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Shoulder · Capsule

Frozen shoulder (adhesive capsulitis)

The capsule around the shoulder joint tightens, causing growing stiffness and pain. It is most common between 40 and 65, more often in women, after a previous frozen shoulder, and with conditions that cause body-wide inflammation such as diabetes or thyroid disease. It moves through freezing (painful and tightening, 2–9 months), frozen (stuck, often less painful, 4–12 months) and thawing (slowly loosening, 12–24 months).

CompleteSource: Rehab Science · Ch 16 · PDF pp. 420–423Frozen Shoulder (Adhesive Capsulitis) protocol →What should I avoid?
4.1

Overview

📖 Rehab Science
Medical name
Adhesive capsulitis of the glenohumeral joint
Common name
Frozen shoulder
Structures involved
Shoulder capsule and ligamentsGlenohumeral joint

The capsule around the shoulder joint tightens, causing growing stiffness and pain. It is most common between 40 and 65, more often in women, after a previous frozen shoulder, and with conditions that cause body-wide inflammation such as diabetes or thyroid disease. It moves through freezing (painful and tightening, 2–9 months), frozen (stuck, often less painful, 4–12 months) and thawing (slowly loosening, 12–24 months).

Source: Rehab Science · Ch 16 · PDF p. 420· 1 original research citationshow sources ▾
  1. [Ch 16·13] de la Serna D, Navarro-Ledesma S, Alayón F, López E, Pruimboom L. A comprehensive view of frozen shoulder: a mystery syndrome. Front Med (Lausanne). 2021;8:663703. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

4.2

Anatomy & biomechanics

ℹ Additional explanation

Think of the capsule as a loose sleeve that normally has spare folds; in frozen shoulder it shrinks and stiffens.

Interactive diagram · Shoulder complex
SupraspinatusRight shoulder seen from the front · schematic, not to scale · tap a structure
Original schematic. Anatomy is additional educational explanation; clinical relevance links to Rehab Science Ch 16 (PDF pp. 358–462).
4.3

Signs & symptoms

📖 Rehab Science
Pain locationDeep, vague, whole-joint pain (not one point).
Pain characteristicsDeep ache; stiffness that feels like hitting a wall.
mobilityLoss of range in a capsular pattern — external rotation first, then abduction, then flexion. Passive and active movement are both restricted; the other side is normal.
otherOne of the only conditions where range of motion is lost completely.
Source: Rehab Science · Ch 16 · PDF p. 421show sources ▾

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

4.4

Why does this happen?

📖 Rehab Science
Established mechanisms
  • Capsular tightening of unclear cause
Possible contributing factors
  • Diabetes or thyroid disease
  • Prior frozen shoulder
  • Age 40–65 and female sex
  • Previous cuff or labral injury
  • Prolonged avoidance of shoulder movement after injury (Ch 10)
Source: Rehab Science · Ch 16 · PDF p. 420· 1 original research citationshow sources ▾
Also cited by the book on this page:
  1. [Ch 16·13] de la Serna D, Navarro-Ledesma S, Alayón F, López E, Pruimboom L. A comprehensive view of frozen shoulder: a mystery syndrome. Front Med (Lausanne). 2021;8:663703. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

4.5

Aggravating factors

📖 Rehab Science
Movement / activityWhy it may cause symptomsTemporary modification
Moving into external rotationThese are the restricted capsular directions.Use dowel PROM to the point of a moderate stretch, not severe pain.
Prolonged immobilisationLack of movement promotes further stiffness (Ch 10, PDF p. 185).Daily mobility, 2–3 sessions per day in phase 2.

Aggravating factors are temporary—tissues are sensitised or not ready yet. The protocol rebuilds capacity so these tasks become comfortable again.

