Medscape is available in 5 Language Editions – Choose your Edition here.


Adhesive Capsulitis (Frozen Shoulder)

  • Author: Albert W Pearsall, IV, MD; Chief Editor: S Ashfaq Hasan, MD  more...
Updated: Dec 28, 2015


Adhesive capsulitis and frozen shoulder syndrome (FSS) are two terms that have been used to describe a painful and stiff shoulder. Historically, the criteria for diagnosing an individual with a frozen shoulder have varied; this has led to inclusion of conditions such as subacromial bursitiscalcifying tendinitis, and partial rotator cuff tears. However it is important to note that the current consensus definiton of a frozen shoulder by the American Shoulder and Elbow Surgeons is "a condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder."[1]

The loss of passive range of motion (ROM) is a critical element in establishing the diagnosis of a true frozen shoulder. Although conditions such as subacromial bursitis, calciifc tendinitis, and partial rotator cuff tears can be associated with significant pain and loss of active ROM, passive ROM is preserved. Therefore, patients with those conditions should not be classified as having a frozen shoulder.

Lundberg divided patients who met the pain and motion requirements of frozen shoulder into two groups: primary and secondary.[2] A patient meets the criteria of primary or secondary FSS if painful, restricted active and passive glenohumeral and scapulothoracic motion occurs for at least 1 month and has either reached a plateau or worsened. This inclusion period for defining frozen shoulder is similar to that described by Binder and colleagues[3, 4] but is shorter than that defined by Lloyd-Roberts and coworkers.[5]

Patients with primary frozen shoulder have no significant findings in the history, clinical examination, or radiographic evaluation to explain their motion loss and pain. Classically, symptoms of primary frozen shoulder have been divided into three phases: painful, stiffening, and thawing.

The initial painful phase is marked by a gradual onset of diffuse shoulder pain lasting from weeks to months. The stiffening phase is characterized by a progressive loss of ROM that may last up to 1 year. Most patients lose glenohumeral external rotation, internal rotation, and abduction during this phase. The final, thawing phase is measured in weeks to months and constitutes a period of gradual motion improvement. Once in this phase, the patient may require up to 9 months to regain a functional ROM.[6, 7, 8, 9]

In contrast to patients with primary FSS, patients with secondary FSS describe an event that preceded the onset of shoulder symptoms, such as trauma or surgery to the affected upper extremity.



Codman originally coined the term frozen shoulder to describe a condition with the following signs and symptoms[10] :

  • Slow-onset shoulder pain
  • Localized discomfort near the deltoid insertion
  • Inability to sleep on the affected side
  • Restricted glenohumeral elevation and external rotation
  • A normal radiologic appearance

The inclusion criteria for FSS include painful restriction of active and passive glenohumeral and/or periscapular motion. Despite these criteria, diagnosing FSS can be controversial because there is little consensus on specific shoulder motion restrictions or duration of symptoms needed to qualify a patient as having a frozen shoulder. Although various authors have classified patients with FSS as those with limited abduction from 45-135º, FSS is still primarily a clinical diagnosis based on clinical motion loss and symptoms.




Frozen shoulder syndrome usually affects patients aged 40-70 years. The incidence of FSS is not precisely known; however, it is estimated that 3% of people develop the disease over their lifetime. Males tend to be affected less frequently than females, and there is no predilection for race.

Adhesive capsulitis has been associated with several conditions. A higher incidence of frozen shoulder exists among patients with diabetes (10-20%) compared with the general population (2-5%). Incidence among patients with insulin-dependent diabetes is even higher (36%), with an increased frequency of bilateral shoulder involvement.[11]  In general, bilateral shoulder involvement is rarely simultaneous and instead occurs sequentially.



