Adhesive Capsulitis

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There is the development of thickened, fibrosed joint capsule with subsequent contraction of the joint and reduced articular volume. The exact cause is unknown โ€“ several possible processes suggested. There is a wide spectrum of presentations and combinations of symptoms.


The peak incidence is between 40-60, more common in women. Patients with diabetes have a 10-20% lifetime risk. Other associated conditions include hypothyroidism, hypercholesterolaemia and heart disease.


History: insidious onset, pain at night, sometimes history of minimal trauma.

Exam: painful movement restriction, passive ext rotation less than 30 degrees, passive elevation less than 100.

Investigations: Xray to check for OA.

3 phases

  • Freezing: stiffness, with progressively worsening pain
  • Frozen: on going stiffness, with improved pain levels
  • Thawing: gradual improvement in ROM. However clinical course is variable.

Differential Diagnosis

Differential Diagnosis
  • Osteoarthritis
  • RC cuff (preserved ER)
  • Septic arthritis (rapid onset, single swollen joint)
  • dislocation (traumatic)
  • Inflammatory arthritis.
  • Neuralgic Amyotrophy



  • Individual approach exploring functional limitation
  • Advise patients to use arm as pain allows
  • Sleep on unaffected side
  • Heat/ice


Simple home exercises โ€“ pendulum, gentle stretching

Physio: main role is in frozen/adhesive phase, with stretches and strengthening.  Add in resistance in thawing at 6 โ€“ 12 weeks.


Steroid Injections provide short term but not long term benefit[1] Intra-articular injections provide better relief than subacromial. Adverse effects include pain, flushing, syncope, infection.

Injections may be supplemented with hydrodilatation or hydrodilatation may be done alone.


In a multi-centre trial of 503 adults with severe persistent frozen shoulder symptoms, arthroscopic capsular release (ACR), manipulation under anaesthesia (MUA), and physiotherapy supplemented with corticosteroid injection were all found to be equal at 12 months. Arthroscopic capsular release has significant side effects such as stroke, pneumonia, deep vein thrombosis.[2]


It is often characterised as a โ€œself limitingโ€ condition that lasts usually 1-3 years. Recent literature suggest 41% report residual symptoms.

Recurrence rare. Up to 20% develop it on the other side

Diabetics have poorer response to treatment.



  1. โ†‘ Kitridis D, Tsikopoulos K, Bisbinas I, Papaioannidou P, Givissis P. Efficacy of pharmacological therapies for adhesive capsulitis of the shoulder: A systematic review and network meta-analysis. Am J Sports Med 2019;47(14):3552-3560.
  2. โ†‘ Rangan et al.. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. Lancet (London, England) 2020. 396:977-989. PMID: 33010843. DOI.

Literature Review