Review Article

Adhesive Capsulitis of the

Shoulder
Abstract
Andrew S. Neviaser, MD
Robert J. Neviaser, MD

Adhesive capsulitis is characterized by painful, gradual loss of

active and passive shoulder motion resulting from fibrosis and
contracture of the joint capsule. Other shoulder pathology can
produce a similar clinical picture, however, and must be
considered. Management is based on the underlying cause of pain
and stiffness, and determination of the etiology is essential. Subtle
clues in the history and physical examination can help differentiate
adhesive capsulitis from other conditions that cause a stiff, painful
shoulder. The natural history of adhesive capsulitis is a matter of
controversy. Management of true capsular restriction of motion (ie,
true adhesive capsulitis) begins with gentle, progressive stretching
exercises. Most patients improve with nonsurgical treatment.
Indications for surgery should be individualized. Failure to obtain
symptomatic improvement and continued functional disability
following 6 months of physical therapy is a general guideline for
surgical intervention. Diligent postoperative therapy to maintain
motion is required to minimize recurrence of adhesive capsulitis.

From the Department of

Orthopaedic Surgery, George
Washington University Medical
Center, Washington, DC.
Neither of the following authors nor
any immediate family member has
received anything of value from or
owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article: Dr. A. Neviaser and
Dr. R. Neviaser.
J Am Acad Orthop Surg 2011;19:
536-542
Copyright 2011 by the American
Academy of Orthopaedic Surgeons.

536

dhesive capsulitis is one of

many conditions that present
with pain and progressive limitation
of active and passive shoulder motion. Both intrinsic and extrinsic pathology of the shoulder can cause
stiffness and pain, and treatment
should address the specific anatomic
cause. Patients who present with a
painful stiff shoulder are frequently
diagnosed with frozen shoulder.
This term, which was first used by
Codman,1 does not denote a specific
pathology. Rather, it applies to what
he described as many conditions
which cause spasm of the short rotators or adhesions about the joint or
bursae. A diagnosis of frozen shoulder is as vague as calling a gait abnormality a limp and should be
avoided. Adhesive capsulitis is a specific pathologic entity in which
chronic inflammation of the capsule

subsynovial layer produces capsular

thickening, fibrosis, and adherence
of the capsule to itself and to the anatomic neck of the humerus.2 The
contracted, adherent capsule causes
pain, especially when it is stretched
suddenly, and produces a mechanical
restraint to motion.
Many conditions can produce
symptoms similar to those of adhesive capsulitis. These include full and
partial-thickness rotator cuff tears,
calcific tendinitis, glenohumeral or
acromioclavicular arthritis, and cervical radiculopathy. In these conditions, motion loss is typically multifactorial rather than the result of
isolated capsular restriction.3 Some
authors have advocated describing
this type of stiffness as secondary
adhesive capsulitis to distinguish it
from the idiopathic (ie, primary)
form.4 This terminology is mislead-

Journal of the American Academy of Orthopaedic Surgeons

Andrew S. Neviaser, MD, and Robert J. Neviaser, MD

Figure 1

Illustrations of the shoulder demonstrating the normal loose axillary fold with
the arm dependent (A) and a contracted axillary fold, as is seen in adhesive
capsulitis (B).

ing, however, because it implies that

the pathology lies within the joint
capsule when, in fact, treatment
should be directed elsewhere. Instead, persons in this category should
be referred to as simply having a
stiff and painful shoulder, which
does not suggest a potential cause.
To manage the pain and stiffness related to these other conditions, therapy should address the specific underlying etiology. Pain and stiffness
should resolve with successful management of the inciting pathology.

Pathology
Adhesive capsulitis has been known
by many names, including periarthritis of the shoulder, Duplay disease,
tendinitis of the short rotators, periarthritis scapulae, and frozen shoulder. In 1945, Neviaser2 described the
gross and histologic pathology in a
series of cases and proposed the term
adhesive capsulitis as a more precise descriptor of the findings. Adhesive capsulitis is characterized by a
thickened, tight glenohumeral joint
September 2011, Vol 19, No 9

capsule with adhesions obliterating

the normally patulous axillary fold.
The fibrotic capsule adheres to itself
and to the anatomic neck of the humerus (Figure 1). There is minimal
synovial fluid in the joint, and overall joint volume is diminished. Normal shoulder joint volumetric capacity is 28 to 35 mL of injected fluid,
whereas in adhesive capsulitis, the
joint accepts only 5 to 10 mL.5 Biopsy of the capsule demonstrates a
chronic inflammatory infiltrate, absence of synovial lining, and moderate to extensive subsynovial fibrosis.
Perivascular lymphocytic reactions
are noted, as well.2
Four stages of disease have been
described based on the arthroscopic
appearance of the joint capsule. The
disease progresses from capsular inflammation to fibrosis.6 Stage 1, the
preadhesive stage, consists of a fibrinous inflammatory synovitic reaction without adhesion formation
(Figure 2, A). At this stage, patients
typically have full motion but report
pain, particularly at night. Symptoms are nonspecific, and misdiagno-

