TECHNIQUE
Adhesive Capsulitis
Theresa A. Chiaia, PT, DPT* and Jo A. Hannafin, MD, PhDw
Abstract: Adhesive capsulitis is a subset of frozen shoulder. Primary
adhesive capsulitis is a distinct pathologic entity whose etiology is yet
to be determined. Understanding of this condition has evolved over the
centuries. Four stages of adhesive capsulitis have been established by
Neviaser and Neviaser. A correlation between these findings, clinical
examination, and histologic appearance was later described by Han-
nafin. Diagnosis is made by physical examination and subjective his-
tory. The stages of adhesive capsulitis represent a continuum. Clinical
decision making can be optimized by recognizing the stage of pre-
sentation, as well as the irritability of the shoulder. The goals of
treatment are to address the symptoms and impairments that the patient
presents with, and to optimize function in the presenting stage.
Key Words: adhesive capsulitis, primary, frozen shoulder, physical
therapy
(Tech Should Surg 2014;15: 2–7)
OVERVIEW
Frozen shoulder is characterized by pain with limited
active and passive range of motion (ROM) of the shoulder. The
terms frozen shoulder and adhesive capsulitis are often used
interchangeably which is a misnomer. Many conditions can
cause the shoulder to become stiff and painful, or frozen,
including pathology such as glenohumeral arthritis, acromio-
clavicular arthritis, rotator cuff injury, calcific tendonitis, and
biceps tendonitis.1 Adhesive capsulitis is a subset of frozen
shoulder.
Primary adhesive capsulitis is an idiopathic condition of
unknown etiology. There is a significant correlation between
adhesive capsulitis and diabetes mellitus.2–4 Sixty percent of
patient with primary adhesive capsulitis have a history of
Dupuytren contracture.5 Thyroid dysfunction was prevalent in
patients with adhesive capsulitis compared with an age-
matched population.6 Fasting serum triglyceride and choles-
terol levels were significantly elevated in patients with
adhesive capsulitis compared with age-matched and sex-
matched controls.7 Twenty percent to 30% recall a minor
trauma to the shoulder.8
Adhesive capsulitis occurs in 2% to 5% of the population
with an age range of 35 to 70 years with the tightest dis-
tribution centering around 55 years.9 It is more common in
females and in the nondominant extremity. Of significance,
20% to 30% of individuals with adhesive capsulitis will
develop it in the opposite shoulder; however, it rarely recurs in
the same shoulder.10
Primary adhesive capsulitis is a distinct pathologic entity,
which is important to recognize and acknowledge so that
From the *Department of Rehabilitation, Sports Rehabilitation and Per-
formance Center, Hospital for Special Surgery; and wDepartment of
Orthopaedic Surgery, Weill Cornell Medical College of Cornell University,
Hospital for Special Surgery, New York, NY.
The authors declare no conflict of interest.
Reprints: Theresa A. Chiaia, PT, DPT, Department of Rehabilitation,
Sports Rehabilitation and Performance Center, Hospital for Special
Surgery, 535 East 70th Street, New York, NY 10021 (e-mail:
chiaiat@hss.edu).
Copyright r 2014 by Lippincott Williams & Wilkins
2 | www.shoulderelbowsurgery.com Techniques in Shoulder & Elbow Surgery
appropriate treatment can be administered, prognosis can be
communicated, and expectations of the patient and treating
clinician can be established. Primary adhesive capsulitis will
be the focus of this discussion.
Understanding the painful and stiff shoulder has evolved
over the centuries. Although Duplay was the first to start the
discussion in 1872, recognizing it as a pathology, Codman, in
1934, was the first to use the term frozen shoulder and listed
the diagnostic criteria as unknown etiology, global restriction
of range of movement of the shoulder, severe restriction of
external rotation, painful at the outset, and normal plain x-ray
findings. Although he described tendinitis with secondary
involvement of the subacromial bursae, Codman noted that
the term frozen shoulder applies to many conditions about the
shoulder. Nevaiser,13 in 1945, directed attention toward the
capsule, describing the pathology as thickening and con-
traction of the capsule, which becomes adherent to the humeral
head, as well as the presence of reparatory inflammatory
changes in the capsule. He suggested the term “adhesive
capsulitis” as the descriptive pathology for “frozen shoulder.”
Lundberg,14 in 1969, documented thickening of the capsule
without adhesions.
