Overview
Frozen Shoulder (Adhesive Capsulitis)
1. Clinical Overview
Summary
Frozen Shoulder (Adhesive Capsulitis) is a condition characterised by progressive loss of both active AND passive range of motion (ROM) of the shoulder, due to fibrosis and contracture of the glenohumeral joint capsule. It is most common in 50-60 year olds (Hence "50s shoulder") and is strongly associated with diabetes mellitus (10-20% of diabetics develop frozen shoulder, with worse prognosis). The condition typically progresses through three phases: Freezing (Painful), Frozen (Stiff), and Thawing (Recovery), with total duration of 1-3 years. The hallmark clinical feature is global restriction of ROM affecting external rotation most severely, with both active AND passive movements equally restricted (Distinguishes from rotator cuff pathology where passive movement is preserved). Management is primarily conservative (Physiotherapy, Analgesia, Steroid injection) as the condition is self-limiting. However, recovery is slow and can be incomplete. Hydrodilatation and Manipulation Under Anaesthesia (MUA) are considered for refractory cases. [1,2,3]
Clinical Pearls
"Active = Passive Restriction": Both active AND passive ROM are globally restricted. If passive ROM is preserved but active is weak, think Rotator Cuff Tear instead.
"External Rotation First": External rotation is affected earliest and most severely. Cannot hand-behind-head (Abduction + ER). Getting dressed is difficult.
"Diabetic Shoulders are Worse": Frozen shoulder in diabetics is more common, more severe, and more likely to be bilateral.
"Self-Limiting but Slow": Will eventually resolve, but may take 1-3 years. Some patients have permanent residual stiffness.
2. Epidemiology
Demographics
| Factor | Notes |
|---|---|
| Age | Peak: 50-60 years ("50s Shoulder"). Rare less than 40 or >70. |
| Sex | Female > Male (Slightly). |
| Laterality | Non-dominant arm slightly more common. Bilateral in 20-30%. |
Risk Factors
| Risk Factor | Notes |
|---|---|
| Diabetes Mellitus | STRONGEST association. 10-20% of diabetics develop frozen shoulder. More severe, Longer duration, Poorer response to treatment. |
| Thyroid Disease | Hypo- and Hyperthyroidism. |
| Dupuytren's Disease | Fibroproliferative disorder. Associated with frozen shoulder. |
| Immobility/Trauma | Post-fracture, Post-surgery, Post-stroke immobility. |
| Cardiac Disease | Post-MI, Cardiac surgery. |
| Cervical Disc Disease | Radicular pain may lead to guarding and secondary stiffness. |
3. Pathophysiology
Anatomy
- Glenohumeral Joint: Ball-and-socket joint. Capsule surrounds the joint.
- Joint Capsule: Normally loose with redundant folds (Axillary recess) to allow full ROM.
Pathological Process
- Inflammatory Phase (Freezing): Synovitis and inflammation of the joint capsule. Pain prominent.
- Fibrotic Phase (Frozen): Fibroblast proliferation, Collagen deposition, Capsular thickening and contracture. Loss of axillary recess. Stiffness prominent.
- Resolution Phase (Thawing): Gradual remodelling and restoration of motion. Pain resolves. Stiffness slowly improves.
