Adhesive Capsulitis (Frozen Shoulder)
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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Risk factors
- Diabetes mellitus (strongest association; often bilateral and refractory)
- Thyroid disease
- Age 40-60, female sex
- Prolonged immobilization (after fracture, surgery, stroke)
- Prior rotator cuff injury or surgery
- Parkinson disease
- Dupuytren contracture (shared fibrotic diathesis)
- Breast cancer treatment
Pathophysiology
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
- Cervical radiculopathy — Neck pain, dermatomal pattern, positive Spurling
- Calcific tendinitis — Acute severe pain, calcium deposit on X-ray; can mimic frozen shoulder during inflammatory phase
- Septic shoulder — Acute fever, erythema, elevated CRP, joint aspiration
- Avascular necrosis of humeral head — Risk factors (steroids, sickle, alcohol); MRI 'crescent sign'
- Locked posterior shoulder dislocation — Rare; history of seizure or electrical shock; arm locked in IR
Diagnostic workup
Diagnostic criteria
Clinical — restricted active AND passive motion (loss of passive external rotation is essentially required) without alternative explanation.
Labs
- Screen for diabetes — fasting glucose / A1c
- TSH if symptoms suggestive
Imaging
- Plain radiographs (AP, scapular Y, axillary) — exclude OA, calcific tendinitis, locked posterior dislocation; often normal
- MRI — capsular thickening, contracted axillary recess, scarring of rotator interval; rules out cuff tear and labral pathology when uncertain
- Ultrasound — coracohumeral ligament thickening, hyperemic capsule
Diagnostic algorithm
| Feature | Adhesive capsulitis | Rotator cuff disease |
|---|---|---|
| Active ROM | Decreased | Decreased (often pain-limited) |
| Passive ROM | Decreased (hallmark) | Preserved |
| Strength (when not pain-limited) | Normal | Decreased in involved tendon |
| Most limited motion | External rotation | Abduction (painful arc) |
| MRI | Capsular thickening, no tear | Tendon signal change ± tear |
| Risk factors | Diabetes, thyroid disease, immobilization | Overhead activity, age, trauma |
| First-line treatment | Intra-articular steroid + gentle PT | PT, NSAIDs, subacromial steroid |
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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