sis is common. Stage 2 is marked by

acute adhesive synovitis with proliferation of the synovium and early
formation of adhesions (Figure 2, B),
most notably in the dependent inferior capsular fold. Pain is a prominent feature, and motion loss is present but typically mild. Stage 3, the
maturation stage, involves less synovitis and more fibrosis (Figure 2, C).
The axillary fold is obliterated. Pain
may be less severe than in stages 1
and 2, but motion is significantly restricted. In stage 4, the chronic stage,
adhesions are fully mature, and motion is severely reduced. Because of
the marked fibrosis, intra-articular
structures may be difficult to identify
at arthroscopy (Figure 2, D). Patients
may have painless, limited range of
motion in stage 4, but pain occurs
when the arm is suddenly moved beyond the limits of the scarred capsule.
Some have questioned whether inflammation is part of this process, suggesting instead that adhesive capsulitis
is a solely fibrotic disease similar to Dupuytren contracture.7 However, biopsy
specimens from patients in the first
three stages demonstrate a clear progression from perivascular mononuclear inflammatory infiltrates to reactive capsular fibrosis, confirming an
inflammatory origin.8,9 Increased levels of transforming growth factor-
and other profibrotic cytokines are
present in capsular biopsy specimens
and likely drive this progression.10
The inciting cause of the inflammation is unknown.

Clinical Presentation
Patients typically present with pain
of insidious onset of several months
duration. The onset of symptoms
tends to be more gradual than in
other shoulder conditions. Pain is
commonly referred to the origin of
the deltoid. Night pain is common,

537

Adhesive Capsulitis of the Shoulder

Figure 2

Arthroscopic findings of adhesive capsulitis. A, Stage 1, fibrinous

inflammatory reaction. The rotator interval capsule as viewed from a
standard posterior portal in a left shoulder. The long head of the biceps
tendon is seen superiorly. B, Stage 2, synovial proliferation and early
adhesion formation. C, Stage 3, the maturation stage, demonstrating
diminished inflammation and greater adhesion formation. D, Stage 4, the
chronic stage, in which identifiable joint anatomy is nearly obliterated.
BT = biceps tendon, RIC = rotator interval capsule

and patients typically cannot sleep

on the affected side. Pain following
repetitive overhead activity is not a
typical feature of this disease and is
suggestive of other pathology.
Loss of motion accompanies or in
rare cases precedes the onset of pain
and typically becomes more prominent with disease progression. Patients have difficulty dressing, combing their hair, reaching to a back
pocket, or fastening a brassiere. In
stages 3 and 4, motion loss becomes
severe, affecting movement in all directions. Pain is reduced and may be

538

apparent only when the shoulder is

moved beyond the limits allowed by
the contracted capsule.
Most patients with adhesive capsulitis are women aged 40 to 60
years.11,12 The nondominant arm typically is most affected.13,14 Adhesive
capsulitis is more common in persons in sedentary vocations than in
persons who perform manual labor.6
There are numerous associations
with systemic conditions, including
cardiovascular disease15 and thyroid
dysfunction,16 as well as breast cancer treatment.17,18 Patients with cere-

brovascular accident, myocardial

infarction, and diabetes are at increased risk of developing adhesive
capsulitis.15,19,20 Diabetes is associated
with a significantly worse prognosis,
greater need for surgery, and suboptimal results.21
Physical examination does not reveal a specific point of tenderness.
Occasionally, the long head of the biceps tendon is tender because its synovium is confluent with that of the
glenohumeral joint. Rotator cuff
strength is usually normal. A mechanical restraint to passive motion
is the hallmark of adhesive capsulitis.
This finding is best appreciated on
passive external rotation with the
arm at the side. In adhesive capsulitis, there is a sense of tethering
caused by the contracted capsule that
is quite different from motion limited
by pain. Discriminating stage 1 disease (ie, before adhesion formation)
from other pathology can be difficult
because the signs and symptoms are
nonspecific. Thus, recognition of the
arthroscopic appearance of this stage
is of great importance. Discovery of
a stage 1 capsule during the joint inspection portion of a planned arthroscopy indicates that the presumed diagnosis may be incorrect,
and the planned procedure should be
reconsidered.
Although radiographs are typically
normal, they are important for eliminating other causes, such as arthritis,
calcific tendinitis, and unrecognized
shoulder dislocation (especially posterior). Disuse osteopenia may be
seen in patients with long-standing
disease. Neither MRI nor magnetic
resonance arthrography is used as a
primary diagnostic tool; however,
recognition of adhesive capsulitis on
these modalities is helpful. Thickening of the joint capsule and diminished filling of the axillary pouch are
useful diagnostic criteria on magnetic resonance arthrography.22,23
Emig et al24 found thickness >4 mm

