Adhesive capsulitis of the shoulder, more commonly known as frozen shoulder, is a painful condition of the shoulder that most often affects women between the ages of 40 and 60.
This condition may sometimes develop after an injury, such as a fracture around the shoulder, or even postoperatively, for example, after arthroscopic shoulder surgery. However, in many cases, the exact cause remains unclear, which is referred to as primary or idiopathic adhesive capsulitis. It has been associated with conditions such as diabetes (both types), thyroid disease (particularly autoimmune), Dupuytren’s disease, atherosclerosis, and cervical disc disease.
Like all joints in the human body, the shoulder joint is surrounded by a fibrous capsule, which is further reinforced by the glenohumeral ligaments. Together, these act as static stabilizers, limiting extreme uncontrolled motion while still allowing a full, functional range of movement and flexibility. In frozen shoulder, these capsuloligamentous structures thicken and contract, leading to a significant reduction in both active and passive shoulder mobility, accompanied by pain of varying intensity.
The condition generally follows a prolonged clinical course, divided into three main stages. The freezing or painful stage is characterized by the gradual onset of diffuse shoulder pain and may last from six weeks to nine months. This is followed by the frozen or stiff stage, where shoulder mobility decreases significantly, interfering with daily activities. This stage can last between four and nine months. Finally, the thawing stage begins, during which movement and function gradually return over a period ranging from five to twenty-six months.
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The most common clinical signs of frozen shoulder include the insidious onset of generalized shoulder pain, followed by reduced mobility that significantly impacts daily life. Pain may be triggered by attempts to move the joint, but can also occur at rest, and in some cases during the night, severely disrupting sleep. Clinical examination reveals a reduction in both active and passive mobility, with a painful range of motion that ends in a firm, unyielding stop. Assessing the shoulder for concurrent conditions such as rotator cuff pathology or long head of biceps tendon disorders is often limited at this stage due to the severe pain and restricted motion.
Initial imaging studies usually include a standard set of plain X-rays to evaluate the bony structures of the shoulder, such as signs of disuse osteopenia or arthritis. MRI, with or without arthrography, may be used to investigate concomitant or alternative pathologies as potential causes of the patient’s symptoms. However, imaging is not required to establish the diagnosis of adhesive capsulitis, which remains primarily clinical.
Management of frozen shoulder includes both non-invasive and surgical approaches. Non-invasive treatment is the first line and is effective in improving pain and mobility in most cases. It involves the use of physical modalities such as heat and cryotherapy, painkillers like paracetamol, NSAIDs, and intra-articular injections of local anesthetics and corticosteroids. These measures are particularly helpful in the initial painful stage, while corticosteroid injections may provide more prolonged pain relief and anti-inflammatory effects lasting several weeks. Physiotherapy plays a fundamental role, generally consisting of daily, progressive stretching exercises performed up to the point of pain. Treatment may last from three to six months, during which patients should be supervised by an experienced physiotherapist. Later, they can transition to a home exercise program until optimal recovery is achieved.
Surgical intervention is reserved for persistent cases where conservative measures fail to restore adequate function, preventing patients from performing normal daily activities. One option is manipulation under anesthesia, where the shoulder is taken through as full a range of motion as possible using steady, controlled force while the patient is under anesthesia and muscle relaxation. To maximize its effectiveness, various methods of postoperative pain control (oral, intravenous, or intra-articular analgesics) are employed, allowing immediate initiation of physiotherapy. In cases where manipulation under anesthesia fails to sufficiently restore range of motion, arthroscopic capsular release may be performed. This procedure aims to release the thickened and contracted soft tissues that restrict shoulder movement. As with manipulation, immediate physiotherapy is crucial to maintain the benefits of the surgery.
In summary, frozen shoulder, or adhesive capsulitis, is a painful condition that is usually idiopathic but fortunately self-limiting. It commonly occurs in women with diabetes, thyroid disorders, or autoimmune diseases. Diagnosis is primarily clinical, and treatment is initially non-invasive, with good functional outcomes for most patients. In the minority of cases where conservative management fails, manipulation under anesthesia or arthroscopic capsular release can restore range of motion. Regardless of the chosen treatment, adherence to a full physiotherapy program of appropriate duration is essential for maintaining the best possible long-term outcomes.
Frozen shoulder is an inflammatory condition that severely restricts shoulder movement.
Gradual pain and stiffness of the shoulder joint are the hallmark symptoms.
Physiotherapy and corticosteroid injections play a major role in recovery.
Full recovery may take anywhere from six months to two years.
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