Frozen Shoulder

Adhesive Capsulitis

Definition

  • Idiopathic inflammatory condition characterised by progressive shoulder pain & stiffness that spontaneously resolves
  • Restriction of GHJ movement in all planes

Epidemiology

  • 40-60 years
  • Women 2:1
  • Non-dominant limb more affected
  • Bilateral in 10-40%
  • 2% of population
  • 11% of diabetic population
  • Sedentary workers ↑

Aetiology

  • Poorly understood
  • Autoimmune theory proposed but not proven

Predisposing Factors

  • Immobility
  • Trauma (often trivial)
  • Cervical disc disease
  • Diabetes Mellitus
    • 10-20% compared with 2% of general population
    • Bilaterality ↑ (40%)
    • > 10 years of IDDM ↑ risk
  • Thyroid disorders
    • Hyperthyroidism
    • Resolves with treatment of disease
  • Myocardial infarction
  • Intrathoracic disorders
    • TB
    • Carcinoma
    • Emphysema
  • Intracranial Pathology
    • Hemiplegia
    • Cerebral Haemorrhage
    • Cerebral tumours
  • Personality disorder

Not Associated with

  • Osteoarthritis
  • Cuff Pathology

Classification

Lunberg

  • Primary
  • Secondary

Apley

Three phases each lasting 4-8 months

PhaseFeatures
FreezingIncreasing pain
FrozenDecreasing pain, increasing stiffness
ThawingDecreasing stiffness

Pathogenesis & Pathology

Initial synovitis of unknown cause

  • Results in
    • Capsulitis
    • Intra-articular adhesions
    • Obliteration of inferior axillary fold
  • Subsequent development of
    • Subacromial adhesions
    • Rotator cuff contracture
    • Then spontaneous resolution
  • Contracted, thickened joint capsule drawn tightly around the humeral head with relative lack of synovial fluid
  • See cellular changes of inflammation with fibrosis & perivascular infiltration in subsynovial layer of capsule (Nevaiser) – similar appearance to Dupuytren’s disease
  • Poor correlation between the microscopic & gross capsular changes
  • Capsular folds & pouches obliterated by synovial adhesions
  • Coracohumeral ligament is shortened & prevents ER
  • Rotator cuff bellies contracted fixed & inelastic
  • Few adhesions in subacromial bursa
  • Spontaneous resolution the rule

Three Classical Stages (Apley)

PhaseFeaturesDuration
FreezingGradual diffuse onset shoulder pain, lateral to arm at deltoid insertion. Worse at night & lying on that side. If reduce movement the pain reducedVariable, 2-9 months
FrozenSlowly progressive loss of shoulder movement with gradual subsidence of pain. Affects ADLs usually. Usually characteristic loss of ER & abduction. 10% have negligible glenohumeral movement4-12 months
ThawingGradually regain shoulder movement. Slow ↑ in movement with loss of discomfort6-9 months to regain functional ROM

Clinical Features

History

  • Insidious onset
  • No history of trauma

Pain

  • Initially
    • At site of deltoid insertion
    • At extremes of motion
  • Becomes more
    • Diffuse
    • Severe
    • Constant
    • Interferes with sleep
  • Then begins to decrease
    • Rest pain disappears
    • Pain only on movement

Stiffness

  • Develops after onset of pain
  • Difficulty reaching
    • Overhead
    • Behind back
  • Activities modified
  • Then stiffness slowly resolves

Examination

  • Muscle atrophy
  • No point tenderness
  • Markedly ↓ ROM, especially
    • Abduction
    • Rotation
    • Pain on forced movement
    • Most sensitive indicator is pain on forced external rotation
  • Scapulothoracic movement substituted for glenohumeral movement

Investigations

Frozen Shoulder, mri showing thickening of the inferior joint capsule in frozen shoulder
MRI showing thickening of the inferior joint capsule in frozen shoulder. Image by RSatUSZ, Wikimedia Commons, CC BY-SA 3.0.

