Frozen Shoulder (Adhesive Capsulitis): Overview and Evidence Summary

Condition Overview

Frozen shoulder, or adhesive capsulitis, is a condition characterized by progressive shoulder pain and significant loss of both active and passive range of motion. Unlike many other shoulder disorders, frozen shoulder is not driven by structural damage such as tears or impingement, but rather by chronic inflammation and subsequent fibrosis of the joint capsule. The capsule thickens, contracts, and adheres to itself, reducing the volume of the glenohumeral joint and limiting movement in multiple directions—most notably external rotation.

The condition typically follows a predictable clinical course, traditionally described in three phases:

1. Freezing Phase (Painful Phase):
   Increasing pain, often severe at night, accompanied by gradually diminishing range of motion. Patients commonly report difficulty lying on the affected side and experience sharp, catching pains with sudden movements.

2. Frozen Phase (Stiff Phase):
   Pain may improve slightly, but stiffness becomes the dominant complaint. Everyday tasks such as reaching overhead, fastening a seatbelt, or putting on a jacket become challenging.

3. Thawing Phase (Recovery Phase):
   Slow but steady return of mobility. The timeline varies widely—some recover in months, others in years.

Frozen shoulder occurs most frequently in adults between 40 and 60 years of age. It is significantly more common in individuals with diabetes, thyroid disease, or autoimmune disorders. It may develop spontaneously ("primary" adhesive capsulitis), or following injury or surgery ("secondary" adhesive capsulitis). Because the condition affects both active and passive motion, and because rotator cuff strength is typically preserved, it presents a distinct clinical picture compared to other shoulder injuries.

While the condition can be profoundly limiting, long-term outcomes are generally good, with most people eventually regaining near-normal function. Treatment focuses on symptom management, staged rehabilitation, and maintaining safe mobility during each phase of the condition.

Summary of Current Evidence for Frozen Shoulder

Evidence-Based Management Discussion

Pathophysiology and Why Frozen Shoulder Behaves Uniquely

Frozen shoulder is unlike most other musculoskeletal conditions because it is driven by a systemic inflammatory cascade rather than mechanical overload. Histological studies show chronic synovial inflammation, fibroblastic proliferation, and capsular thickening—particularly in the rotator interval and anterior capsule. The end result is a severe reduction in joint volume, sometimes to less than half of normal.

Pain is prominent early on due to inflammation and capsular irritation. As the inflammation gradually settles, stiffness dominates because the capsule has become thickened and contracted. Recognizing which phase the patient is in is essential because treatment strategies differ significantly across phases.

Why External Rotation is Most Affected

The inferior and anterior capsule provides much of the shoulder's external rotation. As fibrosis builds, this part of the capsule becomes especially tight, explaining why external rotation is often the earliest and most severely restricted movement. Loss of external rotation not only limits function but also alters movement patterns, placing additional strain on surrounding muscles.

Clinical Course and Prognosis

The traditional belief that frozen shoulder always resolves fully within two years has been challenged. Although many individuals regain excellent function, up to one-third experience long-term mild stiffness or reduced overhead motion. Persistent symptoms are more common in individuals with metabolic disease.

Pain may fluctuate throughout the condition; stiffness often remains the longest-lasting impairment. Understanding that recovery can be slow is essential for maintaining patient morale and adherence to treatment.

Exercise Therapy

A staged, patient-centered exercise approach is essential.

Freezing (Painful) Phase

Goals: Reduce pain, maintain gentle mobility.

• Gentle pendulum exercises

• Supine external rotation in very small arcs

• Pain-limited isometrics

• Avoid aggressive stretching that worsens inflammation

Frozen (Stiff) Phase

Goals: Gradually increase range of motion, reduce capsular restrictions.

• More assertive passive and active-assisted stretching

• Capsule-specific mobilization techniques

• Cross-body adduction stretches

• Wall slides, pulleys, and dowel-assisted motion

Programs should emphasize long, sustained stretches rather than rapid or forced movements.

Thawing (Recovery) Phase

Goals: Restore strength, neuromuscular control, and functional patterns.

• Gradual strengthening of rotator cuff and scapular stabilizers

• Functional overhead movements

• Posture correction and thoracic mobility exercises

• Progressive load tolerance

Research consistently shows that matching the intensity of stretching to the irritability of the shoulder improves treatment tolerance and outcomes.

Manual Therapy

Manual therapy has a well-supported role when used appropriately. Joint mobilizations—particularly anterior and inferior glides—can improve motion and reduce discomfort. Soft tissue work around the pectoralis major/minor, upper trapezius, posterior cuff, and rotator interval may alleviate muscle guarding and reduce protective tension.

During the freezing phase, manual therapy is often gentle and aimed at pain modulation. In the stiff phase, more targeted capsular mobilization is appropriate, but still within patient tolerance.

Medications and Injections

NSAIDs can help manage pain during early phases. Oral corticosteroids may offer short-term relief in the freezing phase but are typically a temporary measure.

Corticosteroid injections—particularly when guided—can significantly reduce inflammation and pain early on, enabling patients to engage more comfortably in exercises. Their benefits diminish in later phases as stiffness becomes the main driver of symptoms.

Interventional and Surgical Options

Frozen shoulder is largely a non-surgical condition, but interventional options exist for cases resistant to rehabilitation:

• Hydrodilatation: Expanding the capsule with fluid, sometimes combined with steroid injection, may improve mobility.

• Manipulation under anesthesia: Can break capsular adhesions but carries risks, including fracture or rotator cuff damage.

• Arthroscopic capsular release: Effective for severe, persistent stiffness unresponsive to conservative care.

These options are considered only after months of well-structured rehabilitation with limited improvement.

Clinical Considerations for Therapists

Therapists play a crucial role in:

• Phase-specific treatment planning

• Managing patient expectations

• Ensuring exercises match irritability level

• Avoiding over-aggressive stretching in early stages

• Encouraging adherence to home exercise programs

• Addressing compensatory movement patterns and postural adaptations

Building trust and maintaining clear communication is essential, as the slow recovery timeline can be discouraging for many patients.

References

Neviaser, A., et al. “Adhesive Capsulitis of the Shoulder: Pathophysiology and Current Treatment.” Journal of the American Academy of Orthopaedic Surgeons, 2011.

Zuckerman, J., et al. “Frozen Shoulder: A Consensus Update.” Journal of Shoulder and Elbow Surgery, 2011 and updates.

Manske, R., et al. “Clinical Commentary on Adhesive Capsulitis: Rehabilitation Perspectives.” Sports Health, 2018.

Hand, C., et al. “Corticosteroid Injection Therapy for Adhesive Capsulitis: Evidence Summary.” BMC Musculoskeletal Disorders, 2008 and updates.

Page, M., et al. “Manual Therapy and Exercise for Frozen Shoulder.” Cochrane Review, 2014.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.