Frozen Shoulder (Adhesive Capsulitis)

What is it?

The shoulder joint has a very ample range of motion. This is largely due to the fact that the humeral head (ball) is much larger than the glenoid (socket), both enclosed by a very thin layer of tissue known as the capsule. The normal shoulder capsule is very stretchy, and somewhat oversized, to allow all this motion.

In some individuals, the capsule of the shoulder joint gets thicker and loses its elasticity, leading to painful stiffness. The inside lining of the shoulder joint becomes red and inflamed. When someone gets a pink eye, it is pretty evident, since the normal eyeball is white. Well, the normal lining of the shoulder is also white, but in patients with adhesive capsulitis it looks like a pink eye or worse.

Arthroscopy in a patient with frozen shoulder
Arthoscopy in a patient with frozen shoulder


Most individuals suffering from this condition go through three phases. Initially, there is just deep pain, but the is shoulder is still able to move. Later on, the pain slowly subsides a little as the shoulder joint loses its range of motion. Eventually, both the stiffness and pain in the shoulder resolves, but the shoulder does not always restore to its normal function.

Why does it happen?

We actually do not know. It is clear that patients with uncontrolled high blood sugar (diabetes mellitus) are much more prone to this condition: approximately 10% of patients with type I and 20% of the patients with type II diabetes develop capsulitis, which translates to 2-4 times the risk of the general population. Some studies suggest that individuals who have had cardiac surgery, suffered a heart attack or stroke, or have thyroid abnormalities are at a higher risk for adhesive capsulitis. Somehow, these conditions elicit an inflammatory and fibrotic response that leads to pain and stiffness. However, in many patients, risk factors for this condition cannot be identified. Adhesive capsulitis seems to be particularly common in women in their 40’s and 50’s.

How to diagnose it?

The hallmark of adhesive capsulitis is a spontaneous onset of pain and stiffness over a course of a few days to a few weeks for no particular reason. Most patients struggle because the pain is substantial and interferes with their ability to sleep. Patients lose their range of motion in every single direction: they cannot raise their hand, reach behind their backs, or reach out to grab something.

When the patient goes to the doctor, radiographs are frequently obtained and found to be normal, but this gives physicians the ability to identify more serious causes for shoulder stiffness. If the clinical diagnosis is clear, and the radiographs are normal, additional testing becomes unnecessary, other than looking for occult diabetes in certain individuals.

Does it get better?

Yes, in most cases, but not very quickly. A number of studies have been published on the natural history of adhesive capsulitis. Some seem to indicate that most patients get better over time. Other studies have reported persistent symptoms in at least half the patients at five years. But everyone agrees on one thing: recovery is slow. The minimum amount of time to get better seems to be around 5 months, but many patients may need up to 2 years, and 10-15% of the patients never get back to normal.

How to treat adhesive capsulitis?

The initial treatment strategy for patients with adhesive capsulitis involves (1) use of over-the-counter anti-inflammatories, (2) physical therapy to slowly stretch the joint, and (3) adequate control of sugar levels in patients with diabetes. Commonly, in the early stages of the disease pain is so bad that therapy cannot be performed. Injecting steroids inside the shoulder joint seems to abolish inflammation to some extent and serves as a jump-start for physical therapy. Stretching exercises in all directions are the mainstay of physical therapy for this condition.


If it does not get better…

Unfortunately, a substantial number of patients do not get better despite injections and physical therapy. Being patient and waiting for the course of this condition to pass is always an option; not pleasant, but always an option. However, in patients with severe pain and stiffness who are clearly not responding to treatment, surgery can be considered.

The procedure we recommend for patients with unresolved adhesive capsulitis is known as arthroscopic contracture release. A puncture wound is used to introduce an arthroscopic camera inside the shoulder joint. Additional puncture holes are used to insert instruments that melt away or remove scar tissue. Most studies seem to indicate that pain resolves very quickly after this procedure, but continued physical therapy is needed to maintain the motion regained in surgery.

Final words of wisdom:

Classic teaching in shoulder surgery is that adhesive capsulitis almost always resolves and surgery should seldom be offered. However, times have changed. In our times, waiting and waiting for the pain to go away and motion to return is simply not an option. It is important to know that if a patient with capsulitis tries really hard with injections and therapy, and improvement is simply not happening, there is a very reasonable surgical solution with few complications and a great outcome in most patients.

Arthroscopic contracture release video: The following video shows how an arthroscopic contracture release is performed. You may not want to watch it if you do not like watching surgery!