STAGES OF ADHESIVE CAPSULITIS
Neviaser and Neviaser1 established 4 stages of the
disease—the preadhesive stage, the freezing stage, the frozen
or maturation stage, and the thawing stage—during arthro-
scopic evaluation in patients with arthrographically docu-
mented adhesive capsulitis. Hannafin et al15 described a
correlation between the arthroscopic stages described by
Neviaser, clinical examination, and the progressive histologic
appearance of capsular biopsy specimens obtained from
patients with stage 1, 2, and 3 adhesive capsulitis.
In stage 1, the preadhesive stage, diffuse glenohumeral
synovitis is present on arthroscopic evaluation. Biopsy speci-
mens show rare inflammatory infiltrates, a hypervascular
synovitis, and normal underlying capsule. Proliferative syno-
vitis with adhesion formation in the dependent fold extending
to the humeral head is observed on arthroscopy, whereas
hypervascular synovitis with perivascular scar formation and
capsular fibroplasia with a hypercellular appearance is evident
on biopsy of patients in the freezing stage, that is, stage 2. The
frozen stage, stage 3, has less synovitis with maturation and
loss of axillary fold on arthroscopy. Specimens reveal a
“burned out” synovitis with a dense, hypercellular collagenous
tissue. In stage 4, capsular scar is mature and markedly
restrictive.
DIAGNOSIS
Diagnosis and staging of adhesive capsulitis is made by
history and physical examination. It is characterized by an
insidious onset of increasing pain and decreasing active and
passive shoulder motion. In the early stages, pain is a sig-
nificant feature, and the identifiers are night pain, a marked
increase in pain with sudden or unguarded movements, dis-
comfort lying on the affected side, and pain easily aggravated
by movement.16 An insidious onset of pain causes the
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Techniques in Shoulder & Elbow Surgery  Volume 15, Number 1, March 2014
individual to gradually limit use of the arm. Inflammation and
pain causes reflex inhibition of the shoulder muscles. Disuse of
the arm results in loss of shoulder mobility, whereas continued
use of the arm through pain results in compensatory move-
ments of the shoulder girdle. Subsequently, the individual
gradually begins to lose motion and finds it increasingly dif-
ficult to perform activities of daily living that require reaching
overhead, out to the side, behind the back, or across the body.
With time, there is a resolution of pain, but the stiffness
persists.
DIFFERENTIAL DIAGNOSIS
Differential diagnoses are impingement syndrome, sub-
acromial bursitis, calcific tendonitis, biceps tendonitis, rotator
cuff injury, and osteoarthritis. Patients with impingement
demonstrate an improvement with initial treatment and do not
have pain with passive external rotation. Patients with bursitis
present with similar complaints of pain, but the pattern of
ROM loss is different with loss of elevation, internal rotation,
and pain during end ROM.
DIAGNOSTIC TESTS
Imaging can be used to rule out underlying pathology.
Routine radiographic evaluation should include anteroposterior
(AP) views in internal rotation and external rotation and
axillary and outlet views to rule out other causes of a stiff,
painful shoulder such as osteoarthritis, long-standing rotator
cuff disease, and calcific tendinitis. Osteopenia may be
observed in patients with adhesive capsulitis (reference), but
otherwise the plain films are negative. Magnetic resonance
imaging (MRI) is not routinely recommended to diagnose
adhesive capsulitis; however, it may be used to rule out con-
comitant rotator cuff and/or labral pathology. If utilized, MRI
in stages 1 and 2 demonstrates increased signal in capsule and
synovium consistent with hyperemia and synovitis. MRI in
stages 3 and 4 demonstrates low signal capsule with capsular
thickening and loss of volume of the axillary pouch. Ultra-
sonography can help differentiate rotator cuff pathology from
adhesive capsulitis and identify soft tissue changes.17,18
Decrease in joint capsule volume with obliteration of the
axillary fold is observed on arthrography.19
Intra-articular injection of steroid and local analgesic can
be useful in the diagnosis and treatment of adhesive capsu-
litis.20 After injection, passive glenohumeral ROM is reeval-
uated. If the patient has significant improvement in pain and
normalization of motion, the diagnosis of stage 1 adhesive
capsulitis is confirmed. If the patient has a significant
improvement in pain without significant improvement in
ROM, then the diagnosis is stage 2 adhesive capsulitis.
