{{short description|Painful disease restricting movement}} {{Use dmy dates|date=December 2020}} {{Infobox medical condition | name = Adhesive capsulitis of the shoulder | synonyms = Frozen shoulder | image = Gray327.png | caption = The right shoulder and glenohumeral joint. | pronounce = | field = Orthopedics | symptoms = Shoulder pain, stiffness<ref name=Ram2019/> | complications = | onset = 40 to 60 year old<ref name=Ram2019/> | duration = May last years<ref name=Ram2019/> | types = Primary, secondary<ref name=Stat2019/> | causes = Often unknown, prior shoulder injury<ref name=Ram2019/><ref name=Stat2019/> | risks = Diabetes, hypothyroidism<ref name=Ram2019/> | diagnosis = | differential = Pinched nerve, autoimmune disease, biceps tendinopathy, osteoarthritis, rotator cuff tear, cancer, bursitis<ref name=Ram2019/> | prevention = | treatment = physical therapy, NSAIDs, oral steroids, steroid injection, nerve block, high pressure saline injection, plasma injection, extracorporeal shockwave therapy, manipulation under anesthesia, surgery<ref name=Ram2019/> | medication = | prognosis = | frequency = 2 to 5%<ref name=Ram2019/> | deaths = }} <!-- Definition and symptoms -->
'''Adhesive capsulitis''', also known as '''frozen shoulder''', is a condition associated with shoulder pain and stiffness.<ref name="Ram2019">{{cite journal | vauthors = Ramirez J | title = Adhesive Capsulitis: Diagnosis and Management | journal = American Family Physician | volume = 99 | issue = 5 | pages = 297–300 | date = March 2019 | pmid = 30811157 | url = https://www.aafp.org/link_out?pmid=30811157 }}</ref> Onset is gradual over weeks to months.<ref name="Stat2019">{{cite book |last1=St Angelo |first1=John M. |title=StatPearls |last2=Taqi |first2=Muhammad |last3=Fabiano |first3=Sarah E. |date=2023 |publisher=StatPearls Publishing |chapter=Adhesive Capsulitis |pmid=30422550 |id={{NCBIBook|NBK532955}}}}</ref> A common shoulder ailment, adhesive capsulitis is marked by pain at rest but especially upon movement, as well as a decrease in range of motion (particularly in external rotation).<ref name="Chiang_2106">{{cite journal | vauthors = Chiang J, Dugan J | title = Adhesive capsulitis | journal = JAAPA | volume = 29 | issue = 6 | pages = 58–59 | date = June 2016 | pmid = 27228046 | doi = 10.1097/01.jaa.0000482308.78810.c1 }}</ref> The shoulder itself, however, often does not hurt significantly when touched.<ref name="Ram2019" />
<!-- Cause and diagnosis --> The exact cause in most cases is unknown.<ref name="Ram2019" /> The condition can also occur after injury or surgery to the shoulder.<ref name="Stat2019" /> The underlying mechanism involves inflammation and scarring within the shoulder joint itself.<ref name="Stat2019" /><ref name="Red2019">{{cite journal |vauthors=Redler LH, Dennis ER |date=June 2019 |title=Treatment of Adhesive Capsulitis of the Shoulder |journal=The Journal of the American Academy of Orthopaedic Surgeons |volume=27 |issue=12 |pages=e544–e554 |doi=10.5435/JAAOS-D-17-00606 |pmid=30632986}}</ref>
Diagnosis is generally based on a person's symptoms and a physical exam.<ref name="Ram2019" /> A key feature that can distinguish adhesive capsulitis from similar conditions is the inability of others to move the shoulder, in addition to the loss of voluntary movement (a loss of both active and passive ranges of motion). This is in contrast to most muscle, tendon, and nerve disorders, where only the active range of motion is limited.<ref name="Ram2019" /><ref name="Stat2019" /> The diagnosis may be supported by an MRI or ultrasound.<ref name="Ram2019" /> <!-- Treatment and epidemiology -->
The condition can sometimes resolve itself over time without intervention, but this may take several years, and results are better when it is treated.<ref name=Ram2019/> There are a number of non-procedural treatments, including nonsteroidal anti-inflammatory drugs, physical therapy, and oral or injected steroids.<ref name=Ram2019/> Surgery is an option for those who do not improve after other treatments.<ref name="Ram2019" /> Additional methods of treatment include nerve block, high pressure saline injection, plasma injection, and extracorporeal shockwave therapy.<ref name=":5" />
Frozen shoulder is most common in people 40–60 years of age.<ref name="Ram2019" /> It is also significantly more common in women.<ref name=":2">{{Cite journal |last1=Sheridan |first1=Monique A. |last2=Hannafin |first2=Jo A. |date=October 2006 |title=Upper extremity: emphasis on frozen shoulder |journal=The Orthopedic Clinics of North America |volume=37 |issue=4 |pages=531–539 |doi=10.1016/j.ocl.2006.09.009 |issn=0030-5898 |pmid=17141009}}</ref> Major risk factors include diabetes and thyroid disease.<ref name="Ram2019" /><ref>{{cite journal |last1=Dyer |first1=Brett Paul |last2=Rathod-Mistry |first2=Trishna |last3=Burton |first3=Claire |last4=van der Windt |first4=Danielle |last5=Bucknall |first5=Milica |date=January 2023 |title=Diabetes as a risk factor for the onset of frozen shoulder: a systematic review and meta-analysis |journal=BMJ Open |volume=13 |issue=1 |doi=10.1136/bmjopen-2022-062377 |doi-access=free|pmc=9815013 |pmid=36599641 |article-number=e062377}}</ref><ref name=":0">{{cite journal |last1=Chuang |first1=Shu-Han |last2=Chen |first2=Yu-Pin |last3=Huang |first3=Shu-Wei |last4=Kuo |first4=Yi-Jie |date=June 2023 |title=Association between adhesive capsulitis and thyroid disease: a meta-analysis |journal=Journal of Shoulder and Elbow Surgery |volume=32 |issue=6 |pages=1314–1322 |doi=10.1016/j.jse.2023.01.033 |pmid=36871608}}</ref> Approximately 2-5% of people have adhesive capsulitis at any given time.<ref name="Ram2019" />
