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Adhesive Capsulitis (Frozen Shoulder)

Frozen-Shoulder-Photo-2Frozen shoulder syndrome, clinically known as adhesive capsulitis, is a painful and debilitating condition affecting up to 5% of the population. Adhesive capsulitis is considered to be fibrosis of the glenohumeral joint capsule with a chronic inflammatory response. Patients experience pain, limited range of motion, and disability generally lasting anywhere from 1 to 24 months (Page & Labbe, 2010).

The presentation of this disorder varies greatly depending on the stage at which the patient presents for examination however it usually affects patients over 40 years of age. There are three main stages of adhesive capsulitis:

Freezing: In the"freezing" stage, pain slowly increases. As the pain worsens, shoulder range of motion decreases. Freezing typically lasts from 6 weeks to 9 months in the absence of treatment.

Frozen: Painful symptoms generally improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult and many patients report a decrease in the ability to reach behind them.

Thawing: Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

The pathophysiology behind adhesive capsulitis was hotly debated by Neviaser (1945) who reported findings of reparative inflammatory changes within the joint capsule.  McLoughlin (1938) found no such inflammatory processes, but instead a contracted and shrunken rotator cuff tendon, which he postulated was due to collagen stiffening.  A further theory by Simmonds (1949) and McNab (1973) was that diffuse capsulitis was caused by a degenerative inflammatory process in the supraspinatus tendon.  DePalma (1983) stated that the pathologic process of adhesive capsulitis involves the fibrous capsule becoming inflexible, inelastic, shrunken and fibrosed. 

Various theories have been suggested over time, however the causes of adhesive capsulitis are still not fully understood. There is no clear connection to either arm-dominance or occupation.  Generally, adhesive capsulitis is more common in women than men.  It can affect either shoulder, although it most commonly affects the non-dominant shoulder.  A fall onto an outstretched hand up to 6 months prior to the onset of shoulder pain is thought to be a possible contributor to the onset of adhesive capsulitis.

Although the aetiology of this disorder is still unclear, a capsular pattern has consistently been found of most limited motion in external rotation, followed by glenohumeral abduction and internal rotation. 

A few of the following factors may put you more at risk for developing frozen shoulder:

  • Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.
  • Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.
  • Immobilisation. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

The aims of treatment for adhesive capsulitis are pain relief and restoration of normal shoulder movement.  It should consist of one or more of the following:

  • Education: the natural history of the condition and support with the use of analgesics
  • Manual therapy: Chiropractic, Physiotherapy or Osteopathy using gentle mobilisation techniques with active exercise and/or other modalities (Jewel et al, 2009)
  • Injection therapy: Corticosteroid injections are commonly used although hylauronic acid injections have also been shown to be effective (Harris et al, 2011)
  • Manipulation under anaesthesia

The treatment given depends on the severity and stage of the condition.  In the initial stage, the 'freezing stage', high pain levels means that manual therapy is likely to increase pain and so injection therapy is more often considered at this point.  In the 'frozen' and 'thawing' stages, lower pain levels allow a more manual approach to be taken to increase range of motion without increasing pain levels.

In conclusion, adhesive capsulitis is a challenging condition for both the physical therapist and patient. It is important for clinicians to make an accurate diagnosis and assessment in order to best choose their interventions. By understanding the published evidence related to the rehabilitation of patients with adhesive capsulitis, both therapist and patient will benefit from an integrated, multi-faceted, evidence-based approach to intervention (Page & Lebbe, 2010).

Compiled by Shelley Doole DC MChiro

DePalma, A. F. (1983) Surgery of the Shoudler. Lippincott, Philadelphia.

Harris,J. D., Griesser, M. J., Copelan, A., Jones, G. Treatment of adhesive capsulitis with intra-articular hyaluronate: A systematic review. International Journal of Shoulder Surgery. 2011 Apr-Jun; 5(2): 31–37.

Jewell, D. V., Riddle, D. L. & Thacker, L. R. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Journal of Physical Therapy. 2009;89:419-429.

McLoughlin, H. L. (1961) The Frozen Shoulder. Clinical Orthopaedics, 20, 126.

McNab, I. (1973) Rotator Cuff Tendonitis. Annals of the Royal College of Surgeons of England, 52, 271.

Neviaser, J.S. (1945) Adhesive Capsulitis of the Shoulder: Study of Pathological Findings in Peri-arthritis of the Shoulder. Journal of Bone and Joint Surgery 27, 211.

Page, P., Labbe, A. Adhesive Capsulitis: Use The Evidence to Integrate Your Interventions. North American Journal of Sports Physical Therapy. 2010;5(4);266-273

Simmonds, F. A. (1949) Shoulder Pain with Particular Reference to the Frozen Shoulder. Journal of Bone and Joint Surgery, 31B, 426.