Journal of the American Academy of Orthopaedic Surgeons

Andrew S. Neviaser, MD, and Robert J. Neviaser, MD

Figure 3

Oblique coronal (A) and axial (B) proton density fast spin-echo magnetic
resonance images demonstrating thickening of the dependent portion of the
capsule (A, arrow) and scarring of the rotator interval (B, arrow).

of the capsule and synovium adjacent to the axillary recess to be

highly specific for adhesive capsulitis; changes in the coracohumeral ligament were not a consistent feature.
Others have reported scarring within
the rotator interval to be a more
common finding23,25 (Figure 3). MRI
with gadolinium enhancement can
demonstrate hypervascularity of the
joint capsule as well.26 These imaging
tests are most valuable in excluding
other causes of symptoms and are
not generally required for diagnosis.

Natural History
The natural history of adhesive capsulitis remains a matter of debate.
Some have suggested that adhesive
capsulitis is self-limiting and need
not be treated. Codman1 counseled
his patients that their symptoms
would gradually subside. Miller
et al20 recommended patience and reported complete resolution of symptoms 4 years after onset in 50 patients treated with only minimal
home exercise and heat.
There may be a natural trend toward symptomatic improvement, but
reported outcomes of minimal treatment vary considerably and are
September 2011, Vol 19, No 9

highly dependent on how they are

measured. Results tend to be more
favorable with subjective outcome
measures than with objective outcome measures. In one study, 90%
of patients treated with minimal
therapy reported satisfaction with
their shoulder function.27 However,
another that used objective outcomes
reported residual pain in 50% of patients and motion deficit in 60%.28
Uncertainty regarding the ultimate
progression of adhesive capsulitis
hampers efforts to measure the effectiveness of new treatments. Given the
prolonged disability these patients
face, interventions should be focused
on hastening recovery of motion and
diminishing pain.

Management
Physical therapy combined with a
home exercise program is the mainstay
of treatment, regardless of stage. Therapy need not be aggressive or painful,
and strengthening is rarely necessary.29 Gentle progressive stretching
is optimal and is effective in most
cases. Nonetheless, patients should
be counseled that they face a prolonged recovery period.
Pharmacologic therapy is often

used as an adjunct to physical

modalities. Nonsteroidal anti-inflammatory drugs may make sleep and
therapy more tolerable, but they do
not have a substantial effect on recovery. Oral and intra-articular steroid injections have been studied
extensively. Although they hold theoretic promise, given the inflammatory nature of the early disease
stages, most studies have shown only
a transient reduction in pain (eg, 3 to
6 weeks), with no improvement in
motion.30-36 Longer-term follow-up
shows no difference between patients
treated with steroids and control
subjects.30-36 Results seem more favorable with the use of image-guided
injections, particularly when given in
the early stages of disease; stagespecific injection warrants further
study.37,38 Numerous other treatments have been described in small
series. Some have reported success
with suprascapular nerve blocks and
hydrodilatation.39,40 However, those
results have not been reproduced by
others, and such interventions are
not widely used.
Patients who do not improve with
physical therapy are treated surgically. Levine et al14 reported that patients who have more severe symptoms initially, are younger at the
time of onset, and who experience a
reduction in motion despite 4
months of compliant therapy are
most likely to require surgery.
Prior to the widespread use of arthroscopy, manipulation under anesthesia was the standard of care for
the management of refractory adhesive capsulitis. Dodenhoff et al41 reported that 94% of patients treated
with manipulation under anesthesia
were satisfied with their outcome at
a minimum follow-up of 6 months,
and most patients regained the ability to do daily tasks within days of
the procedure. Farrell et al42 demonstrated that these favorable results
are sustained 15 years after the pro-

539

Adhesive Capsulitis of the Shoulder

Figure 4

Photograph demonstrating the

immediate postoperative position
for the first night following
management of adhesive capsulitis
and while sleeping throughout the
hospital stay.