Three Phases (Clinical)
| Phase | Duration | Pain | Stiffness |
|---|---|---|---|
| Stage 1: Freezing | 2-9 months | Severe, Night pain | Increasing |
| Stage 2: Frozen | 4-12 months | Decreases | Maximal restriction |
| Stage 3: Thawing | 12-24 months | Minimal | Gradually improves |
4. Differential Diagnosis
| Condition | Key Features |
|---|---|
| Frozen Shoulder | Global ROM loss (Active = Passive), External rotation worst, Diabetes. |
| Rotator Cuff Tear | Weakness, Positive impingement tests, Passive ROM PRESERVED (Or can be moved passively if pain allows). |
| Rotator Cuff Tendinopathy | Painful arc, Impingement signs, ROM preserved. |
| Glenohumeral Osteoarthritis | Older patients, Crepitus, X-ray degenerative changes. |
| Cervical Radiculopathy | Neck pain, Dermatomal weakness/Sensory change, Spurling's positive. |
| Shoulder Dislocation (Old) | Trauma history, X-ray shows old dislocation/Hill-Sachs lesion. |
| Inflammatory Arthritis | Inflammatory markers raised, Polyarticular, RA/Seronegative arthritis. |
5. Clinical Presentation
History
| Feature | Notes |
|---|---|
| Onset | Gradual, Insidious. May follow minor trauma or spontaneous ("Idiopathic"). |
| Pain | Initially severe. Worse at night. Sleep disturbance. Improves in frozen phase. |
| Functional Difficulty | Reaching behind back (Internal rotation), Putting on coat, Combing hair (External rotation + Abduction). |
| Duration | Weeks to months by time of presentation. Total 1-3 year illness. |
| Previous Episode | May have had contralateral frozen shoulder. |
| Diabetes History | Check HbA1c. |
Examination Findings
| Finding | Notes |
|---|---|
| Global ROM Restriction | Key feature. ALL movements restricted (Flexion, Abduction, ER, IR). |
| Active = Passive | Examiner cannot passively move the shoulder beyond the restricted range. |
| External Rotation Most Affected | Earliest and most severe limitation. |
| Capsular Pattern | Classic pattern: External Rotation > Abduction > Internal Rotation (ER > Abd > IR restriction). |
| No Weakness | Power is preserved (Unlike rotator cuff tear). |
| No Crepitus | Unlike OA. |
Special Tests
Passive External Rotation
With arm at side, elbow flexed 90° – Compare rotation to other side.
Hand Behind Back
Cannot reach as high up the back as the unaffected side.
6. Investigations
Imaging
| Modality | Role |
|---|---|
| X-Ray Shoulder | Usually NORMAL. Rules out OA, Calcific tendinitis, Fracture. May show osteopenia from disuse. |
| MRI | Not routine. May show thickening of joint capsule and coracohumeral ligament. Useful to exclude rotator cuff tear if diagnosis uncertain. |
| Ultrasound | Limited role. Can assess rotator cuff if co-existing pathology suspected. |
Blood Tests
| Test | Rationale |
|---|---|
| HbA1c / Fasting Glucose | Screen for undiagnosed Diabetes (Strong association). |
| TFTs | Screen for Thyroid disease (Associated). |
7. Management
Management Algorithm
FROZEN SHOULDER SUSPECTED
(Global ROM loss, Active = Passive, Capsular pattern)
↓
CONFIRM DIAGNOSIS
- Clinical examination (ER most restricted)
- X-ray (Exclude OA, Calcific tendinitis)
- Screen for Diabetes (HbA1c)
↓
PHASE ASSESSMENT
- Freezing (Pain predominant)?
- Frozen (Stiffness predominant)?
- Thawing (Improving)?
↓
CONSERVATIVE MANAGEMENT (First-Line)
┌──────────────────────────────────────────────────────────┐
│ ANALGESIA: │
│ - Paracetamol, NSAIDs (Oral or topical) │
│ │
│ PHYSIOTHERAPY: │
│ - Gentle ROM exercises within pain limits │
│ - Home exercise programme (Pendulum, Wall crawl) │
│ - Avoid aggressive stretching in freezing phase │
│ │
│ CORTICOSTEROID INJECTION: │
│ - Intra-articular Triamcinolone/Methylprednisolone │
│ - US-guided improves accuracy │
│ - Best benefit in Freezing phase (Inflammatory) │
│ - Short-term pain relief, May hasten recovery │
│ - Note: Less effective in Diabetics │
│ │
│ DURATION: 6-12+ months │
└──────────────────────────────────────────────────────────┘
↓
REFRACTORY / SEVERE CASES
┌──────────────────────────────────────────────────────────┐
│ HYDRODILATATION (Arthrographic Distension): │
│ - Large volume saline + Steroid + Local anaesthetic │
│ - Injected into joint under imaging (Fluoroscopy/USS) │
│ - "Bursts" the contracted capsule │
│ - Followed by physio │
│ │
│ MANIPULATION UNDER ANAESTHESIA (MUA): │
│ - General anaesthetic │
│ - Controlled forceful stretching to break adhesions │
│ - Risk: Fracture (Especially osteoporotic bone) │
│ - Followed by aggressive physio │
