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Frozen Shoulder | Adhesive Capsulitis | OrthoFixar 2024

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Frozen Shoulder | Adhesive Capsulitis

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Adhesive Capsulitis or Frozen Shoulder is a contracted, thickened joint capsule that seemed to be drawn tightly around the humeral head with a relative absence of synovial fluid and chronic inflammatory changes within the subsynovial layer of the capsule.

Individuals between the ages of 40 and 70 are more commonly affected (70% of patients are women). The prevalence of frozen shoulder in the general population is slightly greater than 2% (11% of the adult diabetic population)

20–30% of affected patients subsequently will have adhesive capsulitis develop in the opposite shoulder.

The frozen shoulder syndrome was first described by Duplay in 1872, who used the term periarthritis scapulohumerale. It was not until 1934 that Codman used the term frozen shoulder to describe this condition. In 1945, Neviaser introduced the term adhesive capsulitis to reflect his findings of a chronic inflammatory process at surgery and autopsy.

See Also: Scapular Dyskinesis
See Also: What is SLAP Lesion?

What are the frozen shoulder causes?

Although the causes of frozen shoulder remain elusive, the understanding of the pathophysiology has recently improved.

Factors associated with adhesive capsulitis include:

  1. Female gender,
  2. Age older than 40 years,
  3. Trauma,
  4. Diabetes,
  5. Prolonged immobilization,
  6. Thyroid disease,
  7. Stroke or myocardial infarction,
  8. Certain psychiatric conditions,
  9. The presence of autoimmune diseases.
Adhesive Capsulitis

Adhesive Capsulitis Stages

There are 3 stages for adhesive capsulitis of shoulder, these are:

Stage I – Pain:

Patients usually have a gradual onset of diffuse shoulder pain, which is progressive over weeks to months (less than 3 months, duration). The pain usually is worse at night and is exacerbated by lying on the affected side.

The symptoms often mimic those of an impingement syndrome, where restriction of motion is minimal and pain that appears to be due to a rotator cuff tendinitis has been present for less than 3 months. As the patient uses the arm less, pain leading to stiffness ensues.

In this early stage, the majority of motion loss is secondary to the painful synovitis, rather than a true capsular contraction.

Stage II – Stiffness:

Patients seek pain relief by restricting movement. This heralds the beginning of the stiffness phase, which usually lasts 4 to 12 months. Patients describe difficulty with activities of daily living; men have trouble getting to their wallets in their back pockets, and women have trouble with fastening brassieres. As stiffness progresses, a dull ache is present nearly all the time (especially at night), and this often is accompanied by sharp pain during range of motion at or near the new end points of motion.

Stage III – Thawing:

This phase lasts for weeks or months, and as motion increases, pain diminishes. Without treatment (other than benign neglect), motion return is gradual in most but may never objectively return to normal, although most patients subjectively feel near normal, perhaps as a result of compensation or adjustment in ways of performing activities of daily living.


Histologically there is evidence of inflammation and fibrosis. There is a dense matrix of type-III collagen containing fibroblasts and myofibroblasts that appear similar to Dupuytren disease.

Adhesive Capsulitis Histology


Recommended X-ray views include:

  1. AP in neutral rotation
  2. AP in internal rotation
  3. AP in external rotation
  4. scapular-Y
  5. axillary lateral

Radiographic findings include:

  1. disuse osteopenia,
  2. concomitant osteoarthritis,
  3. calcific tendinitis,
  4. hardware indicating prior surgery.

Arthrography may demonstrate a loss of the normal axillary recess, revealing contracture of the joint capsule.

Adhesive Capsulitis arthrography
Shoulder arthrogram showing a contracted and adherent joint capsule

MRI may demonstrate thickening of the glenohumeral joint capsule along the axillary pouch, thickening of the coracohumeral ligament, obliteration of the subcoracoid fat triangle and rotator interval synovitis. However, none of these are pathognomonic.

frozen shoulder MRI
A 61-year-old man with adhesive capsulitis of the shoulder. (AeC) MRI (coronal T1-weighted with gadolinium-chelate enhancement). Note the marked enhancement of the joint capsule and synovial membrane in the axillary recess, measured perpendicular to the adjacent cortex (panel A, white double arrow). CHL (panel B, between white arrows). The enhanced portion in the rotator cuff interval was the widest portion of the capsule and synovium at the central part of the rotator cuff interval (panel C, black double arrow)

Bone scans have been reported to be positive in some patients, and a positive bone scan has been shown to have positive predictive value for treatment with steroid injections.

Clinical improvement has been reported after arthrography because of brisement of adhesions from forcefully injecting fluid into the joint.

Frozen Shoulder Symptoms

Diagnosis is clinical, typically an insidious onset of pain followed by selective loss of external rotation. In later stages, global ROM loss occurs. Classically, active ROM and passive ROM are equivalent.