cedure. Because of its predictable

outcome, knowledge of manipulation under anesthesia and its potential complications remain valuable.43
Proper technique ensures that the inferior capsule is ruptured from the
humerus without causing rupture of
the subscapularis or humeral fracture.6,42
Regional or general anesthesia can
be used in our preferred method of
manipulation.6 The patient is placed
supine, and the scapula of the affected side is stabilized with one
hand. With the other hand, the surgeon grasps the humerus above the
elbow. The arm is externally rotated,
then brought into elevation above
the patients head. External rotation
of the arm before elevation clears the
greater tuberosity from beneath the
acromion and prevents humeral fracture. Elevation is then reduced to
90, and the arm is maximally internally rotated. Typically, an audible
popping of the capsule is heard during manipulation. Arthrography has
confirmed that this series of steps results in isolated capsular rupture and
leaves the subscapularis intact.6
In many institutions, arthroscopic

540

capsular release has supplanted manipulation under anesthesia because

arthroscopy allows complete inspection of the joint, confirmation of the
diagnosis, and a more precise capsulotomy without the risks of manipulation. Compared with manipulation
under anesthesia, arthroscopic capsular division has shown improved
pain relief and restoration of function after 2 to 5 years.44 These results
are maintained at even longer
follow-up.45
We perform arthroscopic capsular
release with the patient in the beachchair position. Severe joint contracture may hamper the creation of a
posterior portal. In such cases, a simple closed forward elevation maneuver can help loosen the joint and assist with inserting the arthroscope.
Electrocautery inserted through an
anterior portal is used to release the
anterior capsule and rotator interval
but not the subscapularis. Use of the
electrocautery is stopped when the
plane between the capsule and the
subscapularis tendon is identified
and is always stopped before the
lower border of the subscapularis to
protect the axillary nerve. An arthroscopic biter can then be used to
extend the release toward the axillary recess, stopping at the 6 oclock
position. Following the anterior and
anterior-inferior releases, the shoulder is brought into external rotation
and abduction followed by internal
rotation to confirm the adequacy of
the release.
Whether to release the posterior capsule remains controversial. Some have
advocated circumferential release of the
capsule or selective posterior release if
there is persistent loss of internal rotation after anterior release.46,47 Comparison studies between anterior release
and circumferential release show mixed
results. Although several studies have
demonstrated early benefit with routine
release of the posterior capsule, outcomes at longer follow-up are similar

to those with isolated anterior release.48,49

Regardless whether capsular release
is achieved arthroscopically or through
manipulation, it should be followed by
early, diligent, and directed therapy to
prevent recurrent stiffness. Surgery can
be performed on an inpatient basis, or
outpatient therapy can be arranged to
begin the day after surgery. The advantages of hospital admission include better pain management options and
physician-monitored rehabilitation.
Outpatient surgery has the advantage
of convenience and lower cost, but it
carries the risk of noncompliance with
therapy.
The senior author (R.J.N.) prefers
inpatient admission and an aggressive motion-preserving therapy strategy. Following surgery, the patient is
kept immobilized in 90 abduction
and external rotation, with the head
of the bed elevated 30 (Figure 4).
Exercises are begun on postoperative
day 1. For the next 2 days, the patients arm is kept in the abducted
position. The patient is encouraged
to maintain the arm in 90 of abduction and reach across the top of the
head to touch the opposite ear as
well as to internally and externally
rotate the arm. Patients perform all
actions (eg, walking, sitting, using
the toilet, eating) with their hand on
top of their head. Patients are discharged when they are comfortable,
usually 2 days after surgery. Sleeping
in abduction is continued for 2
weeks following surgery using a humeral cuff. Outpatient therapy is
continued until full motion is restored and maintained. The intensity
of this therapy is similar to that used
preoperatively, and it should not be
excessively painful or vigorous. A
home stretching program is taught;
stretching should be done three times
per day. Patients undergo supervised
therapy three times per week with no
restrictions on motion. Strengthening
is not emphasized.

Journal of the American Academy of Orthopaedic Surgeons

Andrew S. Neviaser, MD, and Robert J. Neviaser, MD

Summary
The differential diagnosis for the patient who presents with a stiff and
painful shoulder is extensive, and appropriate treatment is based on proper
identification of the inciting pathology.
The term frozen shoulder is nonspecific and should be avoided. Adhesive
capsulitis is characterized by chronic
inflammation of the capsular subsynovial layer, which produces capsular fibrosis, contracture, and adherence of
the capsule to itself and to the anatomic
neck of the humerus. Appropriate
management begins with gentle physical therapy, with an emphasis on range
of motion that is not unduly painful.
Even when nonsurgical treatment is
successful, patients face months of continued symptoms. Pharmacologic measures, such as intra-articular steroid injections, have not been shown to
reduce the duration of symptoms, but
they may provide some early reduction
in pain. Patients who do not improve
after 6 months of diligent therapy are
appropriate candidates for further intervention. Arthroscopic capsular release allows for precise release of the
capsule without the potential complications of manipulation. Continued
therapy postoperatively is critical to
achieve full active motion and preventing recurrence.

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