Painful progressive restriction of both active and passive shoulder motion from glenohumeral capsular fibrosis.
Also known as: frozen shoulder, adhesive capsulitis
Overview
Insidious onset, painful, progressive restriction of active AND passive glenohumeral motion in all planes from fibrotic thickening of the joint capsule. Self-limited but often protracted (12-36 months).
Epidemiology
Affects 2-5% of the population. Peak age 40-60. Female predominance. Strongly associated with diabetes (up to 20% prevalence in diabetics, often bilateral). Frequently contralateral shoulder later affected.
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Inflammation and fibroplasia of the glenohumeral joint capsule, particularly the coracohumeral ligament and rotator interval, with contracture of the axillary recess. Three classical phases — freezing (painful, 2-9 months), frozen (stiffness, 4-12 months), thawing (motion recovery, 5-24 months) — though contemporary classifications emphasize overlapping phases.
Clinical presentation
Symptoms
Insidious onset of shoulder pain and progressive stiffness
Night pain prominent early
Difficulty reaching overhead, behind the back, fastening bra/seatbelt
Pain peaks in freezing phase, then stiffness dominates
Signs / physical exam
Loss of BOTH active and passive range of motion in all planes
External rotation typically lost first and most severely
Diffuse tenderness; no specific impingement signs
Rotator cuff strength intact (when not pain-limited)
Negative imaging studies in early disease
Differential diagnosis
Rotator cuff disease — Passive ROM PRESERVED; weakness on resisted testing; partial relief from injection
Glenohumeral osteoarthritis — Crepitus, X-ray with joint space narrowing and osteophytes
Adhesive capsulitis vs rotator cuff disease — the passive ROM exam separates them.
Treatment
First-line
Patient education — disease is self-limited but often takes 1-3 years
Physical therapy — gentle range of motion exercises, particularly in pain-free range; aggressive stretching during freezing phase can worsen symptoms
NSAIDs — ibuprofen, naproxen, meloxicam — for pain control
Intra-articular corticosteroid injection (triamcinolone or methylprednisolone) — most evidence in freezing phase; can be repeated; ultrasound or fluoroscopic guidance preferred
Glycemic control optimization
Second-line / adjunct
Short course of oral corticosteroids — modest benefit in freezing phase
Hydrodilatation / arthrographic distension
Suprascapular nerve block
Manipulation under anesthesia or arthroscopic capsular release — refractory cases after 6-12 months of conservative care; higher risk of fracture in osteoporotic patients
Complications
Persistent stiffness (residual motion deficit common even at 5 years)
Contralateral involvement (10-20%)
Iatrogenic humeral fracture from manipulation under anesthesia
Recurrent inflammation with steroid injection (rare)
Deconditioning, secondary cervical or thoracic muscle pain
PANCE pearls
The single most useful exam finding is loss of passive external rotation — this differentiates adhesive capsulitis from rotator cuff disease.
Suspect occult diabetes in any patient with idiopathic frozen shoulder — check A1c.
Intra-articular steroid injection in the freezing phase has the best evidence base for accelerating recovery.
Aggressive stretching during the painful freezing phase is often counterproductive — pain-limited motion is sufficient.
Plan for a long course — patients benefit from realistic expectations of 1-3 years.
References
AAOS Appropriate Use 2020 — AAOS Clinical Practice Guideline on Management of Glenohumeral Joint Osteoarthritis (frozen shoulder differential, 2020)
JOSPT 2013 — Shoulder Pain and Mobility Deficits: Adhesive Capsulitis Clinical Practice Guideline (Kelley et al., J Orthop Sports Phys Ther 2013)
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