== Signs and symptoms == Adhesive capsulitis presents with progressively worsening shoulder pain and limited range of motion. Pain due to frozen shoulder is usually dull or aching, and may be worse at night or when lying on the affected shoulder.<ref name=":4">{{Cite journal |last1=Walmsley |first1=Sarah |last2=Rivett |first2=Darren A. |last3=Osmotherly |first3=Peter G. |date=September 2009 |title=Adhesive capsulitis: establishing consensus on clinical identifiers for stage 1 using the DELPHI technique |journal=Physical Therapy |volume=89 |issue=9 |pages=906–917 |doi=10.2522/ptj.20080341 |issn=1538-6724 |pmid=19589853}}</ref> Any movement, especially rapid or unguarded movement, can aggravate the pain.<ref name=":4" /><ref>{{Cite web |title=What Is a Frozen Shoulder? |url=https://www.webmd.com/a-to-z-guides/what-is-a-frozen-shoulder |access-date=2022-01-19 |website=WebMD |language=en}}</ref>
Physical exam findings include restricted range of motion in all planes of movement (but especially in external rotation), and defecits in both active and passive range of motion.<ref>{{cite journal |vauthors=Jayson MI |date=October 1981 |title=Frozen shoulder: adhesive capsulitis |journal=British Medical Journal |volume=283 |issue=6298 |pages=1005–6 |doi=10.1136/bmj.283.6298.1005 |jstor=29503905 |pmc=1495653 |pmid=6794738}}</ref> This contrasts with conditions such as shoulder impingement syndrome, or rotator cuff tendinitis, in which the active range of motion is restricted but passive range of motion is normal. Some exam maneuvers of the shoulder may be impossible due to pain.<ref>{{Cite web |last=Chris |date=2023-10-12 |title=Frozen Shoulder: Causes, Symptoms and Treatment |url=https://urbantherapy.org/frozen-shoulder-causes-symptoms-and-treatment/ |access-date=2024-09-02 |website=Urban Therapy |language=en-US}}</ref>
The symptoms of primary frozen shoulder have been classically described as having three stages.<ref name="titleYour Orthopaedic Connection: Frozen Shoulder">{{cite web |url=http://orthoinfo.aaos.org/topic.cfm?topic=A00071 |title=Your Orthopaedic Connection: Frozen Shoulder |access-date=28 January 2008}}</ref><ref name="Comparison of Treatments for Frozen">{{cite journal |vauthors=Challoumas D, Biddle M, McLean M, Millar NL |date=December 2020 |title=Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis |journal=JAMA Network Open |volume=3 |issue=12 |pages=e2029581 |doi=10.1001/jamanetworkopen.2020.29581 |pmc=7745103 |pmid=33326025}}</ref> * '''Stage one''': The "freezing" or painful stage, which may last from two to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.<ref name=":5" /> * '''Stage two''': The "frozen" or adhesive stage is marked by a slow improvement in pain while stiffness remains. This stage generally lasts from four to twelve months.<ref name="Comparison of Treatments for Frozen" /> * '''Stage three''': The "thawing" or recovery stage, when shoulder motion slowly returns toward normal. This stage is characterized by minimal pain and generally lasts from 5 to 24 months.<ref name="Comparison of Treatments for Frozen" /><ref name=":5" /> Sometimes a fourth, prodromal stage is described occurring before the primary stages, as many as three months prior to the shoulder freezing. It is also known as the "prefreezing" stage.<ref name=":5" /> During this stage, people describe sharp pain at the end of their range of motion, achy pain at rest, and sleep disturbances.<ref name="Kelley_2013">{{cite journal |display-authors=6 |vauthors=Kelley MJ, Shaffer MA, Kuhn JE, Michener LA, Seitz AL, Uhl TL, Godges JJ, McClure PW |date=May 2013 |title=Shoulder pain and mobility deficits: adhesive capsulitis |journal=The Journal of Orthopaedic and Sports Physical Therapy |volume=43 |issue=5 |pages=A1-31 |doi=10.2519/jospt.2013.0302 |pmid=23636125 |doi-access=}}</ref>
== Causes ==
The exact causes of adhesive capsulitis are incompletely understood. However, the condition can sometimes occur after a known trigger, and there are several factors associated with higher risk. Adhesive capsulitis is classified depending on whether the trigger is unknown (primary) or known (secondary).<ref name=":5" />
=== Primary ===
