Adhesive Capsulitis (Frozen Shoulder): Symptoms, Diagnosis, and Treatment

What is Adhesive Capsulitis?

Adhesive capsulitis, also known as frozen shoulder or retractile capsulitis, is a condition of unknown cause that causes progressive pain and stiffness in the shoulder, significantly limiting its function.

The first recorded description of adhesive capsulitis was published by Duplay in 1872, describing it as scapulohumeral periarthritis. However, it wasn't until 1934 that Codman used the term frozen shoulder.

How common is Adhesive Capsulitis?

Adhesive capsulitis occurs in approximately 2–5% of the population. It is more common in women and in the 40–60 age range.

What diseases or conditions predispose to Adhesive Capsulitis?

There is a certain relationship with cardiovascular disease, thyroid disease, diabetes mellitus (more severe forms with a worse prognosis), and Dupuytren's disease. Periods of shoulder immobilization due to fractures, bruises, or other causes can be the onset of the condition, so it is always recommended to mobilize the shoulder under medical supervision to avoid this situation.

It is common for the other shoulder to be affected some time after suffering from it in the first.

What is the cause of adhesive capsulitis?

It can be primary, idiopathic (i.e., without a known cause), or secondary to bruises, fractures, or even surgery.

In frozen shoulder, a chronic inflammatory process occurs that stimulates the formation of adhesions and fibrosis of the shoulder capsule, which thickens and hardens.

What are the stages of adhesive capsulitis?

Four stages have been described:

Stage 1 (pre-adhesive):

The predominant symptom is PAIN. There is inflammation, and the formation of rigid bands of tissue, adhesions, begins. The patient has full mobility, and the condition is often indistinguishable from other conditions such as tendon ruptures, bursitis, or calcific tendonitis. This stage can last up to 3 months.

Stage 2 (adhesive):

In this stage, pain remains the most prominent symptom, with the onset of progressive loss of mobility, with difficulty performing certain activities such as dressing, combing hair, fastening a bra, or reaching for a back pocket. This stage can last 3 to 6 months.

Stage 3 (frozen shoulder):

In this stage, inflammation decreases and fibrosis increases. Pain may improve, but STIFFNESS worsens, and shoulder mobility is reduced. This stage can last 3 to 6 months.

Stage 4 (thawing):

The patient gradually regains mobility, and the pain is mild. It can last a year or more.

How is adhesive capsulitis diagnosed?

The physical examination in the early stages will reveal pain upon movement with possible decreased mobility, a condition often indistinguishable from other shoulder conditions, as previously discussed.

During the freezing phase, the pain will decrease, and shoulder movement, both active (performed by the patient) and passive (performed by the physician), will be drastically reduced.

What additional tests are ordered for adhesive capsulitis?

• Plain X-rays will not be useful for diagnosing frozen shoulder, but they will rule out other shoulder conditions with similar symptoms.
• Ultrasound can rule out tendon ruptures, bursitis, joint effusions, tendon calcifications, among other problems, and is a helpful test, just as X-rays can help rule out other shoulder problems.
• Magnetic resonance imaging (MRI) and, especially, magnetic resonance arthrography (MRI with prior injection of contrast into the joint) can confirm the capsular thickening and adhesions present in frozen shoulder.

How is adhesive capsulitis treated?

As we have previously explained, frozen shoulder usually has a slow but favorable progression, so conservative treatment is initially recommended. These include:

• Anti-inflammatory treatment 

• Rehabilitation/physical therapy

• Corticosteroid injections

• Percutaneous hydrodistension

Many published articles support these treatments for frozen shoulder. Some of them compare these treatments individually or in combination, and extrapolate the results.

