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Adhesive Capsulitis

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Other Names

  • Frozen Shoulder
  • Idiopathic-type Frozen Shoulder
  • Arthrofibrosis

Background

  • This page describes adhesive capsulitis of the Glenohumeral Joint
  • Primarily a self-limited clinical diagnosis based upon history and physical exam
  • Characterized by pain and functional loss of shoulder range of motion

History

  • First described by Simon-Emmanuel Duplay as ‘scapulohumeral periarthritis’ or ‘Periarthritis’
  • The term 'frozen shoulder' came later from Dr Codman in 1934[1]

Epidemiology

  • Incidence
    • 2-5% of general population (need citation)
    • 11-20% of those with diabetes mellitus (need citation)

Introduction

Illustration of adhesive capsulitis[2]
Stages of adhesive capsulitis[3]
Shoulder active range of motion in adhesive capsulitis. (A) Stiffness of shoulder abduction is shown in left side with the rotation of scapula, which means the loss of scapulohumeral rhythm. (B) Stiffness of shoulder external rotation in left side with normal range of motion of right side. (C) Stiffness of shoulder internal rotation in left side with normal range of motion of right side.[4]

General

  • Clinical syndrome characterized by progressive shoulder pain and restricted range of motion due to fibrosis and contracture of the joint capsule
  • Risk is increased in certain individuals such as diabetes, thyroid dysfunction and immobilization
  • The diagnosis is clinical with imaging used to exclude other pathology
  • Most cases improve with conservative management including medications, physical therapy and corticosteroid injections

Pathophysiology

  • Pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint, leading to stiffness, pain and dysfunction[5]
    • Inflammatory process leading to thickening, fibrosis, and adherence of the capsule to itself and humerus
    • Fibroblastic proliferation with abundant type III collagen
  • Typically involves non-dominant extremity
    • Up to 40-50% of cases are reported to be bilateral[6]

Etiology

  • Primary (or idiopathic)
    • Occurs spontaneously without any clear inciting event
  • Secondary
    • Occurs secondary to some other injury or pathologic process
    • Most commonly after a fracture, dislocation, or post-operatively

Anatomy of the Glenohumeral Joint Capsule

  • General
  • Synovial membrane lines the inner surface of the joint capsule
  • Function
    • Capsule is lax, permitting greater mobility, especially abduction
    • Does not keep the bones in contact, allows physiologic separation up to 2.5 cm
    • Synovial fluid lubricates the joint preventing friction between the articular surfaces

Associated Conditions

Risk Factors

Demographic

  • Female sex (up to 70% of cases are female)[7]
  • Age over 40
  • Race: white

Systemic/ Other

Differential Diagnosis

Differential Diagnosis Shoulder Pain

Clinical Features

Instrument assisted Coracoid Pain Test[8]

History

  • Onset is most often insidious
  • Patients typically report shoulder pain followed by loss of range of motion
  • Boyle-Walker et al: 90.6% of patients develop pain before loss of ROM[9]

Physical: Physical Exam Shoulder

  • External rotation is often the first motion most commonly affected
  • Pain is worse at extremes of motion when the capsule is under tension
  • Firm endpoints in passive ROM suggest mechanical rather than pain-related restriction

Special Tests

Evaluation

A,B are ultrasound images for diagnosis. C (before injection) and D (after injection) are US-guided injection into the subacromial Bursa. E (before injection) and F (after injection) are intrathecal injection into the LHBBT sheath. Del, deltoid muscle; TB, Triceps brachii; Corb, coracobrachialis; AJC, axillary joint capsule; HH, humeral head; GT, greater tubercle of humerus; LT, lesser tubercle of humerus; SupraS, supraspinatus tendon; L, lateral; M, medial; yellow star, rotator interval; orange triangle, the long head of the biceps brachii tendon (LHBBT); highlighted red area, subacromial Bursa. White arrows indicate the injection needle.[10]
Sequential T2 fat-saturated BLADE coronal oblique images demonstrating significant thickening and loss of definition of the inferior capsule MRI findings are subtle in frozen shoulder.[11]