Primary adhesive capsulitis, also known as idiopathic adhesive capsulitis, occurs with no known trigger. It is more likely to develop in the non-dominant arm.<ref name="Stat2019" /> This form of the condition is thought to occur when an unknown cause leads to an inflammatory reaction in the shoulder capsule. It is frequently associated with conditions that have a widespread inflammatory or autoimmune component, including diabetes and thyroid disorders.<ref name="Le_2017">{{cite journal |vauthors=Le HV, Lee SJ, Nazarian A, Rodriguez EK |date=April 2017 |title=Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments |journal=Shoulder & Elbow |volume=9 |issue=2 |pages=75–84 |doi=10.1177/1758573216676786 |pmc=5384535 |pmid=28405218}}</ref> In fact, diabetic adhesive capsulitis is increasingly recognized as clinically distinct from other forms of adhesive capsulitis (based on differences in clinical outcomes, pathophysiology and gene expression). A new classification system has been proposed that separates diabetic adhesive capsulitis from other forms of the condition.<ref name=":8">{{Cite journal |last1=Tang |first1=Shuquan |last2=Tan |first2=Xiaoya |date=2024-11-15 |title=Does the intervention for adhesive capsulitis in patients with diabetes differ from that for patients without diabetes?: A systematic review |journal=Medicine |volume=103 |issue=46 |article-number=e40238 |doi=10.1097/MD.0000000000040238 |issn=1536-5964 |pmc=11575982 |pmid=39560544}}</ref><ref>{{Cite journal |last1=Gordon |first1=Joshua A. |last2=Farooqi |first2=Ali S. |last3=Rabut |first3=Emilie |last4=Huffman |first4=G. Russell |last5=Schug |first5=Jonathan |last6=Kelly |first6=John D. |last7=Dodge |first7=George R. |date=January 2022 |title=Evaluating whole-genome expression differences in idiopathic and diabetic adhesive capsulitis |journal=Journal of Shoulder and Elbow Surgery |volume=31 |issue=1 |pages=e1–e13 |doi=10.1016/j.jse.2021.06.016 |issn=1532-6500 |pmc=8665043 |pmid=34352401}}</ref>
=== Secondary ===
Adhesive capsulitis is called secondary when it develops after a known event that directly affects shoulder mobility. Such events include shoulder injury, surgery (either on the shoulder or the chest wall), and periods of prolonged shoulder immobility.<ref name="Stat2019" />
== Pathophysiology ==
Adhesive capsulitis of the shoulder involves an inflammatory process within the joint, leading to the formation of scar tissue (adhesions) and shrinking (contracture) of the space inside the shoulder joint capsule.<ref name="Le_2017" /> Pain-causing inflammatory cytokines are present in the joint fluid during the initial, painful stage (stage I).<ref name="Le_2017" /> This inflammation is followed by an increase in fibroblasts, cells that deposit collagen fibers. This ultimately results in the formation of bulky, excessive collagen bands and a thickened joint capsule, limiting motion.<ref name=":1" /> Beyond this, the pathophysiology is poorly understood, including what causes the initial shoulder inflammation in many cases.<ref>{{Cite journal |last1=Cho |first1=Chul-Hyun |last2=Song |first2=Kwang-Soon |last3=Kim |first3=Beom-Soo |last4=Kim |first4=Du Hwan |last5=Lho |first5=Yun-Mee |date=2018 |title=Biological Aspect of Pathophysiology for Frozen Shoulder |journal=BioMed Research International |volume=2018 |article-number=7274517 |doi=10.1155/2018/7274517 |doi-access=free |issn=2314-6141 |pmc=5994312 |pmid=29992159}}</ref> Systemic inflammation appears to play a significant role in the development of adhesive capsulitis, and many diseases with an inflammatory component are associated with increased risk.<ref>{{Cite journal |last=Pietrzak |first=Max |date=March 2016 |title=Adhesive capsulitis: An age related symptom of metabolic syndrome and chronic low-grade inflammation? |journal=Medical Hypotheses |volume=88 |pages=12–17 |doi=10.1016/j.mehy.2016.01.002 |issn=1532-2777 |pmid=26880627}}</ref>
The first and most severely restricted motion is usually external rotation, primarily due to the thickening of the coracohumeral ligament which forms the roof of the rotator cuff.<ref>{{Cite news |title=Adhesive Capsulitis of the Shoulder: JAAOS - Journal of the American Academy of Orthopaedic Surgeons |url=https://journals.lww.com/jaaos/abstract/2011/09000/adhesive_capsulitis_of_the_shoulder.4.aspx |archive-url=http://web.archive.org/web/20250716054620/https://journals.lww.com/jaaos/abstract/2011/09000/adhesive_capsulitis_of_the_shoulder.4.aspx |archive-date=2025-07-16 |access-date=2025-12-16 |work=LWW |language=en-US}}</ref><ref name=":3">{{Cite journal |last1=Wu |first1=Pin-Yi |last2=Hsu |first2=Po-Cheng |last3=Chen |first3=Tzu-Ning |last4=Huang |first4=Jian-Ru |last5=Chou |first5=Chen-Liang |last6=Wang |first6=Jia-Chi |date=May 2021 |title=Evaluating Correlations of Coracohumeral Ligament Thickness with Restricted Shoulder Range of Motion and Clinical Duration of Adhesive Capsulitis with Ultrasound Measurements |journal=PM&R: The Journal of Injury, Function, and Rehabilitation |volume=13 |issue=5 |pages=461–469 |doi=10.1002/pmrj.12432 |issn=1934-1563 |pmid=32500656}}</ref> In addition, the thickened coracohumeral ligament contributes to limitations in internal rotation, as a result of its connection to other rotator cuff tendons.<ref name=":3" /> As adhesive capsulitis progresses, the shoulder capsule as a whole becomes thickened and stiff, shrinking the space inside the joint.