Are frozen shoulder and adhesive capsulitis the same thing?

Yes. They are two names for the same condition. "Frozen shoulder" is the everyday term that describes how the shoulder feels: painful and stiff, as if frozen. "Adhesive capsulitis" is the medical term that describes what is happening to the tissue. The joint capsule becomes inflamed, then thickens and contracts, sticking down (the "adhesive" part) and restricting movement. The diagnosis, the natural course, and the treatment options are the same regardless of which name is used.

Will frozen shoulder go away on its own?

Most cases will fully resolve in twelve to eighteen months, even without treatment, slowly progressing through the freezing, frozen, and thawing phases. Particularly severe cases (especially in diabetic patients) can take up to two years. If the shoulder has been stiff for more than two years, other diagnoses or causes of stiffness should be considered.

What is the best treatment for frozen shoulder?

Treatment depends on the stage. During the painful freezing stage, the focus is pain management, with one or two cortisone injections usually required. Physiotherapy and stretching exercises should be stopped. Hydrodilatation can be considered, although it is often no more effective than an ordinary cortisone injection. During the frozen stage, treatment is minimal. Any pain is best managed by activity modification to avoid repetitive use of the arm beyond its limited range of motion. Most patients tolerate their symptoms well if they do not overuse the shoulder. During this period the shoulder is monitored for signs of improvement in range of motion, which signals the start of the thawing phase (usually nine to twelve months post onset). Physiotherapy and stretching exercises are commenced when range of motion starts to improve of its own accord. Manipulation under anaesthetic and arthroscopic capsular release are reserved for cases that fail to improve in the expected time frame.

How is frozen shoulder different from a rotator cuff tear?

Both cause pain, but the key difference is movement. Frozen shoulder restricts passive movement (the examiner cannot move the arm even with the patient relaxed), while a cuff tear preserves passive movement. The hallmark examination finding for frozen shoulder is loss of passive external rotation.

Why do I get frozen shoulder if I have diabetes?

Diabetes is a recognised risk factor for frozen shoulder, and diabetic patients often have a more severe and prolonged course. The exact mechanism is not fully understood but involves connective tissue changes related to long-term blood-glucose control. Other risk factors include thyroid disorders, recent shoulder injury or surgery, and previous frozen shoulder on the other side.

Is surgery necessary for frozen shoulder?

For most patients, no. The vast majority of frozen shoulder cases settle with non-operative treatment over twelve to eighteen months. Surgery (manipulation under anaesthetic or arthroscopic capsular release) is reserved for the most resistant cases that persist longer than expected, particularly in patients whose function is significantly limited.

Condition

Frozen shoulder

Frozen shoulder and adhesive capsulitis are two names for the same condition: the shoulder joint capsule becomes inflamed and contracted. It is one of the most common causes of shoulder pain. Although frozen shoulder is a lay term that is commonly used to describe any stiff shoulder, it is actually a specific condition that follows a very predictable course, and is self-limited. The shoulder becomes painful and progressively stiff, usually over a three to six month time frame. It then remains stiff for a few months, and then starts to improve. Typically range of motion starts to improve around nine to twelve months post onset. Most patients fully recover around twelve to eighteen months post onset. Most cases do not require surgery.

Anatomy

The shoulder joint capsule

The shoulder joint is surrounded by a sleeve of connective tissue called the joint capsule. The capsule is normally lax and stretchy, which is part of why the shoulder has so much range of motion.

In frozen shoulder, the capsule becomes inflamed, then thickens and contracts. The result is a tight, shrunken sleeve around the joint that physically prevents the shoulder from moving through its normal range. The medical term adhesive capsulitis describes this directly: the capsule becomes adhesive and sticks down on itself.

Pathology

The phases of frozen shoulder

Frozen shoulder usually progresses through three overlapping phases. The phases vary in length between patients, but the total course may take around twelve to eighteen months from start to finish for most patients.

Freezing phase. Increasing pain and a gradual loss of motion. Often lasts three to six months. Pain at night is common.
Frozen phase. The pain improves, but the shoulder remains very stiff.
Thawing phase. Range of motion gradually returns around nine to twelve months post onset. Most patients regain their full range of motion, but a small number have a permanent loss of end-range movement. If residual stiffness is functionally limiting, a surgical release can be considered.

