Ep 192 – Adhesive capsulitis

In this episode, Dr Roger Henderson looks at adhesive capsulitis, commonly known as a frozen shoulder, reviewing its epidemiology, risk factors and underlying pathophysiology, as well as typical clinical presentations, disease staging and key examination findings that aid diagnosis in primary care. Diagnostic challenges, differential diagnoses and the role of imaging and injections are covered, alongside management strategies, prognosis and indications for surgical intervention, with particular attention to patients with diabetes and endocrine disorders who experience more severe and prolonged disease.

Key take-home points

• Adhesive capsulitis ("frozen shoulder") is characterised by a global loss of both active and passive shoulder range of motion, with external rotation typically affected first and most severely.
• The condition most commonly affects adults between 40 and 60 years of age, with a slight female predominance.
• Diabetes mellitus is the strongest risk factor and is associated with more severe, prolonged and treatment-resistant disease.
• Adhesive capsulitis is classified as primary (idiopathic) or secondary, the latter often following trauma, surgery or prolonged immobilisation.
• The disease progresses through overlapping freezing, frozen and thawing phases, each with distinct clinical features.
• Early disease is dominated by inflammation and pain, while later stages are characterised by capsular fibrosis and stiffness.
• Pathologic changes predominantly involve the rotator interval, coracohumeral ligament and axillary pouch.
• Diagnosis is primarily clinical and relies on history and physical examination rather than laboratory testing or imaging.
• Imaging studies are used to exclude alternative pathology rather than to confirm adhesive capsulitis.
• Persistent restriction of motion after local anaesthetic injection helps differentiate adhesive capsulitis from other shoulder disorders.
• Physical therapy with gradual, controlled range-of-motion exercises is the cornerstone of management.
• Corticosteroid injections are most effective during the early inflammatory phase of the disease.
• Most patients experience substantial recovery, but up to 20% may have residual stiffness or pain.
• Patients with endocrine or metabolic comorbidities often have poorer outcomes and longer disease courses.
• Surgical interventions are reserved for refractory cases and require careful patient selection and postoperative rehabilitation.

Key references

1. Date A, Rahman L. Future Sci OA. 2020;6(10):FSO647. doi: 10.2144/fsoa-2020-0145.
2. Le V, et al. Shoulder Elbow. 2017;9(2):75-84. doi: 10.1177/1758573216676786.
3. Uppal HS, et al. World J Orthop. 2015;6(2):263-268. doi: 10.5312/wjo.v6.i2.263.
4. Georgiannos D, et al. Open Orthop J. 2017;11:65-76. doi: 10.2174/1874325001711010065.