<ref>{{Cite journal |last1=Lee |first1=Sang Yoon |last2=Lee |first2=Kyu Jin |last3=Kim |first3=Won |last4=Chung |first4=Sun G. |date=December 2015 |title=Relationships Between Capsular Stiffness and Clinical Features in Adhesive Capsulitis of the Shoulder |journal=PM&R: The Journal of Injury, Function, and Rehabilitation |volume=7 |issue=12 |pages=1226–1234 |doi=10.1016/j.pmrj.2015.05.012 |issn=1934-1563 |pmid=26003871}}</ref> This increased stiffness and decreased joint volume is associated with difficulty moving the arm forward and out to the side.<ref>{{Cite journal |last1=Lee |first1=Jung-Sang |last2=Do |first2=Jong Geol |last3=Yoon |first3=Kyung Jae |last4=Chae |first4=Seoung Wan |last5=Park |first5=Hee-Jin |last6=Park |first6=Chul-Hyun |last7=Lee |first7=Yong-Taek |date=2020-04-16 |title=Voxel-based Three-dimensional Segmentation of the Capsulo-synovium from Contrast-enhanced MRI Can Represent Clinical Impairments in Adhesive Capsulitis |journal=Scientific Reports |volume=10 |issue=1 |page=6516 |doi=10.1038/s41598-020-63406-9 |issn=2045-2322 |pmc=7162880 |pmid=32300141 |bibcode=2020NatSR..10.6516L }}</ref>
== Diagnosis == Adhesive capsulitis is traditionally diagnosed by history and physical exam. It is often a diagnosis of exclusion, meaning it is only diagnosed after other causes of shoulder pain and stiffness have been ruled out. On physical exam, adhesive capsulitis can be diagnosed if limits of the active range of motion are the same or similar to the limits to the passive range of motion - that is, motion stops at roughly same point whether the patient moves the arm independently or the examiner moves it passively.<ref name=":5">{{Cite journal |last1=Drakes |first1=Shane |last2=Aboulhosn |first2=Petra |last3=Pham |first3=Yolanda |last4=Iuso |first4=Anthony |last5=Morgan |first5=Keri |date=2025-11-12 |title=Adhesive Capsulitis: Review of Current Concepts |journal=Current Physical Medicine and Rehabilitation Reports |language=en |volume=13 |issue=1 |page=42 |doi=10.1007/s40141-025-00516-3 |issn=2167-4833|doi-access=free }}</ref> While the range of motion in external rotation is often the most severely limited, passive range of motion in abduction is particularly useful diagnostically: restriction below 80° is a strong indicator, and restriction below 40° is nearly 100% predictive of adhesive capsulitis.<ref>{{Cite journal |last1=James-Belin |first1=Etienne |last2=Lasbleiz |first2=Sandra |last3=Haddad |first3=Albert |last4=Morchoisne |first4=Odile |last5=Ostertag |first5=Agnès |last6=Yelnik |first6=Alain |last7=Laredo |first7=Jean-Denis |last8=Bardin |first8=Thomas |last9=Orcel |first9=Philippe |last10=Richette |first10=Pascal |last11=Beaudreuil |first11=Johann |date=August 2020 |title=Shoulder adhesive capsulitis: diagnostic value of active and passive range of motion with volume of gleno-humeral capsule as a reference |journal=European Journal of Physical and Rehabilitation Medicine |volume=56 |issue=4 |pages=438–443 |doi=10.23736/S1973-9087.19.05890-8 |issn=1973-9095 |pmid=31742369}}</ref>
=== Imaging === Imaging studies are not required for diagnosis, but may be used to rule out other causes of pain and are often able to confirm the presence of adhesive capsulitis.<ref name="Ram2019" /> Radiographs will often be normal, but imaging features of adhesive capsulitis can be seen on ultrasound or MRI. When performed, ultrasound and MRI may reveal thickening of the coracohumeral ligament, and a width of greater than 3 mm is considered diagnostic for adhesive capsulitis.<ref name=":5" />
Shoulders with adhesive capsulitis also characteristically fibrose and thicken at the axillary pouch and "rotator interval," seen on MRI as a dark signal on T1 sequences with edema and inflammation on T2 sequences.<ref>{{cite journal | vauthors = Shaikh A, Sundaram M | title = Adhesive capsulitis demonstrated on magnetic resonance imaging | journal = Orthopedics | volume = 32 | issue = 1 | pages = 2–62 | date = January 2009 | pmid = 19226048 | doi = 10.3928/01477447-20090101-20 }}</ref> Grey-scale ultrasound is increasingly used in diagnosis of adhesive capsulitis, as it is cost-effective and available even to patients who cannot undergo an MRI.<ref name=":5" /> Inferior capsule/ axillary recess capsule, rotator interval abnormality, and restriction in range of motion in the shoulder can be detected using ultrasound.<ref>{{cite journal | vauthors = Tedla JS, Sangadala DR | title = Proprioceptive neuromuscular facilitation techniques in adhesive capsulitis: a systematic review and meta-analysis | journal = Journal of Musculoskeletal & Neuronal Interactions | volume = 19 | issue = 4 | pages = 482–491 | date = December 2019 | pmid = 31789299 | pmc = 6944810 }}</ref>