Source: Rehab Science · Ch 16 · PDF p. 422· 3 original research citationsshow sources ▾
Also cited by the book on this page:
  1. [Ch 16·14] Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: the effectiveness of conservative and surgical interventions—systematic review. Br J Sports Med. 2011;45(1):49-56. find original ↗
  2. [Ch 16·15] Challoumas D, Biddle M, McLean M, Millar NL. Comparison of treatments for frozen shoulder: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(12):e2029581. Published 2020 Dec 1. find original ↗
  3. [Ch 16·16] Dempsey AL, Mills T, Karsch RM, Branch TP. Maximizing total end range time is safe and effective for the conservative treatment of frozen shoulder patients. Am J Phys Med Rehabil. 2011;90(9):738-745. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

4.6

Assessment & tests

A. Safe self-observations
B. Clinical tests (professional only)
C. Imaging & investigations

    Diagnosis is largely clinical; imaging mainly excludes other causes such as arthritis or fracture.

    No single positive test proves a diagnosis. Clinical tests are interpreted together with history and examination by a trained professional.

    4.7

    Differential considerations

    📖 Rehab Science
    Rotator cuff injury (tear / tendinopathy) — With cuff injury, passive range is usually preserved even if active lifting hurts.
    Shoulder impingement (subacromial pain syndrome) — Painful arc without a hard passive block.

    Conditions with overlapping symptoms may need professional assessment to tell apart.

    4.8

    Treatment & recovery

    📖 Rehab Science
    Prognosis: Treated early with physiotherapy and cortisone injection it can resolve within ~6 months; untreated it may persist 1–3 years. Source: Rehab Science · PDF p. 422

    Physio (joint mobilisations and stretching), anti-inflammatory medication and steroid injections. The protocol focuses on range of motion—no soft-tissue work. Phase 1: passive dowel movements and the table slide, then isometrics to limit muscle loss. Phase 2: long, gentle stretches held up to 2–5 minutes (low-load, long-duration), 2–3 times a day, plus shoulder flexion eccentrics. Phase 3: add strengthening as soon as you have enough range—do not wait for full mobility.

    Diagram · The three-phase frameworkOriginal illustration
    1Calm it down• Reduce pain; modify aggravators• Soft tissue, mobility, isometricsProgress when:No pain at rest≤ 3/10 with the exercisesinflammatory phase2Restore movement• Range of motion & control• Isometric + eccentric loadingProgress when:Full range with controlMild-to-no painmaturation phase3Build capacity• Full-range resistance training• Progressive overload; sportProgress when:Pain resolved — keeptraining to prevent recurrenceremodelling phase
    The same framework treats pain and injury. Progression is driven by symptoms and function—not by days—and with injury it also respects tissue healing time. — Based on concepts in Rehab Science Ch 5 (PDF pp. 80–82), Ch 10 (PDF pp. 182–190), Ch 11 (PDF p. 203).
    Source: Rehab Science · Ch 16 · PDF pp. 422, 423· 3 original research citationsshow sources ▾
    1. [Ch 16·16] Dempsey AL, Mills T, Karsch RM, Branch TP. Maximizing total end range time is safe and effective for the conservative treatment of frozen shoulder patients. Am J Phys Med Rehabil. 2011;90(9):738-745. find original ↗
    Also cited by the book on these pages:
    1. [Ch 16·14] Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: the effectiveness of conservative and surgical interventions—systematic review. Br J Sports Med. 2011;45(1):49-56. find original ↗
    2. [Ch 16·15] Challoumas D, Biddle M, McLean M, Millar NL. Comparison of treatments for frozen shoulder: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(12):e2029581. Published 2020 Dec 1. find original ↗

    Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

    AMBER — get assessed before starting rehab
    If you have shoulder pain and are losing range, see a doctor early—an injection during the freezing stage can help. Source: Rehab Science · PDF p. 423
    4.9

    Prevention

    📖 Rehab Science

    Keep moving an injured shoulder early (PROM in the Shoulder Pain protocol is used partly to prevent frozen shoulder, PDF p. 363).

    Injury prevention principles → · Return-to-sport stages →