│ │
│ ARTHROSCOPIC CAPSULAR RELEASE: │
│ - Keyhole surgery to cut contracted capsule │
│ - Reserved for refractory cases │
└──────────────────────────────────────────────────────────┘
Treatment Summary
| Treatment | Evidence / Notes |
|---|---|
| Physiotherapy | Mainstay. Gentle stretching. Avoid aggressive therapy in freezing phase. |
| Corticosteroid Injection | Short-term benefit. More effective for pain than stiffness. Best in early (Inflammatory) phase. |
| Hydrodilatation | Some evidence of benefit. Often combined with steroid. |
| MUA | Older technique. Effective but risk of fracture. Less popular now with arthroscopic release available. |
| Arthroscopic Release | Surgical option for refractory cases. Rapid improvement in ROM. |
8. Complications
| Complication | Notes |
|---|---|
| Prolonged Disability | 1-3 year illness. Significant impact on work and daily life. |
| Residual Stiffness | ~10-20% have permanent restriction (Especially diabetics). |
| Contralateral Involvement | 20-30% develop frozen shoulder in other arm. |
| Treatment Complications | MUA: Fracture (Humeral neck), Nerve injury (Rare). |
9. Prognosis and Outcomes
| Factor | Notes |
|---|---|
| Natural History | Self-limiting. Most improve over 1-3 years. |
| Complete Recovery | ~70-80% regain functional ROM. |
| Residual Restriction | ~10-20% have permanent, mild restriction (Often asymptomatic). |
| Diabetics | Worse prognosis. Longer duration. More residual stiffness. |
| Bilateral | Second shoulder often affected (20-30%). |
10. Evidence and Guidelines
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Shoulder Pain | NICE CKS | Conservative management first. Steroid injection for pain. |
| Frozen Shoulder | BESS | Physiotherapy and injection. Hydrodilatation or MUA for refractory. |
Evidence Points
- Steroid Injection: Cochrane review shows short-term pain relief. Less effect on long-term stiffness.
- Hydrodilatation: Some RCTs show benefit. Combined with steroid.
- MUA vs Arthroscopic Release: Both effective. Arthroscopic release increasingly preferred (Less fracture risk).
11. Patient and Layperson Explanation
What is Frozen Shoulder?
The shoulder joint is surrounded by a capsule (A bag of tissue). In frozen shoulder, this capsule becomes inflamed and then thickens and tightens, restricting movement like a stiff, shrunken bag.
What causes it?
We don't always know. It is more common in people with diabetes, thyroid problems, or after a period of immobility (Like after surgery or a fracture).
What are the stages?
- Freezing (2-9 months): Pain is the main problem. Movement starts to reduce.
- Frozen (4-12 months): Pain eases but movement is very restricted. Stiff and hard to use.
- Thawing (12-24 months): Movement gradually returns.
How long will it last?
On average 1-3 years. Most people recover well, but it is a long journey. Some have mild permanent stiffness.
What is the treatment?
- Painkillers and physiotherapy exercises (Gentle).
- Steroid injection into the joint helps with pain (Especially early on).
- If still very stiff after many months, procedures like hydrodilatation (Inflating the capsule with fluid) or manipulation may be offered.
12. References
Primary Sources
- Dias R, et al. Frozen shoulder. BMJ. 2005;331(7530):1453-1456. PMID: 16356983.
- Hand C, et al. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg. 2008;17(2):231-236. PMID: 17993282.
- Buchbinder R, et al. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2008;(1):CD007005. PMID: 18254123.
13. Examination Focus
Common Exam Questions
- Key Clinical Finding: "What distinguishes Frozen Shoulder from Rotator Cuff Tear?"
- Answer: Active = Passive ROM restriction in Frozen Shoulder. In Rotator Cuff Tear, passive ROM is preserved (Examiner can move it further than patient can actively).
- Most Restricted Movement: "Which movement is restricted earliest and most severely?"
- Answer: External Rotation.
- Risk Factor: "What is the strongest risk factor for Frozen Shoulder?"
- Answer: Diabetes Mellitus.
- Phases: "Name the three phases of Frozen Shoulder."
- Answer: Freezing (Painful), Frozen (Stiff), Thawing (Recovery).
Viva Points
- Capsular Pattern: ER > Abduction > IR restriction.
- Screen for Diabetes: HbA1c in any frozen shoulder.
- Self-Limiting: Reassure patient it will get better, but slowly.
- Steroid Injection: Most effective in Freezing (Inflammatory) phase.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.