Adhesive Capsulitis (Frozen Shoulder)

Topic updated on 08/20/16 6:07pm
  • Defined as pain and loss of motion in shoulder with no other cause 
  • Pathoanatomy
    • soft tissue scarring and contracture  
    • essential lesion involves the coracohumeral ligament and rotator interval
    • fibroblastic proliferation of capsular tissue seen on biopsy    
  • Associated conditions
    • associated with
      • diabetes (both types) 
        • worse outcomes regardless of treatment
        • increased risk with: older age, increased duration of DM, autonomic neuropathy, history of MI 
      • thyroid disorders (autoimmune etiology)
      • previous surgery (lung and breast)
      • prolonged immobilization
      • extended hospitalization
  • Capsuloligamentous structures
    • function
      • contribute to stability of the glenohumeral joint
      • act as check reins at extremes of motion in their nonpathologic state
    • include the glenohumeral ligaments 
      • superior glenohumeral ligament (SGHL)
      • middle glenohumeral ligament (MGHL)
      • inferior glenohumeral ligament (IGHL) complex with the following components
        • anterior band
        • axillary fold
        • posterior band
  • Rotator interval
    • a triangular region between the anterior border of supraspinatus and the superior border of subscapularis  
    • contains the SGHL and coracohumeral ligament 

Clinical Stages
Painful Gradual onset of diffuse pain (6 wks to 9 mos)
Stiff Decreased ROM affecting activities of daily living (4 to 9 mos or more)
Thawing Gradual return of motion (5 to 26 mos)
Arthroscopic Stages
Stage 1
Patchy, fibrinous synovitis
Stage 2
Capsular contraction and fibrinous adhesions
Stage 3
Increasing contraction, synovitis resolving
Stage 4
Severe contraction

  • Symptoms
    • characterized by pain anstiffness 
  • Physical exam
    • painful arc of motion
    • decreased ROM (especially external rotation)
      • examine and document all seven planes of motion
  • Radiographs
    • recommended views
      • AP in neutral rotation
      • AP in internal rotation
      • AP in external rotation
      • scapular-Y
      • axillary lateral
    • findings
      • disuse osteopenia
      • concomitant osteoarthritis, calcific tendinitis, or hardware indicating prior surgery
  • MR arthrogram
    • loss of axillary recess indicates contracture of joint capsule
  • Nonoperative
    • NSAIDs, physical therapy, and intra-articular steroid injections 
      • physical therapy
        • program of gentle, pain-free stretching and moist heat
        • should be supervised and last for 3-6 months
      • results
        • successful in vast majority although patience is required
        • most common complication is decreased range of motion compared to contralateral extremity 
  • Operative 
    • manipulation under anesthesia (MUA)
      • indications 
        • failure to improve with therapy and NSAIDs
      • surgical techniques
        • may be combined with arthroscopic surgical release
    • arthroscopic surgical release 
      • indications
        • only after extensive therapy has failed ( 3-6 months)
      • surgical techniques
        • arthroscopic lysis of adhesions (LOA)
        • arthroscopic rotator interval release will increase ER 
          • when ER at the side is limited, the most likely diagnosis is contracture of the rotator interval, including the superior glenohumeral and coracohumeral ligaments
        • arthroscopic posterior capsular release will increase IR
  • Axillary nerve injury
  • Rotator cuff tendon disruption
  • Iatrogenic chondral injury
  • Fracture or dislocation
    • caution must be used with manipulation under anesthesia in osteoporotic bone
  • Recurrent stiffness 


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Qbank (10 Questions)

(SBQ11.31) A 45-year-old patient with a history of diabetes presents with increasing shoulder stiffness over the course of the past several months. She has tried non-steroidal anti-inflammatory drugs, but they have not alleviated her pain. On examination she has global pain with passive range of motion, forward elevation of 100 degrees, external rotation to neutral, and internal rotation to her iliac crest. Radiographs of the shoulder are normal. An MR arthrogram is most likely to show which of the following? Topic Review Topic

1. Massive retracted rotator cuff tear
2. Proliferative synovial process with hypertrophied synovium and extensive papillary projections
3. Decreased intra-capsular volume
4. Subscapularis tear with long head of the biceps subluxation
5. Fluid extravasation down the humerus

(SBQ06.44) Which of the following statements is true regarding the anatomical boundaries of the rotator interval in the shoulder? Topic Review Topic

1. Superior border is defined by the biceps long head tendon
2. Inferior border is defined by anterior band of inferior glenohumeral ligament
3. Contains the axillary pouch which is a common site for intra-articular loose bodies
4. Superior border is defined by anterior edge of suprapinatus tendon
5. Inferior border is defined by middle glenohumeral ligament

(SBQ05.87) Which of the following is the most common outcome following non-operative management of adhesive capsulitis with a stretching program? Topic Review Topic

1. Functionally limiting pain
2. Decreased range of motion compared to contralateral shoulder
3. Recurrence of adhesive capsulitis
4. Need for operative intervention
5. Development of rotator cuff arthropathy

(OBQ12.71) Which of the following patients is most likely to have a fibroblastic proliferative process as a cause for their shoulder complaints? Topic Review Topic

1. 65-year-old man with giant cell arteritis and bilateral shoulder pain and stiffness.
2. 40-year-old man with a history of podagra who now has acute shoulder pain.
3. 50-year-old woman with hypothyroidism and loss of both active and passive shoulder motion.
4. 65-year-old woman with ulnar drift of the fingers and shoulder pain and stiffness.
5. 40-year-old woman with antinuclear antibodies with knee and shoulder pain

(OBQ10.68) A 42-year-old female presents to your office with pain in the shoulder that has been present for 1 month, and she notes the shoulder is also becoming stiff. She has not previously sought treatment. After a full evaluation, you determine she has adhesive capsulitis, and is in the early stiffening stage. What treatment do you recommend? Topic Review Topic

1. Immediate aggressive therapy for active-assisted and passive range of motion exercises
2. Platelet-rich plasma (PRP) injections
3. Arthroscopic lysis of adhesions and bursectomy
4. Reassurance and a gentle stretching program as symptoms allow
5. Manipulation under anesthesia

(OBQ05.5) Which of the following is a known risk factor for the development of adhesive capsulitis of the shoulder? Topic Review Topic

1. Menopause
2. Steroid use
3. Diabetes mellitus
4. Renal disease
5. All of the above

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