Duplay was one of the first physicians to present the concept of periarticular tissue pathology rather than periarticular arthritis as the cause of frozen shoulder.[12] Despite a lack of evidence linking frozen shoulder to a specific etiology, various triggers that may predispose patients to this problem appear to exist. A few reported etiologic agents include the following:

  • Trauma
  • Surgery (including but not limited to shoulder surgery)
  • Inflammatory disease
  • Diabetes
  • Regional conditions
  • Various shoulder maladies

In addition, an autoimmune theory has been postulated, with elevated levels of C-reactive protein and an increased incidence of HLA-B27 histocompatibility antigen reported in patients with frozen shoulder versus controls.[13, 14] DePalma proposed that muscular inactivity was a major etiologic factor,[15] while Bridgman identified an increased incidence of FSS in patients with diabetes mellitus.[16] Finally, frozen shoulder also has been associated with cervical spine disease, Parkinson disease,[17] hyperthyroidism,[18] and ischemic heart disease.

Most patients with FSS have a period of shoulder immobilization. Reasons for immobilization can be diverse; however, the common finding in all of these patients is a period of restricted shoulder motion. In a study of neurosurgery patients who immobilized their shoulders for varying periods, Bruckner noted an incidence of frozen shoulder that was 5-9 times greater than that found in the general population.[19]



Prior to examining the patient, a thorough clinical history should be elicited. Specifically, information should be gathered regarding the following:

  • Onset of symptoms
  • Any antecedent trauma or surgery
  • Affected side(s)
  • Duration of symptoms

The patient should also be queried about any existing medical conditions. Given the strong association of adhesive capsulitis with diabetes, it is imperative to screen any new patient presenting with possible frozen shoulder syndrome for diabetes or prediabetes. Adhesive capsulitis has also been reported in patients with hyperthyroidism, and ischemic heart disease. Questions should be directed toward any upper extremity neurologic complaints, including cervical radiculopathy. Any history of cervical pain or radiculopathy should be thoroughly evaluated during the clinical examination to exclude a diagnosis of cervical spondylosisor cervical disc disease.

Any previous treatments that the patient has received for their condition should be documented, as should the individual's current medication list.

The patient's posture should be observed while he or she is wearing a gown and sitting on a stool. The examiner should note whether the patient is listing to one side secondary to pain, or holding the neck to one side secondary to spasm or pain. Such initial observations help determine whether a cervical condition may be contributing to the patient's symptomatology.



Refractory shoulder periscapular pain and limited glenohumeral motion that persists despite a period of at least 3 months of attempted conservative treatment are indications for surgery. Conservative treatment can include the following:

  • A course of prednisone [20]
  • A course of nonsteroidal anti-inflammatory medicine when not on prednisone
  • A subacromial or glenohumeral intra-articular injection at least once but not more than twice within a 3-month period
  • Physical therapy for ROM of the shoulder [21, 22, 23]
  • A physician-directed home therapy program has been shown to have efficacy in helping restore range of motion [67]  

Relevant Anatomy

Critical to the understanding of frozen shoulder syndrome is the concept that shoulder function involves not only the glenohumeral joint but also scapulothoracic articulation. Clinicians must understand the essential role that the scapula plays in facilitating glenohumeral motion. Scapulothoracic and glenohumeral motion occur simultaneously following initial arm abduction. With arm abduction in individuals who are healthy, approximately one third of elevation is attributed to scapulothoracic motion, while two thirds of elevation is provided by glenohumeral motion.

The glenohumeral joint is enclosed by the joint capsule and is surrounded by two sleeves of muscles. The capsule normally is a loose structure with a surface area nearly twice as large as that of the humeral head. The rotator cuff tendons adjacent to the joint capsule thicken the capsule anteriorly, posteriorly, and superiorly, while the glenohumeral ligaments represent further areas of joint capsule thickening.

Histologically, the capsule consists of bundles of type I collagen. Synovial cells line the inner surface of the capsule and enclose the long head of the biceps tendon.