Radiographs

MRI

  • Not required to make diagnosis
  • Findings
    • Thickening of the coracohumeral ligament greater than 2 mm
      • ≥4mm (95% specificity, 59% sensitivity)[12]
    • Subcoracoid fatty infiltration
    • Thickening of the joint capsule in the axillary recess
      • ≥7mm (86% specificity, 64% sensitivity)
    • Reduced joint volume of 5-8 mL (normal 13-15 mL)

Ultrasound

  • Findings
    • Thickening of the joint capsule[13]
    • Continuous limitation of the sliding movement of the supraspinatus tendon against the acromion of the scapula
    • Sensitivity of 91% and a specificity of 100%

Classification

Clinical Stages

  • Per Neviaser and Neviaser[14]
  • Stage I (Freezing/ Painful): Gradual onset of diffuse shoulder pain pain (6 wks to 9 mos)
    • Worse at night, motion preserved, synovitis on arthroscopy
  • Stage II (Frozen/Stiff): Decreased ROM affecting activities of daily living (4 to 9 mos or more)
    • Characterized by early adhesion formation, capsular contraction
  • Stage III: Global loss of ROM, extreme pain
    • Synovitis resolved, axillary fold obliterated
  • Stage IV (chronic): persistent stiffness, no pain
    • Can see thawing, gradual return of motion (5 to 26 mos)

Management

Shoulder manipulation in an awakre patient. How to perform SM. (A) Shoulder manipulation at 45–90 degrees of abduction with gradual ER. (B) After obtaining 90 degrees of abduction and 90 degrees of ER, the arm was maximally adducted until the elbow touched the patient’s rib. (C) The arm was maximally abducted until it touched the patient’s ear. (D) Maximum adduction was then performed, followed by maximum horizontal adduction. (E) The patient’s shoulder under maximum adduction and maximum IR. (F) Full extension was performed, followed by ER and IR in that state. IR was performed until the vertebral height of the dominant thumb equaled that of the nondominant thumb[15]
Photographs from the manipulation under anesthesia of the left shoulder, after manipulation has been performed. Clockwise from the top left, maximal internal rotation at 90 of abduction, abduction, external rotation at 90 of abduction, and external rotation with the arm at the side.[16]

Nonoperative

  • First line management
  • Physical Therapy
  • Medications
    • NSAIDS helpful for pain and inflammation but do not improve mobility[18]
    • Oral Corticosteroids may help with short term pain relief and range of motion, but tend to do worse than controls at 12 weeks[19]
  • Glenohumeral Corticosteroid Injection
    • Faster, superior to oral corticosteroids[20]
    • Provides short term and possibly benefits up to a year, compared to placebo and physical therapy[21]
  • Hyaluronic Acid
    • Improves ROM, constant scores and pain at short term follow up[22]
    • Rovetta et al: Hyaluronic acid, corticosteroids and physical therapy is superior to corticosteroids and physical therapy alone[23]
  • Suprascapular Nerve Block (SSNB)
    • Suprascapular Nerve provides sensory innervation in up to 70% of Glenohumeral Joint[24]
    • Dahan et al: SSNB improved pain but not function[25]
    • Jones et al: when combined with triamcinolone, SSNB offered greater pain control and ROM at 3 months compared to intra-articular corticosteroid injection[26]
  • Hydrodilation
    • Quraishi et al: superior constant score, VAS score compared to manipulation under anesthesia + intra-articular corticosteroids[27]
    • Cochrane review: Improved pain at 3 weeks, disability at 12, however no difference compared to steroids alone[28]
  • Whole Body Cryotherapy
    • Improved VAS, active ROM when combined with physical therapy when compared to physical therapy alone[29]
  • Botulinum Toxin Injection
    • No difference in pain, range of motion compared to triamcinolone but may be an option for those where steroids are contraindicated[30]

Operative

  • Indications
    • Refractory to conservative treatment
  • Technique
    • Manipulation under anesthesia (MUA)
    • Arthroscopic capsulotomy
    • Open capsulotomy

