3. Adhesive Capsulitis of the Shoulder

Adhesive Capsulitis of the Shoulder

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonym: frozen shoulder

Adhesive capsulitis of the shoulder is one of the most common causes of intrinsic shoulder pain. It is a glenohumeral disorder and can occur in one shoulder or both shoulders simultaneously. Thickening and contraction of the glenohumeral joint capsule and formation of adhesions cause pain and loss of movement.

Adhesive capsulitis of the shoulder can occur:

  • Spontaneously.
  • Following rotator cuff lesions/injury.
  • In conditions causing immobility - eg, after a cerebrovascular accident or plaster immobilisation.

See separate articles Shoulder Pain and Shoulder Examination.

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  • Most commonly, it affects ages 40-65 years; the median age is 50-55 years.
  • It affects around 3% of the adult population.
  • It is more common in women.
  • It is more common in those with diabetes.
  • It is also associated with thyroid disease.
  • It usually affects the non-dominant shoulder although it can occur in either shoulder.
  • There is usually a gradual onset of severe pain in the shoulder, which is associated with stiffness.
  • Restriction of all shoulder movements, both active and passive.
  • Inability to sleep on the affected side.
  • Restriction of activities of daily living due to impaired external rotation - eg, driving, dressing.
  • There tends to be three phases:
    • Phase 1 - severe generalised pain associated with stiffness. Daily activities are limited (eg, putting on a jacket). It can last up to nine months.
    • Phase 2 - pain usually gradually subsides but the shoulder is stiff. Movement can become more limited. External rotation is usually very limited. This phase lasts between 4-12 months.
    • Phase 3 - the shoulder becomes less stiff. There is an increase in the range of movement. This phase usually lasts 1-3 years.
Stiffness, pain and loss of motion with insidious onset are usually the major symptoms.
  • The diagnosis is clinical.
    • The whole shoulder joint may be tender to palpation.
    • The main diagnostic test is the inability to do passive external rotation.
  • X-rays are usually only necessary if the presentation is atypical or the patient is not responding to treatment.
  • X-rays are commonly normal.
  • Consider other causes of shoulder pain.
  • Blood tests and radiography should only be performed if red flag symptoms are present. For a list of these, refer to the separate article Shoulder Pain.
  • The aim is to treat early. Ideally you want to prevent an episode of capsulitis becoming adhesive capsulitis.
  • An holistic approach to treatment should be used, considering psychological and psychosocial factors.
  • The first stage is analgesia - paracetamol as first-line with non-steroidal anti-inflammatory drugs (NSAIDs) second-line, provided there are no contra-indications. Use of a transcutaneous electrical nerve stimulation (TENS) machine may also be helpful.
  • Encourage early activity.
  • Provide a written patient information leaflet on shoulder pain.
  • Physiotherapy combined with steroid injection has been shown to have early significant improvements with respect to improving shoulder range of movement, pain and also function.
  • Injection with corticosteroids may reduce pain and duration of symptoms in the early stages.[1]
  • There is, however, no benefit of ultrasound-guided steroid injection.[2]
  • Oral steroids may provide short-term benefit in pain and function but benefit may not persist beyond six weeks. Furthermore, they are unlikely to be superior to intra-articular injections.[3]
  • Some surgeons perform manipulation under anaesthetic and arthroscopic capsular release of the adhesions if conservative treatment fails.[4] 
  • Long-term pain and shoulder stiffness.
  • Symptoms can persist for 18 months to 3 years or more.
  • However, over 90% of patients with spontaneous adhesive capsulitis have been shown to recover to normal levels of function and movement by two years without any treatment.[5] 
  • Consider referral to secondary care if pain and significant disability are present for >6 months despite appropriate conservative management.
  • Relapses in the same shoulder are uncommon.
  • Whatever the reason, avoid prolonged immobilisation - eg, slings, plaster casts - during illness.
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Further reading & references

  1. Buchbinder R, Green S, Youd JM; Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003;(1):CD004016.
  2. Bloom JE, Rischin A, Johnston RV, et al; Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev. 2012 Aug 15;8:CD009147.
  3. Lorbach O, Anagnostakos K, Scherf C, et al; Nonoperative management of adhesive capsulitis of the shoulder: oral cortisone J Shoulder Elbow Surg. 2010 Mar;19(2):172-9. Epub 2009 Oct 1.
  4. Le Lievre HM, Murrell GA; Long-term outcomes after arthroscopic capsular release for idiopathic adhesive capsulitis. J Bone Joint Surg Am. 2012 Jul 3;94(13):1208-16.
  5. Vastamaki H, Kettunen J, Vastamaki M; The natural history of idiopathic frozen shoulder: a 2- to 27-year followup study. Clin Orthop Relat Res. 2012 Apr;470(4):1133-43. Epub 2011 Nov 17.
Original Author: Dr Michelle Wright Current Version: Peer Reviewer: Dr John Cox
Last Checked: 25/10/2012 Document ID: 2802  Version: 22 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

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