Adhesive Capsulitis

Adhesive capsulitis (frozen shoulder) is a condition in which the glenohumeral joint

capsule becomes contracted and adherent to the humeral head. This can result in
shoulder pain and a reduced range of movement in the shoulder.

It affects approximately 3% of the population, it is more common in women, and peak

onset is between 40-70yrs old. Those who have previously been affected by
adhesive capsulitis are more susceptible to developing the condition in the
contralateral shoulder.

Pathophysiology
Adhesive capsulitis may be categorised as primary or secondary:

• Primary adhesive capsulitis (idiopathic)

• Secondary adhesive capsulitis – associated with rotator cuff tendinopathy,
subacromial impingement syndrome, biceps tendinopathy, previous surgery or
trauma, or known joint arthropathy

Adhesive capsulitis is often associated with inflammatory diseases and currently

theory suggests that it may have an autoimmune element.

Classically, adhesive capsulitis progresses in three stages (an initial painful stage,
a freezing stage, and finally a thawing stage). However, there is little evidence to
support the segregation of these phases, and that the pain associated with limitation
in shoulder movement is thought to be present throughout.

Figure 1 – The shoulder joint capsule in relation to the major bursae of the
shoulder
Clinical Features
Patients will describe a generalised deep and constant pain of the shoulder (which
may radiate to the bicep), that often disturbs sleep. Associated symptoms include joint
stiffness and a reduction in function.

On examination, there may be a loss of arm swing and atrophy of the deltoid
muscle. Generalised tenderness on palpation is common.

The patient will have a limited range of motion, principally affecting external
rotation and flexion of the shoulder (a full range of motion should prompt
consideration of alternative differential diagnoses).

Differential Diagnosis
• Acromioclavicular pathology (e.g. acriomioclavicular joint injury,
acromioclavicular arthritis, glenohumeral arthritis) – a more generalised pain
may be present with weakness and stiffness related to pain
• Subacromial impingement syndrome (rotator cuff tendinopathy, subacromial
bursitis) – may present with preserved passive movement and history of
repetitive overuse/external compression of subacromial space risk factors
• Muscular tear (rotator cuff tear, long head of biceps tear) – the weakness often
persists when the shoulder pain is relieved
• Autoimmune disease (polymyalgia rheumatica, rheumatoid arthritis, systemic
lupus erythematous) – may present with a polyarthropathy and systemic
symptoms

Investigations
The diagnosis of adhesive capsulitis is typically a clinical one, therefore can be made
by clinical features alone.

Plain film radiographs are generally unremarkable, but importantly can be used to
rule out acriomioclavicular pathology or atypical presentations of fractures.

MRI imaging can reveal a thickening of the glenohumeral joint capsule in

adhesive capsulitis (Fig. 2), but also can be used to rule out other conditions affecting
the shoulder, such as subacromial impingement syndrome.

The condition is more common in diabetic patients, therefore anyone presenting with
adhesive capsulitis without any risk factors or precipitating events, HbA1c and blood
glucose measurements may be useful.
 Figure 2 – MRI scan showing thickening of the glenohumeral joint capsule

Management
Adhesive capsulitis is a self-limiting condition however recurrence is not
uncommon. Recovery usually occurs over months to years and a proportion of
patients will never recover full range of movement.

Initial management of the patient involves education and reassurance. Patients

should be encouraged to keep active; all patients should receive physiotherapy and
advice concerning appropriate shoulder exercises.

Management of pain initially begins with simple analgesics. Glenohumeral joint

corticosteroid injections may be considered for those patients failing to improve.

Surgical Intervention

For patients with no improvement following prolonged engagement with full

conservative treatment efforts and when symptoms significantly affect quality of life,
surgical intervention may be considered.

Potential surgical interventions include joint manipulation under general

anaesthetic to remove capsular adhesions to the humerus, arthrogaphic
distension, or surgical release of the glenohumeral joint capsule.
Complications
A small proportion of patients will never regain a full range of motion but will regain
movement beyond that required to perform activities of daily living.

In some patients the progression of symptoms may persist beyond two years and
adhesive capsulitis may recur in the contralateral shoulder.