Rehab and Return to Play

Rehabilitation

  • General
    • Interventions should be tailored to the phase of the disease and the patients irritability level[31]
    • Focus on stretching, joint mobilization, functional exercises
  • Painful phase[32]
    • Characterized by pain at rest and at night, marked range of motion loss
    • Gentle stretching and pain control
    • If irritability is lower, can be more aggressive
  • Manual mobilization techniques
    • Maitland method
    • Posterior glenohumeral glide
  • High intensity home stretching[33]
    • Have demonstrated efficacy compared to PT
    • Can restore up to 95% of contralateral ROM, accelerate functional movement
  • Stretching
    • Mandatory
    • Based on pain, irritability, avoid exacerbating symptoms

Return to Play

  • General requirements
    • Restoration of more than 95% of contralateral ROM
    • Minimal pain
    • Functional recovery
  • Return should be gradual
    • Monitor for persistent deficits
    • Individualized progression based on activity demands/ patient goals

Prognosis and Complications

Prognosis

  • General
    • Generally considered a self limited disease that self resolves in 1-3 years
    • 20-50% of patients develop longer lasting symptoms[34]
  • Worse outcomes
    • Patients with more severe initial pain and functional limitations[35]
    • Diabetics have worse functional outcomes compared to non-diabetics[36]