PHYSICAL EXAMINATION
An upper quarter scan is performed; however, positioning
of the upper extremity during special tests causes pain, which
limits their diagnostic value. ROM testing is performed and
active and passive motions are measured and recorded in the
upright position and in the supine position, respectively. The
end feel of passive movement provides useful information for
staging. Rundquist et al21 measured active range of motion
(AROM) in patients with idiopathic frozen shoulder and the
most common patterns were loss of external rotation with the
arm at the side and greater loss of internal rotation than
external rotation with the arm abducted as close to 90 degrees
as possible.
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Adhesive Capsulitis
CLINICAL PRESENTATION
The stages of adhesive capsulitis represent a continuum
rather than distinct well-defined stages. Stage 1 is charac-
terized clinically by pain and a reluctance to move the
shoulder. Patients report a diffuse ache that settles in the del-
toid and sharp, sudden pain that resolves quickly with move-
ment. Sleep is disturbed as a result of night pain, especially
when lying on the affected side. There is tenderness to pal-
pation of the anterior and posterior capsule. ROM assessment
reveals an “empty” end feel, wherein pain stops passive
movement before resistance is felt by the clinician. Loss of
ROM is a result of pain rather than capsular contracture.
Symptoms are present for 3 months. The continuum of
symptoms progresses in stage 2. This freezing stage has
characteristics of stage 1, acute synovitis with persistent,
severe pain, and stage 3, progressive capsular contracture with
loss of motion. ROM testing reveals a capsular end feel with
pain occurring at the end of motion. Pain is reported in the
upper trapezius and periscapular musculature as a result of
compensatory movements. Symptoms are present for 6
months, from months 3 to 9 since onset. Stage 3 is charac-
terized by a stiff shoulder, which is a result of decreased
capsular volume, and resolution of long-standing pain. There is
a capsular end feel and resistance is felt before pain. Pain may
still be present at night. Symptoms have been present from
month 9 to 15.
INTERVENTION
Clinical decision making for a patient with adhesive
capsulitis can be optimized by recognizing the stage of pre-
sentation, as well as the irritability of the shoulder joint. Irri-
tability22 is determined by pain, ROM, and extent of disability
and appears to correlate with the stage of adhesive capsulitis
(Table 1).
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
Isolated treatment with oral nonsteroidal anti-inflamma-
tory drugs is yet to be proven effective.
ORAL CORTICOSTEROIDS
Treatment with oral steroids appears to provide more
rapid relief of pain compared with control subjects, which is
similar to the effects observed following intra-articular steroid
injection. This relief is not sustained. In addition, the potential
for systemic side effects and the inconvenience of daily dosing
does not make this an attractive option.
CORTICOSTEROID INJECTION
Early treatment with intra-articular corticosteroid injec-
tion may provide a chemical ablation of the synovitis, thus
decreasing pain, improving motion, limiting the development
of fibroplasia, and shortening the natural history of the dis-
ease.23 Carette et al,24 in a randomized control trial (RCT),
compared the efficacy of intra-articular injection, supervised
physical therapy (PT), the combination of PT and injection,
and placebo. Utilizing the Shoulder Pain and Disability Index,
the injection and PT group demonstrated faster results; how-
ever, injection alone yields better results than supervised PT
alone. Van der Windt et al25 compared glenohumeral intra-
articular injection to PT in a prospective RCT. At 7 weeks,
77% of the patients treated with injection versus 46% treated
with PT were considered successes based on the patient’s self-
rating. Ryans et al26 investigated the effect of steroid injections
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TABLE 1.
Stages 1 2 3 4
Duration 0-3 3-9 9-15 > 15
(mo)
Complaints Constant ache at deltoid insertion, Pain persists; severe night pain; pain Minimal pain; night pain; Shoulder
sharp pain with movement; night in upper trapezius extending to shoulder stiffness stiffness
pain neck; ROM loss
ROM A & P ROM limited by pain Loss of ROM in capsular pattern Loss of ROM in capsular Gradual ROM
pattern improvement
Signs Empty end feel; capsular pain on Pain at end ROM; hiking of shoulder Capsular end feel; resistance Capsular end
deep palpation of capsule girdle w/arm elevation before pain; hiking of the feel;
shoulder girdle w/arm resistance
elevation before pain
Diagnosis Early loss of ER ROM with intact ROM improves but is not fully No improvement in ROM with
strength; intra-articular anesthetic restored with intra-articular EUA or with local anesthetic;
injection restores ROM; EUA injection examination reveals sense of
reveals normal or minimal ROM mechanical block
loss
Diagnostic X-ray to r/o calcific tendonitis, early X-ray to r/o calcific tendonitis, early X-ray to r/o calcific tendonitis,
tests OA, long-standing RC disease; OA early OA
MRI to r/o RC injury
Arthroscopic Diffuse fibrous synovial Insertion of ‘scope reveals tight Thick capsule on insertion of Fully mature
findings inflammatory reaction; NO capsule, rubbery dense feel; Some ‘scope; loss of capsular adhesions
adhesions or capsular contracture loss of axillary fold; Christmas tree volume; remnants of fibrotic
appearance, hypervascular synovium; loss of axillary
synovitis recess
Biopsy Hypertrophic, hypervascular Hypertrophic, hypervascular Resolving synovitis; dense scar Data is not
synovitis; rare inflammatory cell synovitis; perivascular and formation in capsule available
infiltrates; normal capsule subsynovial scar; fibroplasia and
scar in the capsule
Irritability High Moderate Low
EUA indicates examination under anesthetic; MRI, magnetic resonance imaging; OA, osteoarthritis; RC, rotator cuff disease; r/o, rule out; ROM, range of motion.