== Management == Non-surgical management is the initial treatment of choice for frozen shoulder.<ref name="Millar2022">{{cite journal |last1=Millar |first1=Neal L. |last2=Meakins |first2=Adam |last3=Struyf |first3=Filip |last4=Willmore |first4=Elaine |last5=Campbell |first5=Abigail L. |last6=Kirwan |first6=Paul D. |last7=Akbar |first7=Moeed |last8=Moore |first8=Laura |last9=Ronquillo |first9=Jonathan C. |last10=Murrell |first10=George A. C. |last11=Rodeo |first11=Scott A. |title=Frozen shoulder |journal=Nature Reviews Disease Primers |date=8 September 2022 |volume=8 |issue=1 |page=59 |doi=10.1038/s41572-022-00386-2 |pmid=36075904 }}</ref> Common treatments include exercise, physical therapy, oral anti-inflammatory medication, and corticosteroid injections into the joint. The effects of most treatments are primarily short-term, focusing on alleviating symptoms such as shoulder pain and reduced joint movement. Corticosteroid injections appear to provide the greatest short-term improvements in pain and range of motion, while long-term outcomes tend to be similar for most non-operative treatments.<ref name=":7">{{Cite journal |last1=Forsythe |first1=Brian |last2=Lavoie-Gagne |first2=Ophelie |last3=Patel |first3=Bhavik H. |last4=Lu |first4=Yining |last5=Ritz |first5=Ethan |last6=Chahla |first6=Jorge |last7=Okoroha |first7=Kelechi R. |last8=Allen |first8=Answorth A. |last9=Nwachukwu |first9=Benedict U. |date=2021-07-01 |title=Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials |url=https://www.sciencedirect.com/science/article/pii/S0749806320308045 |journal=Arthroscopy: The Journal of Arthroscopic & Related Surgery |volume=37 |issue=7 |pages=2281–2297 |doi=10.1016/j.arthro.2020.09.041 |pmid=33221429 |issn=0749-8063|url-access=subscription }}</ref> Non-surgical treatment may continue for months, with more complex treatments such as extracorporeal shock wave therapy, movement under anaesthesia, and hydrodilatation. Each of these treatments have been deemed effective but have had different benefits and drawbacks, meaning that clinicians and patients often decide together on the most appropriate treatment.<ref>{{Cite web |last=Beeston |first=Amelia |date=2021-05-18 |title=Frozen shoulder treatments pros and cons |url=https://evidence.nihr.ac.uk/alert/three-treatments-frozen-shoulder-effective-but-different-costs-benefits/ |access-date=2024-05-31 |website=NIHR Evidence |language=en-GB}}</ref><ref name=":6">{{Cite journal |last1=Rangan |first1=Amar |last2=Brealey |first2=Stephen D |last3=Keding |first3=Ada |last4=Corbacho |first4=Belen |last5=Northgraves |first5=Matthew |last6=Kottam |first6=Lucksy |last7=Goodchild |first7=Lorna |last8=Srikesavan |first8=Cynthia |last9=Rex |first9=Saleema |last10=Charalambous |first10=Charalambos P |last11=Hanchard |first11=Nigel |last12=Armstrong |first12=Alison |last13=Brooksbank |first13=Andrew |last14=Carr |first14=Andrew |last15=Cooper |first15=Cushla |date=October 2020 |title=Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial |journal=The Lancet |volume=396 |issue=10256 |pages=977–989 |doi=10.1016/s0140-6736(20)31965-6 |hdl=10871/123376 |hdl-access=free}}</ref>
Gentle movement-based approaches may be used to help maintain mobility and manage discomfort during recovery, such as Tai Chi and the Feldenkrais Method.<ref>{{cite web |title=Frozen shoulder: causes, symptoms, and movement approaches |url=https://feldy.me/feldypedia/pain-and-discomfort/frozen-shoulder |website=Feldypedia |access-date=12 March 2026}}</ref>
Most people (around 90%) can see their symptoms resolve with nonsurgical management alone.<ref>{{Cite journal |last1=Levine |first1=William N. |last2=Kashyap |first2=Christine P. |last3=Bak |first3=Sean F. |last4=Ahmad |first4=Christopher S. |last5=Blaine |first5=Theodore A. |last6=Bigliani |first6=Louis U. |date=2007 |title=Nonoperative management of idiopathic adhesive capsulitis |journal=Journal of Shoulder and Elbow Surgery |volume=16 |issue=5 |pages=569–573 |doi=10.1016/j.jse.2006.12.007 |issn=1532-6500 |pmid=17531513}}</ref> If conservative measures have no effect and the condition is long-lasting, or if evidence suggests surgical intervention, there are several operative procedures that can be used.<ref name="Millar2022" />
=== Non-operative management ===
==== Medication ==== Medications such as nonsteroidal anti-inflammatory drugs (NSAIDS) can be used for pain control, but evidence for their benefit is limited.<ref name="Ram2019" /> Oral steroids may provide short-term benefits in range of movement and pain, but are not used routinely to treat adhesive capsulitis because of a high risk of side effects.<ref name="Ram2019" /> Corticosteroids may also be used by local injection. In the short and medium term, corticosteroid injections appear most effective in pain alleviation and increase in range of motion, and benefits can last as long as six months.<ref name="Comparison of Treatments for Frozen" /> These injections have the most benefit when combined with structured physical therapy, but home exercise also increases their effectiveness.<ref name="Comparison of Treatments for Frozen" />
==== Exercise and physical therapy ==== Shoulder stretching and strengthening exercises can improve shoulder function and decrease pain across all stages of adhesive capsulitis.<ref name=":5" /> Performing supervised exercise is more effective than exercise at home, but home exercise programs are still beneficial especially when combined with other treatments.<ref name="Millar2022" /><ref name="Comparison of Treatments for Frozen" />
