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Frozen Shoulder

What is it?

Adhesive capsulitis, also known as “frozen shoulder syndrome”, is described as an ongoing and painful limitation of active and passive glenohumeral and scapular motion.

There are two different types of frozen shoulder which are primary and secondary. Primary adhesive capsulitis is when patients are unable to identify the start or the reason for their condition. Secondary adhesive capsulitis is more common and usually occurs after a period of restricted shoulder motion, for example after a surgery.

Adhesive capsulitis can be subdivided into 4 different stages.

  1. Stage one is the “precursor” phase characterized by pain when the patient’s shoulder is at the end range of motion and when the joint starts undergoing a disused synovial reaction/inflammation.

  2. Stage two is known as the “freezing” stage where the shoulder gradually loses range of motion over a week to a few months period of time.

  3. Stage three is the “frozen” stage, characterized by pain and significant loss of range of motion. This is usually the stage after prolonged immobilization which causes atrophy, degeneration, and permanent motion restrictions.

  4. Lastly, stage 4 is the “thawing” stage that is associated with a decrease in pain and stiffness. Patients should realize that this last stage may take up to 9 months to regain full functional range of motion.

Adhesive capsulitis is thought to affect 2-5% of the population at some point in their lifetime. The incidence of adhesive capsulitis rises to 10-20% in those with type 2 diabetes, and 36% in those with type 1 diabetes. Patients with thyroid disease are at an increased risk as well. Those with any prior episodes on the contralateral arm have a greater risk of developing adhesive capsulitis.

Clinical Presentation

Patients with primary adhesive capsulitis present with gradual onset pain and stiffness that cannot be explained by either history or clinical findings. Patients with secondary adhesive capsulitis will report shoulder pain that started after an event like a surgery or after another concurrent condition.

Symptoms of adhesive capsulitis include progressive pain that intensifies at the end range of motion. Night pain and disturbances are common with this condition. Difficulty grooming and dressing oneself is often reported.

Functional range of motion deficits limit reaching overhead, behind the back, or to the side. Movement limitations greater than 25% are usually evident in at least two planes of motion. Passive external rotation loss is often greater than 50%.

A thorough evaluation may identify the presence of concurrent biomechanical deficits, such as upper cross syndrome and/or scapular dyskinesis. Normal scapular movement is responsible for up to one-third of total arm elevation, thus scapular dysfunction may have a significant impact on range of motion in adhesive capsulitis patients.


Plain radiographs will not usually show adhesive capsulitis, however it can show signs of osteoarthritis which is common for this condition. Radiographs can also be used to rule out other conditions that may appear like adhesive capsulitis. An MRI is appropriate when needed to define or rule out rotator cuff pathology. An MRI may also be used for patients who do not show improvement after a reasonable period of conservative care. MRI findings for patients with adhesive capsulitis include axillary recess thickening, joint volume reduction, rotator cuff interval thickening, and proliferative synovitis.


Manual therapy for the treatment of adhesive capsulitis demonstrates improvement in range of motion, pain, and function. Manual techniques should include active and passive stretching of the shoulder capsule with end range mobilization. Anterior, posterior, and inferior glide mobilizations performed at the end range of abduction can produce a significant improvement in the shoulder joint. Scapular mobilizations can be beneficial as well.

Cervical and thoracic spinal manipulation has been shown to be helpful in the treatment of shoulder pain and dysfunction.

The use of a pulley or cane may be helpful in performing assisted active range of motion. Clinicians should implement exercises to correct postural deficits, including upper crossed syndrome and scapular dyskinesis.

Implementation of exercises to improve scapular mobility and function are associated with improved outcomes.

Dry needling may improve pain, disability, and range of motion in adhesive capsulitis patients.

Patients must clearly understand the natural chronicity of this condition to limit apprehension and treatment frustration. Adhesive capsulitis has traditionally been thought to be a self-limiting disorder lasting up to 18 months. In some cases, symptoms can last for years.

Reluctant cases may require medical and/or surgical management. Intra Articular corticosteroid injections, when combined with manual therapy, may enhance short-term pain relief. Manipulation under anesthesia can be done to those with a persistent and significant range of motion loss. Another treatment for surgery is an arthroscopic release. A study on adhesive capsulitis found that manipulation under anesthesia or arthroscopic capsular release was not superior to early structured conservative therapy plus steroid injection.

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