Causes

Why frozen shoulder happens

The exact cause of frozen shoulder is unknown. Frozen shoulder can be primary (idiopathic), where there is no obvious trigger, or secondary, where it follows an injury, surgery, or another medical condition.

Risk factors include:

Age between 40 and 60 years. The peak age range for frozen shoulder.
Female sex. More common in women than men.
Diabetes. Diabetic patients are at significantly higher risk and often have a more severe and prolonged course.
Thyroid disorders. Both hyper and hypothyroidism are associated with frozen shoulder.
Recent shoulder injury or surgery. Frozen shoulder is a well-documented complication of shoulder injuries and surgery.
Previous frozen shoulder. Patients who have had frozen shoulder on one side have a higher risk of developing it on the other.

Symptoms

How frozen shoulder feels

The hallmarks of frozen shoulder are pain and progressive stiffness. Pain is often deep and poorly localised, sometimes referred to the upper arm. Pain at night is very common and is one of the most disruptive symptoms in the freezing phase.

Stiffness affects movement in all directions. Patients often describe difficulty reaching behind their back to do up a bra or put a wallet in a back pocket, difficulty reaching overhead, and difficulty sleeping on the affected side.

The combination of pain and stiffness is what distinguishes frozen shoulder from rotator cuff problems, which tend to cause pain or weakness without significant passive stiffness.

Diagnosis

How frozen shoulder is diagnosed

Frozen shoulder is largely a clinical diagnosis based on history and examination. The key examination finding is a loss of passive external rotation of the shoulder, meaning the examiner cannot rotate the arm to its normal range even with the patient relaxed. That distinguishes frozen shoulder from a rotator cuff problem, where passive movement is preserved. The main differential diagnosis is shoulder arthritis. It is the other common cause of a stiff shoulder and should be strongly suspected if someone has had a stiff shoulder for more than a couple of years. A plain x-ray is essential when investigating someone with a frozen shoulder, as it is the quickest way to exclude arthritis as the cause of the stiffness.

Imaging is used to rule out other causes of shoulder pain and stiffness rather than to confirm frozen shoulder itself.

X-ray. An essential investigation, expected to be normal in frozen shoulder. Used to exclude arthritis or other bone causes of stiffness.
MRI scan. Sometimes used to exclude rotator cuff or labral pathology when the clinical picture is mixed. Frozen shoulder may show capsular thickening on MRI but the test is not required for diagnosis.

Blood tests may be considered to screen for diabetes or thyroid disorders if not already known.

Ultrasound scans are not useful in the diagnosis of frozen shoulder.

Treatment

Treatment options for frozen shoulder

Most cases of frozen shoulder are managed with non-operative treatment. Recovery is predictable but slow. The aim of treatment is to control pain during the freezing phase and to maintain or restore movement during and after the frozen phase.

Physiotherapy and home exercises. Although it is commonly tried, physiotherapy or exercises to stretch the shoulder will not improve range of motion during the freezing or frozen stages. In fact, stretching exercises can make symptoms worse. Physiotherapy and home-based exercises are commenced when the frozen shoulder enters the thawing stage, usually around nine to twelve months post onset.
Anti-inflammatory medication and analgesia. For pain control during the freezing phase. Particularly useful at night.
Corticosteroid injection. An intra-articular steroid injection can reduce pain during the freezing phase. A cortisone injection typically provides four to five weeks of pain relief, but the injection itself does not affect the overall time course. Most patients require one or two injections given six weeks apart to get them through the painful freezing phase. By the time the effects of the second injection are wearing off, the frozen shoulder has moved into the frozen stage and the pain is more manageable.
Hydrodilatation. An injection of saline along with steroid into the joint to physically distend the capsule. Performed under image guidance, similar to a cortisone injection.
Manipulation under anaesthetic. The shoulder is moved through its full range under general anaesthetic to break up the capsular contracture. Reserved for cases that have not responded to non-operative measures.
Arthroscopic capsular release. Keyhole surgery to formally release the contracted capsule. Reserved for the most resistant cases that have persisted longer than expected. The procedure is followed by intensive physiotherapy to maintain the gains. Note that any surgery performed during the freezing phase can make symptoms worse, so consideration of surgery should be delayed until after the pain has started to settle.

