FEATURED ARTICLE • MUSCULOSKELETAL PHYSIOTHERAPY
Frozen Shoulder (Adhesive Capsulitis): Assessment & Physiotherapy Management
Frozen shoulder is a painful shoulder condition characterized by progressive restriction of both active and passive movement, with capsular stiffness and contracture.
1. Definition
Adhesive capsulitis is a painful condition in which both active and passive shoulder movements become restricted, commonly associated with capsular stiffness, fibrosis and contracture.
2. Epidemiology
- Typical age: 40–60 years
- More common in females
- Often affects the non-dominant shoulder
- May be bilateral in some patients
3. Risk Factors
- Diabetes mellitus – an important association
- Thyroid disorders
- Shoulder immobilization
- Trauma or surgery
- Stroke or Parkinson’s disease
- Cardiac disease
4. Pathophysiology
Capsular inflammation → fibrosis → capsular thickening → reduced capsular volume → contracture, particularly involving the inferior capsule → restricted joint volume and range of motion.
5. Stages of Frozen Shoulder
| Stage | Typical Duration | Main Features |
|---|---|---|
| Freezing (Painful) | 2–9 months | Pain progressively increases, often with night pain; ROM gradually decreases and sleep/activities become difficult. |
| Frozen (Stiff) | 4–12 months | Pain may decrease while marked stiffness and significant ROM loss remain; daily activities are limited. |
| Thawing (Recovery) | 6–24 months | Pain becomes minimal or absent and ROM gradually improves; weakness or residual restriction may persist. |
6. Capsular Pattern
External Rotation > Abduction > Internal Rotation. External rotation is typically the most restricted movement.
7. Clinical Features
- Dull, poorly localized shoulder pain
- Night pain and disturbed sleep
- Progressive stiffness
- Difficulty combing hair or grooming
- Difficulty reaching overhead
- Difficulty dressing or reaching behind the back
- Difficulty sleeping on the affected side
8. Physiotherapy Assessment
Subjective
- Chief complaint, onset and duration
- Pain intensity, behavior and night symptoms
- Aggravating activities such as overhead reach or reaching behind the back
- Easing factors and previous treatment
- Effect on sleep, dressing, grooming, work and other activities
- Relevant medical history and risk factors
Objective
- Posture and protective/guarded movement
- Scapular movement and shoulder mechanics
- Palpation of relevant shoulder and surrounding tissues
- Active and passive ROM – both are reduced
- Strength – may be normal or reduced due to pain/disuse
- Functional tasks such as overhead reach and behind-back reach
9. Range of Motion Findings
| Movement | Active ROM | Passive ROM |
|---|---|---|
| Flexion | ↓ | ↓ |
| Abduction | ↓ | ↓ |
| External Rotation | ↓↓ | ↓↓ |
| Internal Rotation | ↓↓ | ↓↓ |
| Extension | ↓ | ↓ |
| Horizontal Adduction | ↓ | ↓ |
10. Special Tests & Screening
- Capsular pattern of restriction is a key clinical finding.
- Painful arc, Neer and Hawkins–Kennedy may be positive but are not specific for frozen shoulder.
- Drop-arm testing is generally negative unless another pathology is present.
- Cervical screening should be performed when symptoms could originate from the neck.
11. Differential Diagnosis
- Rotator cuff pathology/tear
- Subacromial shoulder pain/impingement
- Glenohumeral osteoarthritis
- Cervical radiculopathy
- Bicipital tendinopathy
12. Physiotherapy Goals
- Decrease pain
- Improve ROM
- Restore functional ability
- Improve strength and endurance when appropriate
- Reduce disability and persistent stiffness
- Return to work, sport and daily activities
13. Phase-wise Physiotherapy Management
Phase 1 – Freezing / Painful Stage
Goals: reduce pain, maintain available ROM, prevent unnecessary stiffness and educate the patient.
- Education and avoidance of activities that significantly aggravate symptoms
- Heat may be used before exercise when helpful
- TENS/IFC may be used as adjuncts for symptom relief when indicated
- Gentle Grade I–II glenohumeral mobilization for pain modulation when appropriate
- Pendulum (Codman’s) exercises
- Gentle active-assisted ROM and table slides
- Wand/stick exercises for comfortable flexion, abduction and external rotation
- Scapular mobility and postural exercises
- Gentle isometric flexion, abduction, internal and external rotation
Home Program
- Gentle ROM regularly, according to tolerance
- Pendulum exercises
- Gentle active ROM
- Heat before exercise if helpful; ice afterward if soreness increases
Phase 2 – Frozen / Stiff Stage
Goals: improve joint mobility and ROM, address capsular tightness and maintain or improve strength.