Plain Radiography

  • Rule out other conditions
  • Usually normal but may see relative osteopaenia

Bone Scanning

  • May show diffuse ↑ uptake in shoulder

Arthrography

  • Reduced volume < 10mls (normal shoulder 20-30ml)
  • Obliterated axillary capsular recess
  • Irregular joint outline
  • Variable filling of the bicipital tendon sheath
  • 6-20% have normal arthrogram

Arthroscopy

  • Technically demanding due to small capsule
  • Synovitis often present with obliteration of the inferior recess
  • Nevaiser suggested four stagesStage I – Mild reddened synovitisStage II – Acute synovitis with adhesion of dependent foldsStage III – Maturation of adhesionsStage IV – Chronic adhesions

Differential Diagnosis

Treatment

Non-operative

Primary consideration is prevention

  • Early ROM after trauma or surgery
  • Educate care-givers
  • Supportive care primary goal

Reassurance as first treatment

HCLA 2nd line

Avoid physiotherapy as makes it more painful & doesn’t ↑ ROM

Supportive

  • Careful explanation of
    • Nature of disease
    • Natural history
    • Reassurance

Freezing Phase

Directed towards pain relief

  • Simple Analgesics / NSAID
  • Sedatives
  • Sling
  • Ice
  • TENS

Physiotherapy & exercises of no benefit

  • Can make pain worse
  • Can be used to maintain strength of cuff & periscapular muscles?

Frozen Phase

  • Encourage hand use to avoid RSD
  • ? Consider Hydrostatic Distension at this stage if desperate

Thawing Phase

  • Gentle ROM & strengthening
  • ? MUA or Distension

Operative Treatment

MUA & Steroid Injection

  • Controversial
  • Technique (Nevaiser)
    • At least after 6/12 » late Frozen or early Thawing
    • GA
    • Shoulder MUA to regain ROM “out – up – in”
      • External rotation first
      • Then abduction
      • Then internal rotation in abduction
    • Then HCLA
    • Sensation of tearing is the axillary fold tearing on A/S
    • Shoulder abduction 90° for 2/52
    • Postoperative physiotherapy
  • Results
    • Uncertain if alters natural history
    • Reports vary from
      • Shorter rehabilitation time
      • Decreased period of stiffness
      • No ↓ in course of disease
      • No benefit with significant complications
  • Contra-Indications of MUA
    • Osteopaenia
    • Previous fracture or surgery
    • PVD
    • History instability
  • Complications of MUA
    • Humeral fractures & dislocations
    • Cuff tears
    • Increased inflammation & scarring
    • Radial nerve palsy

Hydrostatic Distension

  • Uncertain at what stage to use 😕 Frozen or Thawing
  • Technique
    • Needle into GHJ under LA
    • Joint forcefully distended by injection
      • 5ml LA
      • 1ml Steroid
      • Up to 40ml Saline
    • Distension until capsule ruptures
      • Sudden drop in resistance
    • Immediate postoperative physiotherapy
  • Results
    • Immediate resolution of pain
    • Normal functional ROM by 4/52

Other

  • Arthroscopy*
  • Open Capsulotomy
    • Don’t release axillary pouch

*Capsule rent with MUA usually along anterior capsule & inferiorly through most of IGHL

Some surgeons now suggest controlled division of the capsule arthroscopically – ie MUA without the risk of fractures & dislocations

Problem is arthroscopic access in frozen shoulder

Prognosis

  • Traditionally thought to be benign & self-limiting
  • Resolves after 12-36/12
    • Average 18 months (Chris Blenkin says 2-5 years is average)
    • Maximum 10 years
  • Most have no significant symptoms or functional restriction
  • But not as benign as previously thought
    • 20% have mild pain
    • 30-60% have ↓ ROM
      • Usually external rotation (limitation of ER to less than 60% of opposite)
    • Treat aggressively to avoid Osteoarthritis

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.