(intra-articular and subacromial) and physiotherapy. At 6
weeks, the corticosteroid group/PT group demonstrated the
largest change in the Shoulder Pain and Disability Index;
however, the scores were not significantly different from the
corticosteroid injection only group. Oh et al,27 in a prospective
RCT, divided 71 patients with primary adhesive capsulitis into
glenohumeral or subacromial ultrasound-guided injection. The
GH steroid injection led to earlier pain relief. Hazelman19
reported that the success of the treatment with injection is
dependent on the duration of symptoms; therefore, it is critical
to determine the presenting stage.
PT
The goals of rehabilitation are to address the problems
and functional impairments that the patient presents with and
that are consistent with adhesive capsulitis. They include: pain,
loss of function, sleep disturbance, loss of motion due to pain,
and/or secondary capsular tightness. Maximizing function in
the presenting stage is the objective. This is achieved by
decreasing the inflammatory response and pain, increasing
ROM, and reestablishing normal shoulder kinematics. Treat-
ment includes modalities to decrease pain and inflammation,
to promote relaxation, and increase tissue extensibility; ther-
apeutic exercise and manual therapy to decrease pain, improve
tissue extensibility, ROM, and to reestablish force couples to
normalize scapulohumeral rhythm.
The goal of early treatment of stage 1 is to retard the
progression from synovitis to capsular fibroplasia. Thus,
communication with the physician is paramount for successful
management. Referral for a glenohumeral corticosteroid
injection is indicated to relieve pain, control inflammation,
improve motion, and ultimately halt progression through the
stages.
The goals of treatment for the patient presenting in stage 2
are pain control, modulation of ROM loss, and reestablishment
of force couples. The patient may still benefit from an injec-
tion, but ROM and joint mobilization is needed to increase
capsular extensibility. Recording the improvement in the ROM
is important as the patient will continue to perceive pain at the
end of the ROM and may not recognize the gains. Pain-free
AROM and strengthening are performed in the plane of the
scapula (PoS) to optimize scapulohumeral rhythm and dis-
courage deleterious compensatory movements.
In stage 3, the patient presents with a stiff, painless
shoulder; thus, the goal of rehabilitation is to progress ROM
and flexibility and to restore function. As change in capsular
extensibility takes time, the goal is to have AROM = PROM.
This allows the patient to use the arm during daily activities,
which will enhance ROM gains and maximize function.
Medical massage, active warm-up, joint mobilizations, fre-
quent ROM exercises, and active use of the arm are empha-
sized. Strengthening of the periscapular musculature in the
available ROM will normalize scapulohumeral rhythm as
PROM improves.
Patient education is the mainstay of any rehabilitation
program. In patients with adhesive capsulitis, education in the
diagnosis, the stages of the disease process, and the goals for
each stage will encourage patient compliance and minimize
patient frustration. The individual is taught management of

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Techniques in Shoulder & Elbow Surgery  Volume 15, Number 1, March 2014 Adhesive Capsulitis

signs and symptoms through positioning, during activities of

daily living, and a home exercise program. Helping the patient
find a position of comfort for the shoulder will afford the
patient rest. The patient is instructed to support the arm on a
pillow in supine, as the shoulder tends to be more comfortable
in the plane of the scapula with the elbow at the same height or
slightly higher than the shoulder (Fig. 1). The pillow should
also support the lack of internal rotation, thereby decreasing
the stress on the capsule and helping to relieve pain. Use of the
extremity is encouraged through movement in a pain-free arc.