- Moist heat before stretching when helpful
- Progressive glenohumeral mobilization (Grades III–IV when clinically appropriate)
- Inferior and posterior glides; other directions as indicated
- Capsular stretching within tolerance
- Cross-body, sleeper, pectoral and external-rotation stretches as appropriate
- Active and active-assisted ROM
- Pulley, wall-climbing and finger-ladder exercises
- Theraband strengthening
- Rotator-cuff, deltoid and scapular-stabilizer strengthening
Phase 3 – Thawing / Recovery Stage
Goals: restore ROM, improve strength and endurance, and return to normal work, sport and daily activities.
- Progressive stretching within tolerance
- Advanced mobilization when indicated
- Progressive resistance exercises
- Dumbbell and resistance-band strengthening
- Functional and occupational activity training
- Plyometric and sport-specific exercises for appropriate athletes
14. Manual Therapy
- Maitland Grade I–II mobilization for pain modulation
- Maitland Grade III–IV mobilization for mobility when appropriate
- Mobilization with Movement (MWM) when clinically indicated
- Soft-tissue techniques
- Myofascial techniques
- Scapulothoracic mobilization
15. Strengthening Program
Rotator Cuff
- Theraband external rotation
- Internal rotation
- Side-lying external rotation
- Pain-free strengthening as tolerated
Scapular Muscles
- Scapular retraction and rows
- Wall push-up plus
- Serratus punches
- Lower trapezius strengthening
Proprioception / Closed Chain
- Ball-on-wall exercises
- Closed-chain weight shifting
- Rhythmic stabilization
16. Adjunctive Modalities
- TENS
- IFC
- Moist heat
- Cryotherapy after exercise if soreness occurs
- Therapeutic ultrasound may be considered selectively, but modalities should remain adjuncts rather than the core rehabilitation approach.
17. Functional Training
- Overhead reaching
- Dressing and grooming
- Reaching behind the back
- Lifting and carrying light objects
- Work-specific tasks
- Sports-specific skills for athletes
18. Patient Education & Home Exercise Program
- Recovery is usually gradual and may take months to years.
- Regular, appropriately dosed exercise is important.
- ROM exercises can be performed regularly, often 2–3 times/day according to tolerance.
- Gentle stretching may use 20–30-second holds for 3–5 repetitions when appropriate.
- Strengthening can be performed around 3–4 days/week once appropriate.
- Maintain good posture and avoid sudden jerky movements or excessive loading.
- Sleep on the unaffected side or use pillow support for comfort.
19. Medical & Surgical Options
- Analgesic/anti-inflammatory medication may be prescribed by an appropriate clinician.
- Intra-articular corticosteroid injection may be considered, particularly in pain-dominant presentations.
- Hydrodilatation may be considered in selected cases.
- For persistent resistant cases, manipulation under anesthesia or arthroscopic capsular release may be considered by specialists.
20. Prognosis
Frozen shoulder is often self-limiting, but recovery is variable and may take 1–3 years. Many patients gradually regain useful function, although some may have residual stiffness or movement limitation.
21. Sample Educational Clinical Case Study
Case: A 52-year-old woman reports four months of gradually increasing shoulder pain, marked night pain and difficulty combing her hair and reaching overhead. Examination shows restriction of both active and passive ROM, with external rotation most limited. Cervical screening is unremarkable.
Clinical impression: Findings are consistent with adhesive capsulitis in a pain-dominant/freezing presentation.
Example rehabilitation approach: Education, symptom management, gentle ROM and active-assisted exercises, appropriate manual therapy for pain modulation, and gradual progression according to irritability and functional goals.
Educational note: This is a sample case for learning and does not replace individual clinical assessment or diagnosis.
22. Exam Quick Recall
Classic capsular pattern: ER > Abduction > IR.
Important association: Diabetes mellitus.
Stages: Freezing → Frozen → Thawing.
23. Quick Revision Flashcards
- What is frozen shoulder? Adhesive capsulitis with painful restriction of both active and passive shoulder movement.
- Classic age group? 40–60 years; more common in females.
- Important risk factor? Diabetes mellitus.
- Capsular pattern? External Rotation > Abduction > Internal Rotation.
- Three stages? Freezing, Frozen and Thawing.
- Key clinical features? Pain, night pain, progressive stiffness and difficulty with reaching, dressing and grooming.
- Main physiotherapy goals? Pain management, improve ROM, restore function and improve strength when appropriate.
- Useful ROM exercises? Pendulum, wand exercises, wall slides/climbs and appropriate stretching.
- When is strengthening emphasized? As pain and mobility improve, progressing from isometrics to resistance and functional exercises.
- Prognosis? Usually gradual improvement; recovery may take months to several years and residual stiffness can occur.
Medical disclaimer: This article is for educational purposes and does not replace an individualized diagnosis, medical assessment or physiotherapy treatment plan.