Complications

See Also

Internal

External

References

  1. ↑ D’Orsi GM, Via AG, Frizziero A, et al. Treatment of adhesive capsulitis: a review. Muscles Ligaments Tendons J 2012; 2: 70–78.
  2. ↑ Image courtesy of https://my.clevelandclinic.org/, "frozen shoulder"
  3. ↑ Tache-Codreanu, Diana-Lidia, et al. "rESWT in Shoulder Periarthritis: Does the Protocol Intensity Matter?—A Quasi-Experimental Non-Randomized Comparative Study." Life 15.6 (2025): 922.
  4. ↑ Lee, Ho Jun. "Differential diagnosis of common shoulder pain." J Korean Med Assoc 57.8 (2014): 653-60.
  5. ↑ Neviaser AS and Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg 2011; 19: 536–542.
  6. ↑ Manske RC and Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med 2008; 1: 180–189.
  7. ↑ Sheridan MA and Hannafin JA. Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am 2006; 37: 531–539.
  8. ↑ Mertens, Michel GCAM, et al. "An Instrument-Assisted coracoid pain test: An exploratory diagnostic accuracy study." International Journal of Environmental Research and Public Health 19.19 (2022): 12735.
  9. ↑ Boyle-Walker KL, Gabard DL, Bietsch E, et al. A profile of patients with adhesive capsulitis. J Hand Ther 1997; 10: 222–228.
  10. ↑ Guan, Haitao, et al. "A retrospective study of ultrasound-guided intervention for frozen shoulder in the frozen stage." Frontiers in surgery 9 (2022): 998590.
  11. ↑ Image courtesy of radiologykey.com, "frozen shoulder"
  12. ↑ Mengiardi B, Pfirrmann CW, Gerber C, et al. Frozen shoulder: MR arthrographic findings. Radiology 2004; 233: 486–492.
  13. ↑ Ryu KN, Lee SW, Rhee YG, et al. Adhesive capsulitis of the shoulder joint: usefulness of dynamic sonography. J Ultrasound Med 1993; 12: 445–449.
  14. ↑ Neviaser RJ and Neviaser TJ. The frozen shoulder: diagnosis and management. Clin Orthop Relat Res 1987; 223: 59–64.
  15. ↑ Miyatake, Kazuma, et al. "Silent manipulation for adhesive capsulitis." Current Physical Medicine and Rehabilitation Reports 9.4 (2021): 230-236.
  16. ↑ Ruskin, Jeremy, et al. "Propionibacterium acnes infection of the shoulder after a manipulation under anesthesia for stiffness status post open reduction and internal fixation proximal humerus: a case report." Journal of Orthopaedic Case Reports 8.2 (2018): 19.
  17. ↑ Green S, Buchbinder R and Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003; 2: CD004258.
  18. ↑ Rhind V, Downie WW, Bird HA, et al. Naproxen and indomethacin in periarthritis of the shoulder. Rheumatol Rehabil 1982; 21: 51–53.
  19. ↑ Buchbinder R, Hoving JL, Green S, et al. Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial. Ann Rheum Dis 2004; 63: 1460–1469.
  20. ↑ Widiastuti-Samekto M and Sianturi GP. Frozen shoulder syndrome: comparison of oral route corticosteroid and intraarticular corticosteroid injection. Med J Malaysia 2004; 59: 312–316.
  21. ↑ Ryans I, Montgomery A, Galway R, et al. A randomized controlled trial of intra-articular triamcinolone and/or physiotherapy in shoulder capsulitis. Rheumatology 2005; 44: 529–535.
  22. ↑ Harris JD, Griesser MJ, Copelan A, et al. Treatment of adhesive capsulitis with intra-articular hyaluronate: a systematic review. Int J Shoulder Surg 2011; 5: 31–37.
  23. ↑ Rovetta G and Monteforte P. Intraarticular injection of sodium hyaluronate plus steroid versus steroid in adhesive capsulitis of the shoulder. Int J Tissue React 1998; 20: 125–130.
  24. ↑ Ozkan K, Ozcekic AN, Sarar S, et al. Suprascapular nerve block for the treatment of frozen shoulder. Saudi J Anaesth 2012; 6: 52–55.
  25. ↑ Dahan TH, Fortin L, Pelletier M, et al. Double blind randomized clinical trial examining the efficacy of bupivacaine suprascapular nerve blocks in frozen shoulder. J Rheumatol 2000; 27: 1464–1469.
  26. ↑ Jones DS and Chattopadhyay C. Suprascapular nerve block for the treatment of frozen shoulder in primary care: a randomized trial. Br J Gen Pract 1999; 49: 39–41.
  27. ↑ Quraishi NA, Johnston P, Bayer J, et al. Thawing the frozen shoulder: a randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br 2007; 89: 1197–1200.
  28. ↑ Buchbinder R, Green S, Youd JM, et al. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev 2008; 1: CD007005.
  29. ↑ Ma SY, Je HD, Jeong JH, et al. Effects of whole-body cryotherapy in the management of adhesive capsulitis of the shoulder. Arch Phys Med Rehabil 2013; 94: 9–16.
  30. ↑ Joo YJ, Yoon SJ, Kim CW, et al. A comparison of the short-term effects of a botulinum toxin type a and triamcinolone acetate injection on adhesive capsulitis of the shoulder. Ann Rehabil Med 2013; 37: 208–214.
  31. ↑ Costantino, Cosimo, et al. "Rehabilitative treatments in adhesive capsulitis: a systematic review." The Journal of Sports Medicine and Physical Fitness 62.11 (2022): 1505-1511.
  32. ↑ Kelley, Martin J., Phillip W. Mcclure, and Brian G. Leggin. "Frozen shoulder: evidence and a proposed model guiding rehabilitation." Journal of orthopaedic & sports physical therapy 39.2 (2009): 135-148.
  33. ↑ Teytelbaum, David E., et al. "Efficacy of a high-intensity home stretching device and traditional physical therapy in non-operative management of adhesive capsulitis-a prospective, randomized control trial." BMC Musculoskeletal Disorders 25.1 (2024): 305.
  34. ↑ Binder AI, Bulgen DY, Hazleman BL, et al. Frozen shoulder: a long-term prospective study. Ann Rheum Dis 1984; 43: 361–364.
  35. ↑ Griggs, Sean M., Anthony Ahn, and Andrew Green. "Idiopathic adhesive capsulitis: a prospective functional outcome study of nonoperative treatment." JBJS 82.10 (2000): 1398.
  36. ↑ Griggs SM, Ahn A and Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 2000; 82: 1398–1407.
Created by:
John Kiel on 17 June 2019 19:26:57
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Last edited:
10 September 2025 23:34:01
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