Frozen shoulder (adhesive capsulitis) !
Frozen shoulder (adhesive capsulitis) is a painful stiffening of the shoulder as its capsule thickens and shrinks; turning the arm outward is lost first.
Updated 2026-10-29
Structures involved
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In the clinical exam
Why it happens
- Fibrosis in organs: TGF-β and the myofibroblast
- Synovial joints: capsule, synovial membrane and articular cartilage
What it is
Painful stiffening of the shoulder joint caused by inflammation and then fibrosis and contraction of the joint capsule, with loss of both active and passive movement, most of all external rotation.
Who gets it
Typical of middle age, usually between 40 and 60 years, and more frequent in women. Much more common in people with diabetes, a frequent condition in Colombian outpatient practice.
Causes
- Primary (idiopathic): no clear trigger
- Secondary: after shoulder injury, surgery or a period of immobilisation
- Associated with systemic diseases such as diabetes and thyroid disease
Risk factors
- Diabetes mellitus (types 1 and 2)
- Thyroid disease (hypo- or hyperthyroidism)
- Age 40 to 60 years and female sex
- Prolonged shoulder immobilisation after trauma or surgery
- Stroke, cardiac disease or Dupuytren contracture
- Previous frozen shoulder on the other side
Pathophysiology
An inflammatory phase of the synovium and capsule is followed by fibroblast proliferation and collagen deposition. The capsule thickens and contracts, especially at the rotator interval and coracohumeral ligament, and joint volume falls. The tight capsule blocks movement in every direction, external rotation first.
Classification
- Freezing (painful) phase: diffuse pain, worse at night, with gradually increasing stiffness
- Frozen (stiff) phase: pain eases but marked stiffness persists
- Thawing phase: slow, spontaneous recovery of movement
- Primary (idiopathic) or secondary (to trauma, surgery or systemic disease)
Symptoms and signs
- Gradual onset of dull, poorly localised shoulder pain
- Night pain and difficulty lying on the affected side
- Progressive stiffness: trouble reaching overhead, behind the back or combing the hair
- Loss of active and passive range of motion, external rotation most affected
- Normal strength when tested within the available range
Diagnosis
- Clinical
- Clinical diagnosis: global loss of active and passive movement, with external rotation reduced the most, and normal X-rays.
- Tests
- Blood glucose or HbA1c and thyroid function tests are often checked to look for associated disease.
- Imaging
- X-ray is normal and excludes glenohumeral arthritis, missed dislocation or tumour; ultrasound or MRI may show a thickened capsule and coracohumeral ligament.
Differential diagnosis
- Glenohumeral osteoarthritis
- Rotator cuff tear or tendinopathy
- Subacromial impingement
- Missed posterior shoulder dislocation
- Calcific tendinitis
- Cervical radiculopathy
Goal of treatment
Control pain, keep and restore range of motion and shorten the time the patient spends disabled, while the condition runs its natural course.
Treatment
- Medical
- Simple analgesics and non-steroidal anti-inflammatory drugs for pain, especially in the freezing phase.
- Procedure
- Intra-articular corticosteroid injection, which gives faster short-term pain relief; hydrodilatation (distension of the capsule with fluid) in some centres.
- Rehabilitation
- Physiotherapy with gentle stretching and range-of-motion exercises, progressed as pain allows.
- Surgical
- For stiffness that does not improve: manipulation under anaesthesia or arthroscopic capsular release.
Complications
- Persistent mild stiffness or pain
- Long-term functional limitation in daily activities
- Fracture or cuff injury during manipulation under anaesthesia
- Recurrence in the other shoulder
Prognosis
Usually self-limiting, with recovery over months to a few years. Many regain good function, but some keep mild stiffness; outcomes tend to be worse in people with diabetes.
Test yourself
Think of the answer, then tap the question to see it.
Which shoulder movement is typically lost first and most in frozen shoulder?
External rotation, lost both actively and passively.
What feature separates frozen shoulder from a rotator cuff tear on examination?
In frozen shoulder passive movement is lost as much as active movement; in a cuff tear passive range is usually preserved.
Which systemic disease is most strongly associated with adhesive capsulitis?
Diabetes mellitus; thyroid disease is also associated.
What are the three classic phases of frozen shoulder?
Freezing (painful), frozen (stiff) and thawing (recovery).
What is the role of a plain X-ray in suspected frozen shoulder?
It is normal in frozen shoulder and is used to exclude glenohumeral arthritis, missed dislocation or tumour.
Related conditions
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Adhesive Capsulitis (Frozen Shoulder) (StatPearls (NCBI Bookshelf), 2025).
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