What are Frozen Shoulder (Forty-Shoulder/Fifty-Shoulder)?
In medical terms, "forty-shoulder" and "fifty-shoulder" are known as Frozen Shoulder (Adhesive Capsulitis), a condition characterized by shoulder joint pain and limited range of motion, common in individuals aged 40-60. There is no official age distinction; the terms "forty-shoulder" and "fifty-shoulder" simply refer to the age of onset, and the pathology is the same.
Often, there is no clear cause, and inflammation occurs in the joint capsule surrounding the shoulder joint, leading to contracture. While it can resolve naturally, severe symptoms may persist for 1-3 years, and appropriate treatment and gradual rehabilitation can accelerate recovery.
"It will heal even if left untreated" is half true, half misconception.
Many cases improve with natural progression, but if left untreated, restricted range of motion may persist. Excessive rest during the frozen stage, in particular, can worsen contracture, while moderate exercise and pain management accelerate recovery.
Stages of Progression (3 Stages)
| Stage | Duration | Characteristics | Treatment Focus |
|---|---|---|---|
| Freezing Stage | 2-9 months | Severe pain, night pain, progressive decrease in range of motion | Pain control |
| Frozen Stage | 4-12 months | Pain lessens, but range of motion restriction is prominent | Gradual rehabilitation |
| Thawing Stage | 6-24 months | Gradual recovery of range of motion | Functional recovery training |
Full recovery can take 1-3 years
The typical progression is 1-3 years in total. Many cases improve naturally, but some may experience delayed healing due to incorrect management (prolonged rest, excessive exercise) along the way.
Characteristics of Symptoms
Characteristics of Pain
- Gradual onset of shoulder pain (no clear injury)
- Night pain, pain when turning over in bed
- Sharp pain with specific shoulder movements
- Worsens with movement, improves with rest
- Radiates from shoulder to upper arm when arm is raised
Range of Motion Restriction
- Difficulty tying hair (hair-dressing movement)
- Difficulty reaching back (tying apron strings behind back)
- Unable to reach high objects on shelves (limited elevation)
- Unable to tie apron strings
- Unable to spread arm sideways (limited abduction)
- Unable to rotate arm inwards (limited internal rotation)
Objective Findings
- Restricted range of motion in shoulder joint (even passively)
- Muscle weakness in deltoid and supraspinatus (disuse atrophy)
- Tension in scapular muscles
Diseases with Similar Symptoms to Frozen Shoulder (Differentiation is Important)
Shoulder pain can also be caused by other diseases. Correct diagnosis allows for appropriate treatment.
| Disease | Difference from Frozen Shoulder |
|---|---|
| Rotator Cuff Tear | Injury/aging, pain with specific movements, passive range of motion is relatively preserved |
| Calcific Tendinitis | Sudden, severe pain onset, calcium deposits visible on X-ray |
| Cervical Spondylotic Radiculopathy | Worsens with neck movement, numbness in arm and hand |
| Thoracic Outlet Syndrome | Numbness and pain in arm with arm elevation |
| Angina (referred pain) | Worsens with exertion, widespread pain from left shoulder to jaw |
| Polymyalgia Rheumatica | Over 50 years old, stiffness in both shoulders and hips, elevated CRP |
| Rheumatoid Arthritis | Polyarthralgia, morning stiffness lasting over 1 hour |
| Osteoarthritis of the Shoulder | Elderly, joint deformity on X-ray |
Risk Factors
- 40-60 years old
- Female (2-4 times more common than men)
- Diabetes (2-4 times higher risk, tends to be intractable)
- Thyroid dysfunction
- Prolonged shoulder joint immobilization (due to fracture, post-surgery, etc.)
- Hemiplegia after stroke
- Parkinson's disease
- Post-myocardial infarction
- Desk work, hunched posture
Examination and Tests
Medical Interview
- Onset time, trigger, progression
- Nature of pain, presence of night pain
- Difficulties in daily life
- Past medical history (diabetes, thyroid, stroke, etc.)
- Previous treatment history
Examination and Tests
| Item | Content |
|---|---|
| Shoulder Joint Range of Motion Test | Evaluation of active and passive elevation, external rotation, and internal rotation |
| Muscle Strength Test | Assessment for rotator cuff tears |
| Impingement Sign | Evaluation for rotator cuff impingement |
| X-ray (within chest X-ray coverage) | Exclusion of calcium deposits and osteoarthritis |
| Blood Test | Evaluation of diabetes, thyroid, and CRP |
| MRI/Ultrasound | Differentiation of rotator cuff tear (referral to orthopedics) |
Treatment Options
Pharmacotherapy (Pain Management)
- NSAIDs (Loxoprofen, Celecoxib, etc.): For inflammation and pain
- Acetaminophen: For those who cannot use NSAIDs
- Topical medications (Indomethacin, Diclofenac gel, patches)
- Neurotropin: For chronic pain
- Weak opioids (Tramadol) may be considered for severe pain
Intra-articular Injections
| Drug | Purpose/Characteristics |
|---|---|
| Steroid (Triamcinolone, etc.) + Local Anesthetic | Effective for severe inflammation and night pain, every 3-4 months (up to 2-3 times a year) |
| Hyaluronic Acid | Smooths joint movement, once a week for 5 weeks per course |
Referral to Orthopedics for Intra-articular Injections
If precise injections under ultrasound guidance or intra-articular injections under X-ray fluoroscopy are necessary, we will refer you to a specialized orthopedic medical institution. At our clinic, we initially observe with conservative treatment (medication, lifestyle guidance).