Recovery

Recovery from frozen shoulder

Frozen shoulder is an unusually slow condition to recover from compared to other shoulder problems. Even with optimal treatment, full recovery often takes more than a year. Diabetic patients in particular may have a more prolonged course.

After a manipulation under anaesthetic or capsular release, physiotherapy starts within the first day or two. Maintaining the gained range of motion in the early weeks is critical, because contracture can recur if the shoulder is allowed to stiffen again.

Most patients regain function comparable to the other shoulder, although some people have a small permanent loss of end-range of motion, particularly external rotation.

Complications and risks

Risks of treatment

Non-operative treatment of frozen shoulder is generally low-risk. Specific risks of injections, manipulation, and surgical release include:

Injection-related risks. Pain at the injection site, transient elevation of blood sugar in diabetic patients, and very rare infection. A small number of people have a "flare" reaction to an intra-articular cortisone injection, which can make the pain worse for 24–48 hours after the injection. The pain then settles and the injection can still be effective in reducing pain for the next four to five weeks.
Recurrence of stiffness. Particularly in diabetic patients. Some patients need further treatment.
Fracture during manipulation. Rare but recognised. The risk is higher in patients with osteoporosis.
Surgical risks. Infection, persistent pain, recurrence of contracture, complex regional pain syndrome (CRPS), and anaesthetic complications.

FAQ

Frequently asked questions

Are frozen shoulder and adhesive capsulitis the same thing?: Yes. They are two names for the same condition. "Frozen shoulder" is the everyday term that describes how the shoulder feels: painful and stiff, as if frozen. "Adhesive capsulitis" is the medical term that describes what is happening to the tissue. The joint capsule becomes inflamed, then thickens and contracts, sticking down (the "adhesive" part) and restricting movement. The diagnosis, the natural course, and the treatment options are the same regardless of which name is used.
Will frozen shoulder go away on its own?: Most cases will fully resolve in twelve to eighteen months, even without treatment, slowly progressing through the freezing, frozen, and thawing phases. Particularly severe cases (especially in diabetic patients) can take up to two years. If the shoulder has been stiff for more than two years, other diagnoses or causes of stiffness should be considered.
What is the best treatment for frozen shoulder?: Treatment depends on the stage. During the painful freezing stage, the focus is pain management, with one or two cortisone injections usually required. Physiotherapy and stretching exercises should be stopped. Hydrodilatation can be considered, although it is often no more effective than an ordinary cortisone injection. During the frozen stage, treatment is minimal. Any pain is best managed by activity modification to avoid repetitive use of the arm beyond its limited range of motion. Most patients tolerate their symptoms well if they do not overuse the shoulder. During this period the shoulder is monitored for signs of improvement in range of motion, which signals the start of the thawing phase (usually nine to twelve months post onset). Physiotherapy and stretching exercises are commenced when range of motion starts to improve of its own accord. Manipulation under anaesthetic and arthroscopic capsular release are reserved for cases that fail to improve in the expected time frame.
How is frozen shoulder different from a rotator cuff tear?: Both cause pain, but the key difference is movement. Frozen shoulder restricts passive movement (the examiner cannot move the arm even with the patient relaxed), while a cuff tear preserves passive movement. The hallmark examination finding for frozen shoulder is loss of passive external rotation.
Why do I get frozen shoulder if I have diabetes?: Diabetes is a recognised risk factor for frozen shoulder, and diabetic patients often have a more severe and prolonged course. The exact mechanism is not fully understood but involves connective tissue changes related to long-term blood-glucose control. Other risk factors include thyroid disorders, recent shoulder injury or surgery, and previous frozen shoulder on the other side.
Is surgery necessary for frozen shoulder?: For most patients, no. The vast majority of frozen shoulder cases settle with non-operative treatment over twelve to eighteen months. Surgery (manipulation under anaesthetic or arthroscopic capsular release) is reserved for the most resistant cases that persist longer than expected, particularly in patients whose function is significantly limited.

References

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