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Adhesive Capsulitis

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Other Names

  • Frozen Shoulder
  • Idiopathic-type Frozen Shoulder
  • Arthrofibrosis


Illustration of adhesive capsulitis[1]
  • 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


  • First described by Simon-Emmanuel Duplay as ‘scapulohumeral periarthritis’ or ‘Periarthritis’
  • The term 'frozen shoulder' came later from Dr Codman in 1934[2]


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



  • Pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint, leading to stiffness, pain and dysfunction[3]
    • 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[4]


  • 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


Risk Factors

Differential Diagnosis

Differential Diagnosis Shoulder Pain

Clinical Features


  • 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[6]

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


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.[7]
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.[8]



  • Not required to make diagnosis
  • Findings
    • Thickening of the coracohumeral ligament greater than 2 mm
      • ≥4mm (95% specificity, 59% sensitivity)[9]
    • 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)


  • Findings
    • Thickening of the joint capsule[10]
    • Continuous limitation of the sliding movement of the supraspinatus tendon against the acromion of the scapula
    • Sensitivity of 91% and a specificity of 100%


Clinical Stages

  • Per Neviaser and Neviaser[11]
  • 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)



  • First line management
  • Physical Therapy
  • Medications
    • NSAIDS helpful for pain and inflammation but do not improve mobility[13]
    • Oral Corticosteroids may help with short term pain relief and range of motion, but tend to do worse than controls at 12 weeks[14]
  • Glenohumeral Corticosteroid Injection
    • Faster, superior to oral corticosteroids[15]
    • Provides short term and possibly benefits up to a year, compared to placebo and physical therapy[16]
  • Hyaluronic Acid
    • Improves ROM, constant scores and pain at short term follow up[17]
    • Rovetta et al: Hyaluronic acid, corticosteroids and physical therapy is superior to corticosteroids and physical therapy alone[18]
  • Suprascapular Nerve Block (SSNB)
    • Suprascapular Nerve provides sensory innervation in up to 70% of Glenohumeral Joint[19]
    • Dahan et al: SSNB improved pain but not function[20]
    • Jones et al: when combined with triamcinolone, SSNB offered greater pain control and ROM at 3 months compared to intra-articular corticosteroid injection[21]
  • Hydrodilation
    • Quraishi et al: superior constant score, VAS score compared to manipulation under anesthesia + intra-articular corticosteroids[22]
    • Cochrane review: Improved pain at 3 weeks, disability at 12, however no difference compared to steroids alone[23]
  • Whole Body Cryotherapy
    • Improved VAS, active ROM when combined with physical therapy when compared to physical therapy alone[24]
  • Botulinum Toxin Injection
    • No difference in pain, range of motion compared to triamcinolone but may be an option for those where steroids are contraindicated[25]


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

Rehab and Return to Play


  • Needs to be updated

Return to Play

  • Needs to be updated

Prognosis and Complications


  • Generally considered a self limited disease that self resolves in 1-3 years
    • 20-50% of patients develop longer lasting symptoms[26]
  • Diabetics have worse functional outcomes compared to non-diabetics[27]


See Also




  1. Image courtesy of https://my.clevelandclinic.org/, "frozen shoulder"
  2. D’Orsi GM, Via AG, Frizziero A, et al. Treatment of adhesive capsulitis: a review. Muscles Ligaments Tendons J 2012; 2: 70–78.
  3. Neviaser AS and Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg 2011; 19: 536–542.
  4. Manske RC and Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med 2008; 1: 180–189.
  5. Sheridan MA and Hannafin JA. Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am 2006; 37: 531–539.
  6. Boyle-Walker KL, Gabard DL, Bietsch E, et al. A profile of patients with adhesive capsulitis. J Hand Ther 1997; 10: 222–228.
  7. Guan, Haitao, et al. "A retrospective study of ultrasound-guided intervention for frozen shoulder in the frozen stage." Frontiers in surgery 9 (2022): 998590.
  8. Image courtesy of radiologykey.com, "frozen shoulder"
  9. Mengiardi B, Pfirrmann CW, Gerber C, et al. Frozen shoulder: MR arthrographic findings. Radiology 2004; 233: 486–492.
  10. 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.
  11. Neviaser RJ and Neviaser TJ. The frozen shoulder: diagnosis and management. Clin Orthop Relat Res 1987; 223: 59–64.
  12. Green S, Buchbinder R and Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003; 2: CD004258.
  13. Rhind V, Downie WW, Bird HA, et al. Naproxen and indomethacin in periarthritis of the shoulder. Rheumatol Rehabil 1982; 21: 51–53.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. Ozkan K, Ozcekic AN, Sarar S, et al. Suprascapular nerve block for the treatment of frozen shoulder. Saudi J Anaesth 2012; 6: 52–55.
  20. 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.
  21. 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.
  22. 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.
  23. Buchbinder R, Green S, Youd JM, et al. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev 2008; 1: CD007005.
  24. 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.
  25. 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.
  26. Binder AI, Bulgen DY, Hazleman BL, et al. Frozen shoulder: a long-term prospective study. Ann Rheum Dis 1984; 43: 361–364.
  27. 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
Last edited:
23 March 2024 21:41:35