff, can help ease the tension that builds up as the shoulder compensates. Techniques like gentle kneading and myofascial release can also relieve referred pain caused by tight muscles. Massage can also improve circulation, which helps reduce inflammation.

Heat and Ice Therapy: Alternating between heat and cold packs can ease both pain and inflammation. Applying ice after any activity can help reduce swelling, while a heating pad before gentle movement can make the joint feel more flexible. A hot shower before massage or gentle stretching is also beneficial.

Pain Relief and Medications: For severe cases, consulting with a physician about anti-inflammatory medications may be helpful. Corticosteroid injections may be considered for pain relief in some cases, though these are typically used sparingly.

Stretching and Gentle Exercise: While this phase isn’t ideal for intense stretching, light pendulum swings and other passive stretching exercises can help maintain a bit of movement without overloading the joint. The focus is on gentle motion to prevent the joint from stiffening further. Stretching should be gentle, and pain-free if possible.

Phase 2: The Frozen Phase

What It Is and How It Feels

The frozen phase is marked by a significant decrease in pain but a simultaneous increase in stiffness. Clients often describe the sensation as their shoulder being “locked” in place. For many, the inability to raise the arm above a certain level can be frustrating and limiting. This phase can last four months to a full year, and while the pain may lessen, the frustration typically increases due to decreased mobility.

Symptoms

In this phase, stiffness is the dominant symptom, while pain becomes more of a dull ache. The shoulder may feel frozen, as though range of motion is “blocked.” Clients find it challenging to reach across their bodies, raise their arm, or perform routine activities without discomfort or limitation.

Therapeutic Treatments

Since the pain has decreased, we can introduce more active therapeutic techniques to gradually address the stiffness. Massage and manual therapy can both play a central role here, along with targeted stretches and exercises.

Massage and Myofascial Release: At this stage, massage therapists can apply a bit more pressure to work on compensating muscles that have tightened due to limited shoulder movement. Techniques such as trigger point release and deep tissue massage on the trapezius, rhomboids, and deltoids help reduce compensatory tension that may further restrict movement. Myofascial release targeting the pectorals, biceps, and triceps can also help relieve referred pain and improve circulation around the shoulder joint.

Trigger Point Therapy: Trigger points in the muscles surrounding the shoulder can be exacerbated by restricted movement and compensatory patterns. Working on these trigger points, particularly in muscles like the deltoid, biceps, and trapezius, can offer significant relief and enhance mobility.

Manual Therapy and Joint Mobilization: Gentle joint mobilization can begin at this phase, with therapists focusing on graded techniques to stretch the joint capsule. Techniques such as Grade III and IV mobilizations help the shoulder joint begin to open and restore a bit of range.

Strengthening and Stretching Exercises: Strengthening the rotator cuff and scapular stabilizers is essential in this phase. Exercises such as wall walks, pulley stretches, and external and internal rotation with resistance bands allow for controlled strengthening while improving flexibility. By strengthening these muscles, we build a foundation that will support the shoulder as mobility increases.

Phase 3: The Thawing Phase

What It Is and How It Feels

In the thawing phase, clients start to experience gradual improvement in range of motion and a decrease in stiffness. Movement feels easier, and the shoulder seems less “locked.” The thawing phase can last from six months to over two years, depending on how long the previous phases lasted and the effectiveness of treatment.

Symptoms

During the thawing phase, the shoulder slowly regains its ability to move without restriction. The once-rigid stiffness starts to ease up, allowing clients to perform daily activities with greater ease. There may still be minor discomfort, but pain is usually minimal compared to the earlier stages.

Therapeutic Treatments

With the shoulder more tolerant to movement and pressure, this phase is all about regaining strength, flexibility, and full function. Treatment approaches can be more vigorous in this stage, as the shoulder can handle increased activity.

Massage and Deep Tissue Therapy: Massage therapy is key in this phase, as it can work on deeper muscle layers to release tension and promote circulation. Deep tissue massage techniques targeting the scapular stabilizers, deltoids, and rotator cuff muscles help alleviate any compensatory tightness and provide relief.

Strengthening Exercises and Resistance Training: Now, we can introduce resistance training with bands, weights, and body weight exercises. The focus is on building strength in the deltoids, rotator cuff, and surrounding muscles to support the shoulder joint. Movements should be slow and controlled, with a focus on maintaining good form.

Advanced Stretching Techniques: Proprioceptive Neuromuscular Facilitation (PNF) stretching is a beneficial addition in the thawing phase. This advanced stretching method helps increase flexibility by working the muscle through its full range, encouraging shoulder mobility. PNF is particularly useful for athletes and active individuals working toward optimal performance.

Functional Exercises: Exercises that mimic daily activities, such as reaching overhead, pushing, and lifting, can be incorporated at this stage. These exercises help clients regain confidence in their shoulder's ability to perform day-to-day tasks and improve overall function.

Conclusion: Embracing a Holistic Approach and Continuing Education

Navigating through the stages of frozen shoulder requires patience, determination, and a willingness to adapt treatments to each phase. For both therapists and clients, understanding the nature of frozen shoulder allows for a more comprehensive and effective approach. Each stage has its unique challenges, and a well-rounded, individualized plan can make all the difference in achieving full recovery.

For therapists looking to deepen their expertise and specialize in treating frozen shoulder, advanced training can be incredibly beneficial. Niel Asher Education offers an in-depth online course on treating frozen shoulder that includes a range of therapeutic techniques, from manual therapy to stretching and strengthening exercises. This course is designed to equip therapists with the knowledge and tools to effectively manage frozen shoulder through every stage of the journey.

With the right knowledge, a supportive therapist, and a commitment to regular practice, recovery from frozen shoulder is achievable. Empowered by a greater understanding of each phase and the best strategies for managing symptoms, therapists can guide their clients toward improved shoulder health and freedom of movement.

Disclaimer

This article is for informational purposes only and should not replace professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider before beginning any new treatment or therapy, especially if you have a medical condition.

References

Neviaser, A. S., & Hannafin, J. A. (2010). Adhesive capsulitis: A review of current treatment. American Journal of Sports Medicine, 38(11), 2346-2356.

Wong, C. K., & Levine, W. N. (2013). Frozen shoulder: A comprehensive overview of etiology, diagnosis, and treatment. Orthopedic Clinics of North America, 44(4), 507-514.

Zuckerman, J. D., & Rokito, A. (2011). Frozen shoulder: A consensus definition. Journal of Shoulder and Elbow Surgery, 20(2), 322-325.