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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Question 1MusculoskeletalMedium
A 55-year-old diabetic woman has gradual right shoulder stiffness with progressive loss of both active and passive range of motion in all planes, especially external rotation. Radiographs are normal. Which of the following is the most likely diagnosis?
ASuprascapular nerve entrapment
BAdhesive capsulitis
CSubacromial bursitis
DRotator cuff tear
Reveal answer & full explanation
Correct answer: B — Adhesive capsulitis
ASuprascapular nerve entrapment
BAdhesive capsulitis✓
CSubacromial bursitis
DRotator cuff tear
Why Adhesive capsulitis is correct
Adhesive capsulitis (frozen shoulder) is fibrosis and contracture of the glenohumeral capsule causing stiffness and pain
The hallmark is loss of BOTH active and passive range of motion, especially external rotation
Strongly associated with diabetes (up to 5x higher risk), thyroid disease, prolonged immobilization, age 40–60, and female sex
Progresses through three phases over 1–3 years: freezing (painful), frozen (stiff), and thawing
Radiographs are typically normal, matching this presentation
Why the others are wrong
Suprascapular nerve entrapment — produces posterolateral shoulder pain with supraspinatus and infraspinatus weakness and atrophy, but passive range of motion stays full because the joint capsule is uninvolved
Subacromial bursitis — causes painful-arc impingement, not global loss of passive ROM in all planes (right-concept-wrong-setting)
Rotator cuff tear — presents with weakness and a drop-arm sign while passive ROM is preserved, so global passive restriction argues against it (confused-with a weakness-dominant disorder)
Additional high-yield points
Treatment: NSAIDs, physical therapy, and intra-articular corticosteroid injection
Refractory cases: hydrodilatation, manipulation under anesthesia, or arthroscopic capsular release
Screen diabetic and thyroid patients presenting with insidious global shoulder stiffness
Question 2MusculoskeletalMedium
A 54-year-old woman with type 2 diabetes mellitus presents with 3 months of progressive right shoulder pain and stiffness that is worst at night and limits reaching overhead and behind her back. She denies trauma. On exam, both active and passive range of motion are markedly reduced in all planes, with external rotation lost first and most severely; rotator cuff strength is intact when not limited by pain. Radiographs of the shoulder are normal. Which of the following is the most appropriate initial management?
AOral corticosteroid taper over weeks
BArthroscopic capsular release surgery
CManipulation of shoulder under anesthesia
DIntra-articular corticosteroid injection
Reveal answer & full explanation
Correct answer: D — Intra-articular corticosteroid injection
AOral corticosteroid taper over weeks
BArthroscopic capsular release surgery
CManipulation of shoulder under anesthesia
DIntra-articular corticosteroid injection✓
Why Intra-articular corticosteroid injection is correct
This patient has classic adhesive capsulitis (frozen shoulder): insidious, painful loss of BOTH active and passive glenohumeral motion in all planes, with passive external rotation lost first and most severely, intact rotator cuff strength, and normal radiographs. Diabetes is the strongest risk factor.
She is in the early, painful freezing phase, where first-line care is conservative: education, NSAIDs, glycemic control, and pain-free range-of-motion therapy.
Intra-articular corticosteroid injection has the best evidence for accelerating recovery when given during the freezing phase, making it the most appropriate next step alongside conservative measures.
Why the others are wrong
Manipulation under anesthesia is reserved for refractory disease after 6-12 months of failed conservative care; it carries iatrogenic humeral fracture risk and is premature at 3 months.
Arthroscopic capsular release is also a refractory-case surgical option after prolonged conservative therapy fails, not an initial step for early disease.
Oral corticosteroid taper offers only modest, short-lived benefit and is a second-line option; intra-articular injection delivers more durable, targeted relief in the freezing phase.
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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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