Conditions & Treatments - Adhesive Capsulitis - Frozen Shoulder


Adhesive capsulitis, commonly termed "frozen shoulder," is a complicated, painful condition in which a patient presents with shoulder pain and develops a gradual loss of both active and passive shoulder range of motion (1). Adhesive capsulitis occurs in approximately 2-5% of the population and is more prevalent in females, individuals age 40-65, and those who have had a prior episode of adhesive capsulitis in the opposite shoulder (1). Two types of adhesive capsulitis exist: primary idiopathic adhesive capsulitis and secondary adhesive capsulitis. Secondary adhesive capsulitis may be related to systemic disease (diabetes mellitus and thyroid disorders) or a variety of intrinsic or extrinsic factors (stroke, proximal humeral fracture, causative rotator cuff, and labral pathology) (2).

Pathology/Etiology (3)
In patients with adhesive capsulitis, the inferior capsule of the glenohumeral joint thickens (a thickening observed on an MRI of >4 mm is considered diagnostic of the condition) Arthrograms reveal reduced glenohumeral joint spaces (10-15 mL, normal is 20-30 mL). Serum cytokine, which facilitates tissue repair and remodeling as part of the inflammatory process of healing, is often elevated. Some researchers believe that a minor injury triggers the healing process, and fibroblasts produce more collagen than is reabsorbed, leading to excess collagen and stiffness in the joint capsule.

Several stages are often used to describe the progression of adhesive capsulitis. A description of each stage can be found in the table below.

Table1: Stages of Adhesive Capsulitis (3)

Stage Stage I Stage II Stage III Stage IV
Nickname Pre-freezing Freezing Frozen Thawing
Duration 0-3 months 3-9 months 9-14 months > 14 months
Presentation Pain with AROM/PROM; pain inhibition Chronic pain with AROM/PROM; spasm end-feel, may have night pain, positive impingement signs Decreased pain, globally limited ROM, pain at end range Stiffness, minimal pain, slow recovery of ROM
Pathology Hypertrophic vascular synovitis noted from arthroscopy; normal capsule as indicated by biopsy Dense hypervascular synovitis Capsule shows dense scar formation Patient is improving

Clinical Examination
Patients may report having difficulty maintaining a lying position, putting on clothes, taking off clothes, and reaching (2). Patients may also report having trouble completing daily routines, lifting, carrying, throwing, climbing, swimming, bathing, caring for their hair, cleaning, or completing a variety of other activities (2). Patients may exhibit a flexed posture and rounded shoulders (3). During ambulation, arm swing may be limited or absent (3).

Clinicians should ask patients questions regarding their ability to sleep through the night (ability to sleep indicates lower irritability) and if the chief complaint is pain or stiffness (to help determine staging) (3). Clinicians should also have patients fill out a validated functional outcome measure, such as the DASH, the ASES, or the SPADI (2). Clinicians should measure AROM and PROM, assess pain, and assess glenohumeral joint accessory motion (2).

Treatment Recommendations
In May 2013, Clinical Practice Guidelines were published for the treatment of adhesive capsulitis. The following table is a summary of the intervention guidelines presented in the article (2).

Table 2: Recommendations for the treatment of adhesive capsulitis from the Clinical Practice Guidelines.
Intervention Description Recommendation Based On
Corticosteroid injections When combined with shoulder mobility and stretching exercises, more effective in short term pain reduction than shoulder mobility and stretching exercises alone Strong evidence
Patient Education Clinicians should describe the course of the disease, promote activity modification, and match the intensity of intervention to the patient's current irritability level Moderate evidence
Modalities Short wave diathermy, ultrasound, electrical stimulation in addition to mobility and stretching exercises to reduce pain and increase ROM Weak evidence
Joint Mobilization Mobilizations primarily at the glenohumeral joint to reduce pain and increase ROM Weak evidence
Translational Manipulation Translational manipulation under anesthesia at the glenohumeral joint in patients not responding to conservative treatment Weak evidence
Stretching Exercises Stretching exercises at an intensity appropriate for the irritability level of the patient  Moderate evidence


Research since the creation of the Clinical Practice Guidelines has continued to support the inclusion of static stretching in the treatment of adhesive capsulitis.  In a study by Ibrahim et al. (4), sixty patients with adhesive capsulitis were randomly assigned to a treatment group or a control group.  Both groups received 3 PT sessions/wk for 4 weeks; however, the treatment group also used a static progressive stretch device (one 30 minute session per day for the first week, two 30 minute sessions per day for the second and third weeks, and three sessions per day for the fourth week).  At baseline, no differences existed between the two groups.  However, after the intervention, differences between the two groups were statistically significant.  The treatment group had lower pain ratings, lower DASH scores, increased PROM shoulder abduction, increased PROM shoulder ER, and increased AROM shoulder abduction.  The differences between the two groups persisted at a 12 month follow up (4).



Although mild to moderate mobility deficits and pain may persist 12-18 months after the onset of adhesive capsulitis, many patients report minimal to no disability (2).  27-50% of patients report having mild symptoms 2-7 years after the onset of adhesive capsulitis (3).  It is important to note that patients with diabetes mellitus may experience worse outcomes (2).


Last revised: July 20, 2014
by Michelle Kornder, DPT



1) Lynch TS and Edwards SL. Adhesive capsulitis: current concepts in diagnosis and treatment. Current Orthopaedic Practice. 2013;24(4):365-369. Available from University of Wisconsin Madison, Madison, WI. Accessed July 7, 2014.
2) Kelley MJ, Shaffer MA, Kuhn JE et al. Shoulder Pain and Mobility Deficits: Adhesive Capsulitis. J Orthop Sports Phys Ther. 2013;43(5):A1-A31. Available from University of Wisconsin Madison, Madison, WI. Accessed July 7, 2014.
3) Hallisy, Thein-Nissenbaum. PT 677 -MS Dysfunction: Examination, Diagnosis, & Management II. Madison, WI: Department of Physical Therapy; 2013.
4) Ibrahim M, Donatelli R, Hellman M, Echternach J. Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study [published online ahead of print 2013]. Physiotherapy. Available from University of Wisconsin Madison, Madison, WI. Accessed July 7, 2014.
5) Frozen Shoulder-OrthoInfo-AAOS. American Academy of Orthopaedic Surgeons. Updated January, 2011. Accessed July 7, 2014.
6) Standard of Care: Shoulder Adhesive Capsulitis. Brigham and Women's Hospital. Updated 2010. Accessed July 7, 2014.
7) Physical Therapist's Guide to Frozen Shoulder (Adhesive Capsulitis). American Physical Therapy Association Move Forward Guide. Accessed July 7, 2014.



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