Estimated reading time: 6 minutes
If you’re asked to discuss or diagnose a case of adhesive capsulitis (frozen shoulder) in your exams or wards, there’s a certain structure that can make all the difference.
Dr. Harpreet Singh, known for his clear, concept-driven teaching, explains exactly how to approach such cases — from history taking to examination and management — just the way an examiner expects.
How to Begin Your Diagnosis?
Start confidently. Say:
“My diagnosis is a case of adhesive capsulitis involving the dominant/non-dominant shoulder, of this duration, in a 50-year-old gentleman who has difficulty performing daily activities.”
It’s important to mention both duration and functional disability.
The typical presentation revolves around pain and stiffness. Pain usually develops gradually. Talk about:
- How long has the pain lasted
- Its nature, intensity, and whether it radiates
Here’s something to remember — shoulder pain, when it radiates, usually goes only up to the elbow. If the pain goes beyond that, it’s often not from the shoulder joint, but from cervical or plexus involvement.
Among shoulder disorders, only acute calcific tendonitis presents with a sudden onset of severe pain without any trauma — the kind that appears “out of nowhere.” This can be picked up on ultrasound, not X-ray or MRI.
Points to Cover While Taking History
When presenting a long case, always describe:
- How pain and stiffness affect daily life
- That pain worsens with movement and eases with rest
- The presence of night pain makes it hard to lie on the affected side
Patients often say they can’t perform tasks like combing their hair, dressing, or bathing.
Importantly, mention that stiffness has no morning variation, which helps rule out inflammatory causes.
Take negative histories too:
- No trauma → rules out dislocation
- No numbness or tingling → rules out cervical involvement
- No fever or weight loss → rules out infection or systemic inflammation
- No other joint issues → rules out rheumatoid or autoimmune pathologies
Always check for underlying systemic conditions like diabetes, thyroid problems, lipid abnormalities, and Dupuytren’s contracture — all linked with a higher risk of frozen shoulder.
Also, note any history of cardiac surgery or stroke.
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Understanding the Condition
Frozen shoulder isn’t just general stiffness — it’s a defined disease that typically affects one shoulder at a time, rarely recurs in the same joint, and is self-limiting.
However, even after resolution, some residual stiffness or mild pain may remain.
Differential Diagnosis You Should Mention
Based on history alone, keep in mind:
- Rotator cuff tear
- Impingement syndrome
- Glenohumeral arthritis
- Neglected or missed dislocation
These should be differentiated during clinical examination and imaging.
How to Examine the Shoulder?
Examine the shoulder from front, side, and back in sitting, standing, and supine positions.
Undress the patient up to the trunk for proper visualisation.
Inspection
Look for muscle wasting — especially in the supraspinatus or infraspinatus regions.
Even if you don’t find anything striking, mention both your positive and negative findings.
Palpation
- Check for warmth or tenderness.
- Coracoid tenderness is quite characteristic of adhesive capsulitis.
- Tenderness in the bicipital groove may also be noted.
Movement Assessment
The key to diagnosis lies here.
In adhesive capsulitis, both active and passive movements are restricted, especially external rotation (ER).
That’s your hallmark.
- Never diagnose adhesive capsulitis without noting the loss of external rotation.
- Always compare movements on both sides and mention the degree of limitation clearly.
Investigations to Confirm the Diagnosis
- X-ray (AP and Axillary views) – to rule out arthritis and neglected dislocation
- Ultrasound – may show thickening of the coracohumeral ligament or detect a cuff tear
- MRI – only if there’s diagnostic confusion; may reveal thickened CHL, rotator interval edema, or reduced axillary pouch volume
Pathology Behind the Disease
The root problem lies in new blood vessel formation (neovascularization) in the rotator interval and coracohumeral ligament.
This brings inflammation, which later turns into fibrosis, leading to tightening of the capsule and restriction of motion — especially external rotation.
Stages of the Disease
Adhesive capsulitis progresses in three overlapping stages:
- Freezing Phase (2–3 months) – Painful stage, increasing stiffness due to inflammation.
- Frozen Phase (around 6 months) – Constant pain, persistent stiffness, fibrotic changes dominate.
- Thawing Phase (up to a year) – Gradual improvement as fibrosis softens and motion returns.
It usually resolves within 2–3 years, but 30–70% of untreated cases may have residual stiffness.
Treatment Strategy
Conservative Approach (First Line)
Most patients respond well without surgery.
Treatment aims to reduce inflammation, pain, and stiffness.
- NSAIDs and local heat therapy for pain relief
- Physiotherapy, focusing on mobilisation and stretching, not just machines like IFT or TENS
- Teach home exercises to be done at least three times a day, holding each stretch briefly
Steroid Injections
Indicated for:
- Persistent or severe night pain
- Poor response to physiotherapy
- Pain that increases with movement
Injections can be given intra-articularly or into the rotator interval, preferably under ultrasound guidance.
They help patients perform exercises more comfortably in the short term.
Surgical Options
If no improvement is seen after 3–6 months of proper conservative care, then discuss:
- Manipulation under anesthesia (MUA)
- Arthroscopic capsular release
Open procedures are rarely done now. During MUA, always use a short lever arm and gentle, sustained movements to prevent iatrogenic fractures, the most common complication.
Why You Should Treat It?
Although it isn’t life-threatening, adhesive capsulitis causes long-standing pain and loss of motion, often lasting for years.
No one should have to live that way — and with the right diagnosis and structured management, recovery can be smooth and complete.
Conclusion:
Dr. Harpreet Singh’s key message is simple —Adhesive capsulitis is primarily a clinical diagnosis, confirmed by loss of external rotation and exclusion of other causes through imaging. A careful combination of history, examination, physiotherapy, and selective interventions ensures excellent outcomes in most patients.
Click Here to Watch: The Expert’s Guide to Mastering Adhesive Capsulitis Diagnosis by Dr. Harpreet Singh