Below, we briefly explain these treatments:

• Anti-inflammatory treatment with NSAIDs or oral corticosteroids will help control pain in the early stages. They tend to have a short-term effect and are not without side effects, so they should be taken for short periods of time and under medical supervision. They can help us during the freezing phase to make RHB sessions more bearable.
• Rehabilitation treatment and physical therapy are the first-line and almost universal treatment. They will help us prevent the loss of shoulder mobility in the early stages and recover it during the freezing phase. The most commonly used techniques are passive mobility and capsular stretching.(See stretching and strengthening exercises for Adhesive Capsulitis) We can combine physical therapy with shock waves, electromagnetic stimulation, or acupuncture.
• Corticosteroid injections are another widely used therapy, although their effect will be short-term (around 6 weeks) and will improve pain, but not stiffness. Combined with physical therapy, we can be more aggressive with physical therapy and shorten recovery times.(See article on ultrasound-guided glenohumeral infiltration for adhesive capsulitis)
• Percutaneous hydrodistension, first described by Andren, involves the intra-articular introduction of large volumes of fluid (up to 40-50 cc) to distend the joint capsule and eliminate adhesions and neovascularization in the frozen shoulder, thereby restoring lost mobility. It can be performed under CT (both emit ionizing radiation and therefore irradiate the patient and require an operating room or radiology suite) or under ultrasound (available during the office visit and without the emission of ionizing radiation). Subject to multiple comparative studies evaluating its effectiveness with other types of treatment, it is considered useful in improving range of motion, surpassing its effectiveness in association with intra-articular corticosteroids (Gam et al., 1998; Courveil et al., 1992; Tveita et al., 2008), physical therapy (Khan et al., 2005), and even surpassing other procedures such as mobilization under general anesthesia (Quraishi et al., 2007).

20 Frequently Asked Questions About Adhesive Capsulitis (Frozen Shoulder):

 

How long does adhesive capsulitis last?

It can last between 1 and 2 years, depending on the individual case and the treatment applied.

Can adhesive capsulitis be prevented?

Yes, by avoiding prolonged shoulder immobilization after injuries or surgeries.

Can it affect both shoulders?

Yes, although not simultaneously, it is common for the other shoulder to be affected over time.

What causes adhesive capsulitis?

It can appear without a clear cause or after injuries, surgeries, or shoulder immobilization.

What is the most common treatment?

It includes physical therapy, anti-inflammatory drugs, corticosteroid injections, and, in some cases, joint hydrodistension.

What are the stages of this condition?

It has four stages: initial pain, progressive stiffness, maximum limitation, and gradual recovery.

Does the pain worsen at night?

Yes, it's common for the pain to be more intense at night and interfere with sleep.

Is surgery necessary?

In most cases, no. Surgery is only used if conservative treatments fail.

Can full mobility be restored?

Yes, with proper treatment, most patients regain normal or near-normal mobility.

What tests help diagnose it?

A physical examination, ultrasound, and MRI are useful to confirm the diagnosis.

What exercises help improve frozen shoulder?

Stretching and passive mobility exercises guided by a physical therapist are very effective.

What medications are used?

Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, both oral and injected, are used.

Who is most commonly affected?

It primarily affects women between 40 and 60 years of age and is more common in people with diabetes or thyroid problems.

Can it leave permanent aftereffects?

If not treated properly, it can leave some stiffness or loss of residual movement.

How is it different from tendonitis?

Capsulitis causes a significant loss of active and passive mobility, while tendonitis primarily limits active movement due to pain.

What symptoms does it present?

Shoulder pain, progressive stiffness, and difficulty performing everyday movements such as combing hair or dressing.

Can it be detected on an X-ray?

Not directly. X-rays help rule out other causes, but they don't show adhesive capsulitis.

Are injections effective?

Yes, especially for pain relief and facilitating physical therapy in the early stages.

What is shoulder hydrodistension?

It is a technique in which fluid is injected into the joint to break up adhesions and improve mobility.

Is physical therapy sufficient?

In many cases yes, especially if started in the early stages and combined with other therapies as needed.

Make an appointment with Dr. Jordi Jiménez. He will see you in the center of Palma and help you regain your quality of life.