Various physical therapy techniques are helpful in treating adhesive capsulitis, but have different demonstrated rates of success. Posterior glenohumeral mobilization has shown a large effect; mirror therapy, rotator cuff strengthening, spray & stretch, and end range mobilization have demonstrated moderate results; continuous passive motion, scapular recognition, scapulothoracic exercises, yijin jing, and lower trapezius strengthening show only a small effect. Electromagnetic therapy, Kaltenborn mobilization, and instrument assisted soft tissue mobilization are not proven to be beneficial.<ref name="Mertens">{{cite journal |last1=Mertens |first1=Michel G. |last2=Meert |first2=Lotte |last3=Struyf |first3=Filip |last4=Schwank |first4=Ariane |last5=Meeus |first5=Mira |title=Exercise Therapy Is Effective for Improvement in Range of Motion, Function, and Pain in Patients With Frozen Shoulder: A Systematic Review and Meta-analysis |journal=Archives of Physical Medicine and Rehabilitation |date=May 2022 |volume=103 |issue=5 |pages=998–1012.e14 |doi=10.1016/j.apmr.2021.07.806|pmid=34425089 |hdl=10067/1802000151162165141 |hdl-access=free }}</ref> This systematic review and meta-analysis found that combining acupuncture with physical therapy may reduce pain and improve shoulder range of motion more than physical therapy alone in patients with frozen shoulders. <ref>{{Cite journal |last=Xu |first=Bo |last2=Zhang |first2=Lei |last3=Zhao |first3=Xudong |last4=Feng |first4=Shouhan |last5=Li |first5=Jinxia |last6=Xu |first6=Ye |date=2024-12-01 |title=Efficacy of Combining Acupuncture and Physical Therapy for the Management of Patients With Frozen Shoulder: A Systematic Review and Meta-Analysis |url=https://www.painmanagementnursing.org/article/S1524-9042(24)00194-2/abstract |journal=Pain Management Nursing |language=English |volume=25 |issue=6 |pages=596–605 |doi=10.1016/j.pmn.2024.06.009 |issn=1524-9042 |pmid=38991907}}</ref>
Exercise and manual techniques are kept limited when pain is high, and gradually increased as pain subsides.<ref>{{Cite journal |last1=Kelley |first1=Martin J. |last2=McClure |first2=Philip W. |last3=Leggin |first3=Brian G. |date=February 2009 |title=Frozen shoulder: evidence and a proposed model guiding rehabilitation |journal=The Journal of Orthopaedic and Sports Physical Therapy |volume=39 |issue=2 |pages=135–148 |doi=10.2519/jospt.2009.2916 |issn=0190-6011 |pmid=19194024}}</ref> Especially in the painful (freezing) stage of adhesive capsulitis, it is recommended that stretching exercises not exceed the threshold of pain and be kept short (1–5 seconds).<ref>{{Cite web |title=Physical therapy in the management of frozen shoulder |url=http://www.smj.org.sg/article/physical-therapy-management-frozen-shoulder |access-date=2025-12-16 |website=www.smj.org.sg |language=en}}</ref>
==== Other non-operative interventions ==== Nerve block at the suprascapular nerve (SSNB) is a minimally invasive procedure that can provide significant pain relief and functional improvement by directly blocking the main nerve for sensation to the shoulder (suprascapular nerve). There is some evidence that SSNB is superior to corticosteroid injections and physical therapy.<ref name=":5" />
Hydrodilatation or distension arthrography can be effective for pain and function, but wide differences in protocol make the extent of benefit unclear.<ref name=":5" /><ref>{{cite journal |last1=Lädermann |first1=Alexandre |last2=Piotton |first2=Sébastien |last3=Abrassart |first3=Sophie |last4=Mazzolari |first4=Adrien |last5=Ibrahim |first5=Mohamed |last6=Stirling |first6=Patrick |date=August 2021 |title=Hydrodilatation with corticosteroids is the most effective conservative management for frozen shoulder |journal=Knee Surgery, Sports Traumatology, Arthroscopy |volume=29 |issue=8 |pages=2553–2563 |doi=10.1007/s00167-020-06390-x |pmid=33420809}}</ref> Hydrodilatation has also been combined with SSNB, but seems to provide no additional benefit.<ref name=":5" />
Injections of platelet-rich plasma (PRP) have grown popular as an adjunct treatment. These injections have proven benefits for pain, function and range of motion, especially in the early stages (first 12 to 24 weeks).<ref name=":5" />
Extracorporeal shock wave therapy can provide pain relief, and is also capable of improving function.<ref name=":5" /> Ultrasound deep heat therapy (UST) can decrease pain outcomes in adhesive capsulitis when combined with exercise or physical therapy. However, UST has not been shown to improve range of motion or function.<ref name=":5" /> When combined with stretching exercises, laser therapy can have similar effects: improving pain, but not helping with function.<ref name=":5" />
=== Operative management === If conservative and interventional measures are unsuccessful, operative measures can be trialed. These options are typically considered after 9–12 months of nonsurgical management have failed.<ref name=":1" /> Two of the most common procedures are arthroscopic capsular release (ACR) surgery and manipulation under anaesthesia (MUA).