Rehabilitation
Gradual rehabilitation tailored to the stage of the disease is the most important treatment. We also provide guidance on exercises that can be done at home.
| Stage | Principle of Exercise |
|---|---|
| Inflammatory Stage (Severe pain) | Pendulum exercises and light stretching within a pain-free range |
| Frozen Stage | Range of motion expansion training, gradually and without overexertion |
| Thawing Stage | Active range of motion training, muscle strengthening training |
Exercises You Can Do at Home
- Pendulum exercise: Lean forward, relax your arm, and draw large and small circles
- Wall climb exercise: Place your hand on the wall and walk your fingers upwards
- Towel exercise: Hold both ends of a towel and move it up and down behind your back
- Table stretch: Place your hands on a table, lower your body to stretch your shoulders
- Codman's exercise: Gently swing your arm back and forth within a pain-free range
Don't endure pain, don't overdo it
During rehabilitation, a slight stretching sensation or mild pain is acceptable, but exercises that cause sharp pain or increased night pain should be avoided. Overexertion can worsen inflammation and delay recovery.
The Deep Connection with Diabetes
People with diabetes are 2-4 times more likely to develop frozen shoulder and it tends to be more difficult to treat. Treatment in parallel with blood sugar control is crucial.
- Diabetes patients are more likely to experience bilateral and chronic frozen shoulder.
- Range of motion restriction tends to be more severe.
- Improvement in HbA1c leads to better treatment outcomes.
- Our internal medicine department can also manage blood sugar control.
Key Points for Daily Life
During Sleep
- Do not lie on the painful shoulder.
- When lying on your back, place a cushion under the arm on the painful side.
- When lying on your side, lie on the opposite side and place a cushion in front of the affected arm.
Adapting Daily Activities
- Carry heavy bags with the unaffected arm.
- Tie apron strings in front and then rotate them to the back.
- Put on clothes by first inserting the painful arm.
- Use a tote bag or backpack instead of a shoulder bag.
- Avoid prolonged static postures (desk work).
- Perform appropriate stretches multiple times a day.
Using Heat and Cold
- Acute phase / Night pain phase: Cooling can be an option to reduce inflammation.
- Chronic phase / Contracture phase: Bathing, warm towels, or hot packs to promote blood circulation.
- Warming up before exercise makes stretching easier.
Consult us if you experience these symptoms
- Shoulder pain that persists for 2-3 weeks or longer
- Unable to sleep due to night pain
- Difficulty with daily activities such as tying hair or reaching behind your back
- Have diabetes or thyroid disease
- Severe shoulder pain after an injury (suspecting a rotator cuff tear)
- Accompanied by numbness in the neck, arm, or hand
- Pain and stiffness in both shoulders (could also be polymyalgia rheumatica)
- Over-the-counter medications or patches are ineffective
Cases Requiring Orthopedic Referral
- Significant daily life impairment due to severe range of motion restriction
- Expectation of dramatic improvement with steroid intra-articular injection
- Suspicion of rotator cuff tear based on MRI
- Consideration of non-operative manipulation (manipulation under anesthesia) or surgery
- No improvement with long-term conservative treatment
Features of Our Clinic's Frozen Shoulder Treatment
- As an internal medicine clinic, we evaluate blood tests for diabetes, thyroid function, and polymyalgia rheumatica.
- Pain management using NSAIDs, acetaminophen, topical medications, neurotropin, etc.
- Guidance on home exercises such as pendulum exercises and stretching.
- For combined diabetes cases, management is integrated with blood sugar control.
- For intra-articular injections, MRI, and rehabilitation, we refer to orthopedics.
- Differentiation of other diseases such as rotator cuff tears and cervical spondylopathy.
- No appointment necessary, same-day consultation OK / Open daily 9am-9pm / 1-minute walk from Jujo Station.
Don't rush, don't give up, don't give up
Frozen shoulder is a condition with a long course of 1-3 years. While it can resolve naturally, continuing appropriate treatment and rehabilitation can shorten the duration of pain and minimize residual symptoms.