Contraindications to surgical intervention for recalcitrant frozen shoulder include the following:

  • Concomitant neurologic complaints or abnormalities originating from the cervical spine
  • An inadequate trial of conservative therapy (<3 mo)
  • Ongoing infection of any type [24]
  • Isolated capsular release in the face of adhesive capsulitis and concomitant glenohumeral arthritis (in this situation, capsular release or lengthening should be performed in conjunction with total shoulder arthroplasty)
  • Ongoing oncologic process involving the affected shoulder
Contributor Information and Disclosures

Albert W Pearsall, IV, MD Associate Professor, Department of Orthopedic Surgery, University of South Alabama College of Medicine; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

  1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg. 2011 Mar. 20 (2):322-5. [Medline].

  2. Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl. 1969. 119:1-59. [Medline].

  3. Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen shoulder: a long-term prospective study. Ann Rheum Dis. 1984 Jun. 43(3):361-4. [Medline]. [Full Text].

  4. Binder AI, Bulgen DY, Hazleman BL, Tudor J, Wraight P. Frozen shoulder: an arthrographic and radionuclear scan assessment. Ann Rheum Dis. 1984 Jun. 43(3):365-9. [Medline]. [Full Text].

  5. Lloyd-Roberts GC, French PR. Periarthritis of the shoulder. A study of the disease and its treatment. Br Med J. 1959. 1:1569-71.

  6. Tveita EK, Sandvik L, Ekeberg OM, Juel NG, Bautz-Holter E. Factor structure of the Shoulder Pain and Disability Index in patients with adhesive capsulitis. BMC Musculoskelet Disord. 2008 Jul 17. 9:103. [Medline]. [Full Text].

  7. Tasto JP, Elias DW. Adhesive capsulitis. Sports Med Arthrosc. 2007 Dec. 15(4):216-21. [Medline].

  8. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg. 2008 Mar-Apr. 17(2):231-6. [Medline].

  9. Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br. 2007 Jul. 89(7):928-32. [Medline].

  10. Codman EA. The shoulder. Boston, Mass: Thomas Todd; 1934.

  11. Tighe CB, Oakley WS Jr. The prevalence of a diabetic condition and adhesive capsulitis of the shoulder. South Med J. 2008 Jun. 101(6):591-5. [Medline].

  12. Duplay ES. De la periarthritis scapulohumerale et des raiderus de l'epaule qui en son la consequence. Arch Gen Med. 1872. 20:513-42.

  13. Bulgen DY, Binder A, Hazleman BL, et al. Immunological studies in frozen shoulder. J Rheumatol. 1982 Nov-Dec. 9(6):893-8. [Medline].

  14. Bulgen DY, Hazleman BL, Voak D. HLA-B27 and frozen shoulder. Lancet. 1976 May 15. 1(7968):1042-4. [Medline].

  15. DePalma AF. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952. 135:193-204.

  16. Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis. 1972 Jan. 31(1):69-71. [Medline]. [Full Text].

  17. Chang YT, Chang WN, Tsai NW, Cheng KY, Huang CC, Kung CT, et al. Clinical Features Associated with Frozen Shoulder Syndrome in Parkinson's Disease. Parkinsons Dis. 2015. 2015:232958. [Medline]. [Full Text].

  18. Wohlgethan JR. Frozen shoulder in hyperthyroidism. Arthritis Rheum. 1987 Aug. 30(8):936-9. [Medline].

  19. Bruckner FE, Nye CJ. A prospective study of adhesive capsulitis of the shoulder ("frozen shoulder'') in a high risk population. Q J Med. 1981 Spring. 50(198):191-204. [Medline].

  20. Saeidian SR, Hemmati AA, Haghighi MH. Pain relieving effect of short-course, pulse prednisolone in managing frozen shoulder. J Pain Palliat Care Pharmacother. 2007. 21(1):27-30. [Medline].

  21. Flannery O, Mullett H, Colville J. Adhesive shoulder capsulitis: does the timing of manipulation influence outcome?. Acta Orthop Belg. 2007 Feb. 73(1):21-5. [Medline].