Other two causes of selective loss of external rotation are glenohumeral osteoarthritis and a locked posterior shoulder dislocation. For this reason, radiographs must be obtained prior to making a diagnosis of frozen shoulder.

See Also: Shoulder Special Tests

Adhesive Capsulitis Treatment

Traditionally, frozen shoulder has been considered a self-limiting condition, lasting 12 to 18 months without long-term sequelae.

Initial adhesive capsulitis treatment is nonoperative, with emphasis placed on control of pain and inflammation. Approximately 90% of patients respond to physical therapy

The primary goal of conservative intervention is the restoration of the ROM and focuses on the application of controlled tensile stresses to produce elongation of the restricting tissues.

The conventional management incorporates:

  1. Patient advice,
  2. Analgesics,
  3. NSAIDs,
  4. Steroid injection (phase 1 or early phase 2 of the clinical course),
  5. A wide array of physical therapy methods.

Transcutaneous electrical nerve stimulation and ultrasound may be helpful, combined with passive and active range-of-motion exercises.

Closed manipulation under anesthesia has a good results and efficacy. Failures usually are related to inability to maintain postoperative motion rather than intraoperative complications.

Closed manipulation is contraindicated in:

  1. Patients with significant osteopenia,
  2. Recent surgical repair of soft tissues about the shoulder, or in the presence of fractures, neurologic injury and instability.

A gradual return of full mobility occurs within 18 months to 3 years in most patients, even without specific intervention.

Patients seeking care earlier usually recover more quickly. Dominant shoulder involvement has been reported to be predictive of a good result, whereas occupation and treatment programs are not statistically significant.

Operative Treatment:

Patients who fail 12 to 16 weeks of nonsurgical treatment and whom closed manipulation fails are offered arthroscopic capsular release.

If arthroscopic release fails to relieve symptoms, open release of contractures has been recommended, with emphasis on release of the coracohumeral ligament and reestablishment of the interval between the supraspinatus and subscapularis.

Adhesive Capsulitis arthroscopic treatment
Arthroscopic frozen shoulder treatment


Surgical frozen shoulder treatment may complicate with any of the following:

  1. Axillary nerve injury
  2. Rotator cuff tendon disruption
  3. Iatrogenic chondral injury
  4. Fracture or dislocation of the proximal humerus.
  5. Recurrent stiffness

If dislocation occurs after closed reduction, rehabilitation should be aggressive, but the abducted, externally rotated position should be avoided.

Arthroscopic release is an option when closed manipulation fails or for patients who have had prolonged, recalcitrant adhesive capsulitis, with marked improvement reported in 80% to 90% of patients.


  1. Janda DH, Hawkins RJ. Shoulder manipulation in patients with adhesive capsulitis and diabetes mellitus: A clinical note. J Shoulder Elbow Surg. 1993 Jan;2(1):36-8. doi: 10.1016/S1058-2746(09)80135-3. Epub 2009 Feb 19. PMID: 22959295.
  2. Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg. 2011 Sep;19(9):536-42. doi: 10.5435/00124635-201109000-00004. PMID: 21885699.
  3. Hannafin JA, Chiaia TA. Adhesive capsulitis. A treatment approach. Clin Orthop Relat Res. 2000 Mar;(372):95-109. PMID: 10738419.
  4. Neviaser JS. Adhesive capsulitis and the stiff and painful shoulder. Orthop Clin North Am. 1980 Apr;11(2):327-31. PMID: 7001312.
  5. Griggs SM, Ahn A, Green A: Idiopathic adhesive capsulitis: a prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 82-A:1398–1407, 2000.
  6. Hannafin JA, DiCarlo EF, Wickiewicz TL, et al: Adhesive capsulitis: Capsular fibroplasia of the glenohumeral joint. J Shoulder Elbow Surg 3 (Suppl.):66–74, 1994
  7. Rodeo SA, Hannafin JA, Tom J, et al: Immunolocalization of cytokines and heir receptors in adhesive capsulitis of the shoulder. J Orthop Res 15:427–436, 1997.
  8. Pajareya K, Chadchavalpanichaya N, Painmanakit S, et al: Effectiveness of physical therapy for patients with adhesive capsulitis: a randomized controlled trial. J Med Assoc Thai 87:473–480, 2004.
  9. Rizk TE, Christopher RP, Pinals RS, et al: Adhesive capsulitis (frozen shoulder): A new approach to its management and treatment. Arch Phys Med Rehabil 64:29–33, 1983.
  10. Nicholson GG: The effects of passive joint mobilization on pain and hypomobility associated with adhesive capsulitis of the shoulder. J Orthop Sports Phys Ther 6:238–246, 1985.
  11. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
  12. Campbel’s Operative Orthopaedics 12th edition Book.
  13. Millers Review of Orthopaedics -7th Edition Book.
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