==== Surgery ==== Surgery to cut the adhesions (capsular release) may be indicated in prolonged and severe cases; the procedure is performed by arthroscopy. This type of surgery is minimally invasive, consisting of a small camera and small incisions. This technique allows the surgeon to find and correct the underlying cause of restricted shoulder movement (such as contracture of coracohumeral ligament and rotator interval). The surgeon will then make an incision to open the contracted shoulder capsule. This is followed by manipulating the shoulder manually with the arm, breaking up additional adhesions and confirming release of the capsule.<ref name=":6" />
Arthroscopic capsular release surgery provides better range of motion outcomes than other interventions.<ref name=":7" /> The procedure has long-lasting effects with little risk of complications. Motion typically returns to that of the unaffected shoulder, though functional outcomes are slightly better for primary adhesive capsulitis compared to secondary.<ref>{{Cite journal |last1=Le Lievre |first1=Hugh M. J. |last2=Murrell |first2=George A. C. |date=2012-07-03 |title=Long-term outcomes after arthroscopic capsular release for idiopathic adhesive capsulitis |journal=The Journal of Bone and Joint Surgery. American Volume |volume=94 |issue=13 |pages=1208–1216 |doi=10.2106/JBJS.J.00952 |issn=1535-1386 |pmid=22760389}}</ref><ref>{{Cite journal |last1=Galasso |first1=Olimpio |last2=Mercurio |first2=Michele |last3=Luciano |first3=Francesco |last4=Mancuso |first4=Claudia |last5=Gasparini |first5=Giorgio |last6=De Benedetto |first6=Massimo |last7=Orlando |first7=Nicola |last8=Castricini |first8=Roberto |date=November 2023 |title=Arthroscopic capsular release for frozen shoulder: when etiology matters |journal=Knee Surgery, Sports Traumatology, Arthroscopy|volume=31 |issue=11 |pages=5248–5254 |doi=10.1007/s00167-023-07561-2 |issn=1433-7347 |pmc=10598184 |pmid=37702747}}</ref>
Surgical evaluation of other potential problems with the shoulder, e.g., subacromial bursitis or rotator cuff tear, may be needed. Rotator cuff tears that exist alongside adhesive capsulitis can be addressed during the same surgery.<ref>{{Cite journal |last1=Zhang |first1=Kailai |last2=de Sa |first2=Darren |last3=Kanakamedala |first3=Ajay |last4=Sheean |first4=Andrew J. |last5=Vyas |first5=Dharmesh |date=March 2019 |title=Management of Concomitant Preoperative Rotator Cuff Pathology and Adhesive Capsulitis: A Systematic Review of Indications, Treatment Approaches, and Outcomes |journal=Arthroscopy: The Journal of Arthroscopic & Related Surgery|volume=35 |issue=3 |pages=979–993 |doi=10.1016/j.arthro.2018.10.126 |issn=1526-3231 |pmid=30733032}}</ref>
==== Manipulation under anesthesia ==== Performed in isolation or during capsular release surgery, manipulation under anaesthesia is a procedure that aims to directly break up adhesions in the shoulder by manually moving the arm. General anesthesia is given to prevent pain and resistance during the procedure. While manipulation under anaesthesia without capsular release surgery appears similarly effective and can be more cost-efficient, the procedure carries additional risk of fracture, dislocation, tendon rupture, and nerve injury.<ref name="Stat2019" /><ref name=":1">{{Cite journal |last1=Mullen |first1=Joseph P. |last2=Hauer |first2=Tyler M. |last3=Lau |first3=Emily N. |last4=Lin |first4=Albert |date=July 2025 |title=Adhesive Capsulitis of the Shoulder |journal=Arthroscopy: The Journal of Arthroscopic & Related Surgery|volume=41 |issue=7 |pages=2176–2178 |doi=10.1016/j.arthro.2025.03.027 |issn=1526-3231 |pmid=40545326}}</ref>
==== Post-operative management ==== After surgery, it is recommended that rehabilitative physical therapy begin within 24–72 hours and continue 2-3 times per week for at least 6 weeks.<ref name=":6" /> Pain is expected during these exercises and multimodal pain control is used, but persistient pain is a reason for reassessment.<ref name=ew>{{Cite journal |last1=Willmore |first1=Elaine |last2=McRobert |first2=Cliona |last3=Foy |first3=Chris |last4=Stratton |first4=Irene |last5=van der Windt |first5=Danielle |date=April 2021 |title=What is the optimum rehabilitation for patients who have undergone release procedures for frozen shoulder? A UK survey |journal=Musculoskeletal Science & Practice |volume=52 |article-number=102319 |doi=10.1016/j.msksp.2021.102319 |issn=2468-7812 |pmid=33588155}}</ref> Physical therapy is utilized to regain range of motion and prevent stiffness. Range of motion exercises, such as passive and active assisted exercises, are used first to provide mobility to the joints while preventing further stress/damage to the healing tissues. Stretching exercises are usually added later, followed by strengthening exercises.<ref name=ew/> During the strengthening phase, muscles are put under stress to build support for the shoulder. Once the strengthening phase is complete, the individual gets reintroduced gradually to activities of daily living and prior training goals.<ref>{{Cite journal |last1=Gaunt |first1=Bryce W. |last2=Shaffer |first2=Michael A. |last3=Sauers |first3=Eric L. |last4=Michener |first4=Lori A. |last5=McCluskey |first5=George M. |last6=Thigpen |first6=Chuck A. |date=March 2010 |title=The American Society of Shoulder and Elbow Therapists' Consensus Rehabilitation Guideline for Arthroscopic Anterior Capsulolabral Repair of the Shoulder |url=https://www.jospt.org/doi/10.2519/jospt.2010.3186 |journal=Journal of Orthopaedic & Sports Physical Therapy |volume=40 |issue=3 |pages=155–168 |doi=10.2519/jospt.2010.3186 |pmid=20195022 |issn=0190-6011|url-access=subscription }}</ref>
== Prognosis ==