  22. Vermeulen HM, Rozing PM, Obermann WR, et al. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther. 2006 Mar. 86(3):355-68. [Medline].

  23. Ibrahim M, Donatelli R, Hellman M, Echternach J. Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study. Physiotherapy. 2013 Oct 3. [Medline].

  24. De Ponti A, Viganò MG, Taverna E, et al. Adhesive capsulitis of the shoulder in human immunodeficiency virus-positive patients during highly active antiretroviral therapy. J Shoulder Elbow Surg. 2006 Mar-Apr. 15(2):188-90. [Medline].

  25. Sanja MR, Mirjana ZS. Ultrasonographic study of the painful shoulder in patients with rheumatoid arthritis and patients with degenerative shoulder disease. Acta Reumatol Port. 2010 Jan-Mar. 35(1):50-8. [Medline].

  26. Song KD, Kwon JW, Yoon YC, Choi SH. Indirect MR Arthrographic Findings of Adhesive Capsulitis. AJR Am J Roentgenol. 2011 Dec. 197(6):W1105-9. [Medline].

  27. Carbone S, Napoli A, Gumina S. MRI of adhesive capsulitis of the shoulder: Distension of the bursa in the superior subscapularis recess is a suggestive sign of the pathology. Eur J Radiol. 2013 Oct 29. [Medline].

  28. Neviaser AS, Hannafin JA. Adhesive Capsulitis: A Review of Current Treatment. Am J Sports Med. 2010 Jan 28. [Medline].

  29. Mitra R, Harris A, Umphrey C, Smuck M, Fredericson M. Adhesive capsulitis: a new management protocol to improve passive range of motion. PM R. 2009 Dec. 1(12):1064-8. [Medline].

  30. Blanchard V, Barr S, Cerisola FL. The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy. 2010 Jun. 96(2):95-107. [Medline].

  31. Roh YH, Yi SR, Noh JH, Lee SY, Oh JH, Gong HS, et al. Intra-articular corticosteroid injection in diabetic patients with adhesive capsulitis: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2011 Nov 24. [Medline].

  32. Bal A, Eksioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clin Rehabil. 2008 Jun. 22(6):503-12. [Medline].

  33. Tveita EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord. 2008 Apr 19. 9:53. [Medline]. [Full Text].

  34. Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev. 2006 Oct 18. CD006189. [Medline].

  35. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The resistant frozen shoulder. Manipulation versus arthroscopic release. Clin Orthop. 1995 Oct. (319):238-48. [Medline].

  36. Warner JJ, Allen A, Marks PH, et al. Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J Bone Joint Surg Am. Dec 1996. 78(12):1808-16. [Medline].

  37. Warner JJ, Allen AA, Marks PH, et al. Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am. Aug 1997. 79(8):1151-8. [Medline].

  38. Chen J, Chen S, Li Y, Hua Y, Li H. Is the extended release of the inferior glenohumeral ligament necessary for frozen shoulder?. Arthroscopy. 2010 Apr. 26(4):529-35. [Medline].

  39. Ahn K, Jhun HJ, Choi KM, Lee YS. Ultrasound-guided interventional release of rotator interval and posteroinferior capsule for adhesive capsulitis of the shoulder using a specially designed needle. Pain Physician. 2011 Nov. 14(6):531-7. [Medline].

  40. Warner JJ, Greis PE. The treatment of stiffness of the shoulder after repair of the rotator cuff. Instr Course Lect. 1998. 47:67-75. [Medline].

  41. Pearsall AW, Osbahr DC, Speer KP. An arthroscopic technique for treating patients with frozen shoulder. Arthroscopy. Feb 1999. 15(1):2-11. [Medline].

  42. Lee HJ, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil. 2009 Dec. 90(12):1997-2002. [Medline].

  43. Andren L, Lundberg BJ. Treatment of rigid shoulders by joint distention during arthrography. Acta Orthop Scand. 1965. 36:45-53.

  44. Askey JM. The syndrome of painful disability of the shoulder and hand complicating coronary occlusion. Am Heart J. 1961. 22:1-12.

