Adhesive capsulitis of the shoulder

Last revised by Joachim Feger on 7 Feb 2024

Adhesive capsulitis of the shoulder, also known as frozen shoulder, is a condition characterized by thickening and contraction of the shoulder joint capsule and surrounding synovium. Adhesive capsulitis can rarely affect other sites such as the ankle 8.

The incidence in the general population is thought to be 3-5%. Adhesive capsulitis typically affects women in their 5th to 6th decades, although patients with co-morbidities such as diabetes mellitus may develop the condition at earlier ages. The incidence in patients with diabetes is reported to be 2 to 4 times higher than in the general population.

The characteristic symptom is shoulder pain and associated with it a painfully limited range of motion. The pain also occurs at night, which negatively affects sleep quality 22.

Adhesive capsulitis presentation can be broken into three distinct stages:

  • freezing: painful stage 

    • patients may not present during this stage because they think that eventually, the pain will resolve if self-treated

    • as the symptoms progress, pain worsens and both active and passive range of motion (ROM) becomes more restricted

    • this can eventually result in the patient seeking medical consultation

    • typically lasts between 3 and 9 months and is characterized by acute synovitis of the glenohumeral joint

  • frozen: transitional stage

    • most patients will progress to the second stage

    • during this stage, shoulder pain does not necessarily worsen

    • because of pain at the end of the range of motion, arm movement may be limited, causing muscular disuse

    • can last between 4 to 12 months

    • the common capsular pattern of limitation has historically been described as diminishing motions with external shoulder rotation being the most limited, followed closely by shoulder flexion, and internal rotation

    • a point is eventually reached in the frozen stage where pain does not occur at the end of the range of motion

  • thawing stage

    • begins when the range of motion starts to improve

    • lasts anywhere from 12 to 42 months and is defined by a gradual return of shoulder mobility

Adhesive capsulitis is divided into two main types: 

  • primary or idiopathic

    • absence of preceding trauma

  • secondary 

    • major or minor repetitive trauma

    • shoulder or thoracic surgery

    • endocrine, e.g. diabetes, hyperthyroidism 12

    • rheumatological conditions

Described features of fluoroscopic arthrography include:

  • limited injectable fluid capacity of the glenohumeral joint 

  • small dependent axillary fold

  • small subscapularis bursa

  • irregularity of the anterior capsular insertion at the anatomic neck of the humerus

  • lymphatic filling may be present

  • limitation of movement of the supraspinatus is considered a sensitive feature 7

  • limited external rotation, identified when positioning for subscapularis tendon assessment

  • thickened coracohumeral ligament (CHL) can be suggestive 9

  • thickening of the inferior glenohumeral capsule 16

  • hypoechoic soft tissue around the long head of biceps at rotator interval 13,20

  • increased vascularity of the long head of the biceps at rotator interval 13,20

The signs of adhesive capsulitis are variable with some but rarely all of the following expected to be present:

  • T2 hyperintensity of the inferior glenohumeral ligament on T2 fat-saturated sequences 17,19

  • coracohumeral ligament thickening >4-7 mm 4,19

  • subcoracoid triangle sign 4

  • joint capsule thickening 2

    • anterior capsule thickness >3.5 mm and abnormal hyperintensity 14

    • axillary pouch thickening >3-4 mm has been specicic for adhesive capsulitis in some studies 1,2,5 but not in others 3,4,17-19

  • abnormal soft tissue thickening within the rotator interval with signal alteration 18

  • abnormal soft tissue encasing the biceps anchor 18

  • variable capsular and synovial enhancement within the axillary recess and rotator interval 18

  • distention of the subscapular recess is very suggestive 21

Chronic frozen shoulder may show low T2 signal and pericapsular scarring 15

Adhesive capsulitis is typically a self-limiting disease that improves over 1-2 years. Treatment options include:

  • physiotherapy

  • corticosteroid injections

  • glenohumeral hydrodilatation

  • closed manipulation under anesthesia

  • arthroscopic capsular release with lysis of adhesions

ADVERTISEMENT: Supporters see fewer/no ads

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.