Disuse of the arm will result in loss of shoulder mobility,
strength, and osteopenia, whereas continued use of the arm
through pain may result in impingement of the subacromial
space. Education regarding the importance of early recognition
and treatment and should symptoms appear in the contralateral
shoulder is discussed. It is the authors’ experience that early
treatment is associated with shorter duration of disability.
As therapeutic modalities are not used in isolation, rather
in combination with other treatment modalities, it is difficult to
assess their effectiveness. Therapeutic modalities28,29 are used
to reduce pain (transcutaneous electrical nerve stimulation and
cryotherapy), control inflammation (cryotherapy), and promote
relaxation (moist heat). Low power laser therapy was more
effective than placebo treatment in reducing pain and disability
scores.30 Ultrasound, phonophoresis, and iontophoresis
reduced the likelihood of improvement.31
Manual therapy is used throughout the course of this
disease and will be modified based on the stage and irritability
of the shoulder.22 Low-grade joint mobilization will be used in
stage 1 and early stage 2 to modulate pain.32 With decreased
capsular volume and a decrease in the axillary recess, joint FIGURE 2. P-A AROM IR in PoS in supine. AROM indicates active
mobilization will focus on tissue extensibility.33 Posterior range of motion; PoS, plane of the scapula.
directed mobilization has been shown to be more effective than
anterior directed mobilization in improving ER ROM.34 An active, pain-free warm-up utilizing upper body ergometry
Flexibility of the anterior and posterior cuff can be provides deep heating of soft tissues and increased blood flow.
addressed with stretching into ER and IR, respectively, ROM exercises37 are performed to the shoulder’s toler-
utilizing proprioceptive neuromuscular facilitation such as ance. It is important to get to know the shoulder and its
hold-relax techniques (Fig. 2). response to treatment. This will guide the dosage—frequency,
Medical massage is recommended for soft tissue release intensity, and duration—of ROM exercises. The total end
of the subscapularis35 and rotator cuff interval22,36 and to range time is determined by manipulating these variables and
achieve scapula-humeral dissociation (Figs. 3–6). is based on the irritability of the shoulder.38 ROM exercises
Therapeutic exercise will address imbalances created by beyond the shoulder’s pain threshold may delay progress.39
pain, disuse, and loss of capsular volume and contracture. Pulley exercises are introduced with adequate ROM (B135
Pendulum exercises create a distraction at the shoulder joint. degrees elevation) and humeral head control to avoid

FIGURE 1. Resting position in supine with pillow support. FIGURE 3. Subscapularis release in supine.

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Chiaia and Hannafin Techniques in Shoulder & Elbow Surgery
FIGURE 4. Progressive subscapularis release in supine.
anterosuperior migration and, thus, subacromial impingement.
Advancement to self-stretching of the posterior capsule is
initiated when horizontal adduction, and sleeper stretch can be
performed without impingement symptoms caused by anterior-
superior migration of the humeral head.40
Strengthening will focus on improving scapulohumeral
rhythm with emphasis on the periscapular musculature and
addressing force couples41 necessary for arm elevation (ser-
ratus anterior, lower trapezius). Resistance exercises must be
pain-free and performed within the available arc of motion.
Closed chain exercises will help combat osteopenia and
encourage cocontraction of the surrounding musculature.42
Hydrotherapy can be utilized for its buoyancy to provide
an environment for active-assistive exercise and hydrostatic
pressure properties.43
SUMMARY
Primary adhesive capsulitis occurs more commonly in
females in their fifth and sixth decades of life. To date, there is
known etiology, although several risk factors (diabetes melli-
tus, thyroid dysfunction, and hyperlipidemia) have been
identified. It progresses through 4 stages, from an insidious
onset of pain to shoulder stiffness and ultimate resolution
within 24 months, if left untreated. Recognition of the stage of
adhesive capsulitis at the time of presentation is critical for
FIGURE 5. Pectoralis major, clavicular fibers, and myofascial
release.
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FIGURE 6. Latissimus-serratus anterior fascial release in sidelying.
successful intervention. Early treatment, in the form of an
intra-articular steroid injection, has been shown to decrease
pain and improve mobility in these early stages. ROM exer-
cises in varying dosages will be prescribed in all stages. In the
early stages, pain and inflammation will be addressed, whereas
in the later stages soft tissue balance will be the focus. Irre-
spective of the stage of presentation, the goal of treatment was
to optimize function in that stage.
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