Adhesive capsulitis is generally self-limiting, and has favorable long-term outcomes. Many people experience a painful "freezing" phase (2–9 months), stiff "frozen" phase (4–12 months) and "thawing" recovery phase (5–24 months), after which symptoms resolve.<ref name="Comparison of Treatments for Frozen" /> However, recovery can be slow and incomplete, with around 40% of people reporting symptoms even 4 years after onset.<ref name=":6" /> In the past, adhesive capsulitis was believed to resolve on its own within 1–2 years even without treatment, but this idea has been challenged by more recent evidence. Those who do not receive any treatment can experience protracted or incomplete resolution of their symptoms, while a significant majority will see their symptoms resolve with nonoperative management.<ref name="Ram2019" />
People who have diabetes (a significant risk factor for developing adhesive capsulitis) often experience worse outcomes, including relatively lower restored range of motion and pain reduction.<ref name=":8" /><ref>{{Cite journal |last1=Rill |first1=Brian K. |last2=Fleckenstein |first2=Cassie M. |last3=Levy |first3=Martin S. |last4=Nagesh |first4=Vinutha |last5=Hasan |first5=Samer S. |date=March 2011 |title=Predictors of outcome after nonoperative and operative treatment of adhesive capsulitis |journal=The American Journal of Sports Medicine |volume=39 |issue=3 |pages=567–574 |doi=10.1177/0363546510385403 |issn=1552-3365 |pmid=21160014}}</ref>
== Epidemiology == Adhesive capsulitis affects between 2-5% of the general population, and every year there are approximately 2.4 new cases per 1,000 people.<ref name=":1" /><ref name=":6" /> The condition often develops in the sixth decade of life, and the average age at which symptoms begin is 56 years old.<ref name=":9">{{Cite journal |last1=Kingston |first1=Kiera |last2=Curry |first2=Emily J. |last3=Galvin |first3=Joseph W. |last4=Li |first4=Xinning |date=August 2018 |title=Shoulder adhesive capsulitis: epidemiology and predictors of surgery |journal=Journal of Shoulder and Elbow Surgery |volume=27 |issue=8 |pages=1437–1443 |doi=10.1016/j.jse.2018.04.004 |issn=1532-6500 |pmid=29807717}}</ref>
Women are affected disproportionately - approximately 60-70% of people who experience adhesive capsulitis are female.<ref name=":2" /> Adhesive capsulitis is a known complication after breast surgery, and is 2-3 times more common in people with thyroid disorders (both of which are experienced more by women).<ref>{{cite journal |vauthors=Yang A, Sokolof J, Gulati A |date=September 2018 |title=The effect of preoperative exercise on upper extremity recovery following breast cancer surgery: a systematic review |journal=International Journal of Rehabilitation Research |volume=41 |issue=3 |pages=189–196 |doi=10.1097/MRR.0000000000000288 |pmid=29683834}}</ref><ref name=":0" />
Rates are approximately 3 times higher in people with diabetes.<ref>{{Cite journal |last1=Lo |first1=Sui-Foon |last2=Chu |first2=Ssu-Wei |last3=Muo |first3=Chih-Hsin |last4=Meng |first4=Nai-Hsin |last5=Chou |first5=Li-Wei |last6=Huang |first6=Wei-Cheng |last7=Huang |first7=Chung-Ming |last8=Sung |first8=Fung-Chang |date=January 2014 |title=Diabetes mellitus and accompanying hyperlipidemia are independent risk factors for adhesive capsulitis: a nationwide population-based cohort study (version 2) |journal=Rheumatology International |volume=34 |issue=1 |pages=67–74 |doi=10.1007/s00296-013-2847-4 |issn=1437-160X |pmid=23949624}}</ref> Both type 1 diabetes and type 2 diabetes are risk factors for the condition.<ref name="Le_2017" /> Other risk factors for developing adhesive capsulitis include the aforementioned thyroid disorders, prior shoulder surgery, hyperlipidemia (high cholesterol), cardiovascular disease, Parkinson's disease, obesity, osteoarthritis (especially of the shoulder), and evidence of systemic inflammation (elevated hs-CRP).<ref name=":6" /><ref>{{Cite journal |last1=Sarasua |first1=Sara M. |last2=Floyd |first2=Sarah |last3=Bridges |first3=William C. |last4=Pill |first4=Stephan G. |date=2021-09-27 |title=The epidemiology and etiology of adhesive capsulitis in the U.S. Medicare population |journal=BMC Musculoskeletal Disorders |volume=22 |issue=1 |page=828 |doi=10.1186/s12891-021-04704-9 |doi-access=free |issn=1471-2474 |pmc=8474744 |pmid=34579697}}</ref><ref name=":9" /><ref name=":10">{{Cite journal |last1=Jacob |first1=Louis |last2=Gyasi |first2=Razak M. |last3=Koyanagi |first3=Ai |last4=Haro |first4=Josep Maria |last5=Smith |first5=Lee |last6=Kostev |first6=Karel |date=2023-01-14 |title=Prevalence of and Risk Factors for Adhesive Capsulitis of the Shoulder in Older Adults from Germany |journal=Journal of Clinical Medicine |volume=12 |issue=2 |page=669 |doi=10.3390/jcm12020669 |issn=2077-0383 |pmc=9866675 |pmid=36675599 |doi-access=free}}</ref><ref>{{Cite journal |last1=Park |first1=Hyung Bin |last2=Gwark |first2=Ji-Yong |last3=Jung |first3=Jaehoon |last4=Jeong |first4=Soon-Taek |date=2020-05-06 |title=Association Between High-Sensitivity C-Reactive Protein and Idiopathic Adhesive Capsulitis |journal=The Journal of Bone and Joint Surgery. American Volume |volume=102 |issue=9 |pages=761–768 |doi=10.2106/JBJS.19.00759 |issn=1535-1386 |pmid=32379116}}</ref>
== See also == * Shoulder impingement syndrome * Calcific tendinitis * Milwaukee shoulder syndrome * Shoulder injury related to vaccine administration
== References == {{Reflist}}
== External links == {{Medical resources | DiseasesDB = 34114 | ICD10 = {{ICD10|M|75|0|m|70}} | ICD9 = {{ICD9|726.0}} | ICDO = | OMIM = | MedlinePlus = 000455 | eMedicineSubj = orthoped | eMedicineTopic = 372 | MeshID = }} {{Soft tissue disorders}}
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{{DEFAULTSORT:Adhesive Capsulitis Of Shoulder}} Category:Disorders of fascia Category:Soft tissue disorders Category:Orthopedic surgical procedures Category:Shoulder Category:Wikipedia medicine articles ready to translate