  45. Baker CL, Liu SH. Comparison of open and arthroscopically assisted rotator cuff repairs. Am J Sports Med. 1995 Jan-Feb. 23(1):99-104. [Medline].

  46. Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES. Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am. 1992 Dec. 74(10):1505-15. [Medline].

  47. Bigliani LU, Ticker JB, Flatow EL, et al. The relationship of acromial architecture to rotator cuff disease. Clin Sports Med. 1991 Oct. 10(4):823-38. [Medline].

  48. Clarke GR, Willis LA, Fish WW, et al. Preliminary studies in measuring range of motion in normal and painful stiff shoulders. Rheumatol Rehabil. 1975 Feb. 14(1):39-46. [Medline].

  49. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet. 1982 May. 154(5):667-72. [Medline].

  50. DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am. 1984 Apr. 66(4):563-7. [Medline].

  51. Freedman L, Munro RR. Abduction of the arm in the scapular plane: scapular and glenohumeral movements. A roentgenographic study. J Bone Joint Surg Am. 1966 Dec. 48(8):1503-10. [Medline].

  52. Grey RG. The natural history of "idiopathic" frozen shoulder. J Bone Joint Surg Am. 1978 Jun. 60(4):564. [Medline].

  53. Groh GI, Simoni M, Rolla P. Loss of the deltoid after shoulder operations: an operative disaster. J Shoulder Elbow Surg. 1994. 3:243-53.

  54. Hawkins RJ. Impingement syndrome. Orthop Trans. 1979. 3:274.

  55. Hazleman BL. The painful stiff shoulder. Rheumatol Phys Med. 1972 Nov. 11(8):413-21. [Medline].

  56. Hollinshead WH. Anatomy for Surgeons: The Back and Limbs. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1982.

  57. Hoppenfeld S, DeBoer P. Surgical Exposures in Orthopaedic Surgery: The Anatomic Approach. Philadelphia, Pa: Lippincott-Raven; 1984.

  58. Inmann VT, Saunders JB, Abott LC. Observations on the shoulder joint. J Bone Joint Surg Am. 1959. 41:877-82.

  59. Kay NR. The clinical diagnosis and management of frozen shoulders. Practitioner. 1981 Feb. 225(1352):164-7. [Medline].

  60. Kelly BT, Kadrmas WR, Speer KP. Empty can versus full can exercise for rotator cuff rehabilitation: An EMG analysis (unpublished data).

  61. Kessel L. Clinical Disorders of the Shoulder. New York, NY: Churchill Livingstone; 1982.

  62. Levy HJ, Uribe JW, Delaney LG. Arthroscopic assisted rotator cuff repair: preliminary results. Arthroscopy. 1990. 6(1):55-60. [Medline].

  63. Ozaki J, Nakagawa Y, Sakurai G, et al. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am. 1989 Dec. 71(10):1511-5. [Medline].

  64. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975. 4(4):193-6. [Medline].

  65. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am. 1992 Jun. 74(5):738-46. [Medline].

  66. Speer KP. Anatomy and pathomechanics of shoulder instability. Operative Tech in Sports Med. 1993. 1:252-5.

  67. Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg. 2004 Sep-Oct. 13 (5):499-502. [Medline].

True anteroposterior view of the glenohumeral joint (left); axillary lateral view (middle); supraspinatus outlet view (right)
Table 1.
Corticosteroid Dosing in Patients With Refractive Frozen Shoulder Syndrome*
Week Number Medication Dose
1 (Days 1-7) Prednisone 40 mg/d
2 (Days 8-14) Prednisone 30 mg/d
3 (Days 15-18) Prednisone 20 mg/d
4 (Days 19-21) Prednisone 10 mg/d
5 (Days 22+) Discontinue ----
*Before oral corticosteroid medication is prescribed, the patient should be extensively questioned about pertinent medical problems that may be contraindications to taking the medicine.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.