- Primary (idiopathic) or secondary (associated with trauma, rotator cuff tendonitis, bursitis, fracture neck of humerus, cardiovascular disease, diabetes, thyroid dysfunction, rotator cuff disease, post mastectomy, cardiac surgery).
- Self-limiting condition: highly variable in terms of presentation and duration. May take 2-5 years to settle
- Typically ages 40-60, 15% have bilateral symptoms, can affect 3-6% population.
Adhesive Capsulitis
General information
Symptoms and signs
- Global limitation in active and passive range of shoulder movements with disproportionately severe reduction in passive external rotation with normal XR.
- Pain can radiate to elbow/wrist
- Clinical presentation typically in three overlapping phases: As overlap between phases, terminology now favours classifying into “pain predominant” and “stiffness predominant” phases
- Phase 1: "Freezing" or painful stage, may last from six weeks to nine months, with slow onset of pain. As pain worsens, shoulder loses movement.
- Phase 2: "Frozen" or adhesive stage lasting 4- 12 months, marked by slow improvement in pain but stiffness remains with considerable restriction in range.
- Phase 2: "Frozen" or adhesive stage lasting 4- 12 months, marked by slow improvement in pain but stiffness remains with considerable restriction in range.
- Phase 3: "Thawing" or resolving phase, with gradual improvement in range of movement with resolution of stiffness - can last from 12 to 42 months
Initial management
- Reassure and advise to mobilise. Self-limiting condition
- Pain control - Analgesia & NSAIDs as appropriate
- Refer MSK Physiotherapy.
- Glenohumeral joint steroid injection by appropriately trained GP or physiotherapist (Up to three injections)
Primary care diagnostics
- X-ray shoulder
- Consider testing for diabetes.
Useful resources
NICE CKS Frozen Shoulder
Frozen shoulder patient info leaflet (NHS Tayside)
NHS Lanarkshire Frozen Shoulder Patient Information
Frozen shoulder patient info leaflet (NHS Tayside)
NHS Lanarkshire Frozen Shoulder Patient Information
Who to refer
- Refer if failure to improve for 6-9 months conservative treatment and patient wishes to consider surgery (usually arthroscopic). N.B. Must have had formal Physiotherapy and at least one CSI prior to referral
- Consider referral sooner if patient diabetic or has association with Dupuytren's and failure to respond to initial interventions.
How to refer
- If under the care of the NHS MSK physiotherapy team, investigations and onward referral to UL service, if appropriate, will be organised by Physiotherapy service without the need for further GP intervention.
- SCI Gateway/Orthopaedics-Shoulder and Elbow. Patient may be appointed to see and Advanced Practice Physiotherapist initially.
Information to include when referring:
- Duration and any cause of symptoms, dominance, effect on ADL, work, hobbies
- Indicate site/spread of pain and if pain constant or intermittent, and/or waking at night
- Indicate ROM (active and passive) and any weakness
- Include treatment to date (injections/ physiotherapy)
- XR results