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For further information, see CMDT Part 41-02: Musculoskeletal Injuries of the Shoulder

Key Features

Essentials of Diagnosis

  • Very painful shoulder triggered by minimal or no trauma

  • Pain out of proportion to clinical findings during the inflammatory phase

  • Stiffness during the "freezing" phase and resolution during the "thawing" phase

General Considerations

  • A self-limiting but very debilitating disease

  • Caused by acute inflammation of the shoulder capsule followed by scarring and remodeling

  • Injury to the shoulder likely triggers mast cell activation and release of growth factors and cytokines, which lead to metaplasia of fibroblasts into myofibroblasts, resulting in abnormal collagen deposition and fibrosis in the shoulder capsule


  • Commonly in patients 40- to 65-years-old

  • Occurs more often in women than in men, especially in perimenopausal women or in patients with endocrine disorders, such as diabetes mellitus or thyroid disease

  • The incidence of adhesive capsulitis is higher following shoulder trauma (such as surgery) or breast cancer care (such as mastectomy), which may create a pro-inflammatory condition in the shoulder

Clinical Findings

  • Painful shoulder that has a limited range of motion with both passive and active movements

  • A useful clinical sign is limitation of movement of external rotation with the elbow by the side of the trunk (Table 41–1)

  • Strength is usually normal but can appear diminished when the patient is in pain

  • There are three phases

    • Inflammatory phase

      • Usually lasts 4–6 months

      • Patients complain of a very painful shoulder

      • No obvious clinical findings to suggest trauma, fracture, or rotator cuff tear

    • Freezing phase

      • Also usually lasts 4–6 months

      • The shoulder becomes stiffer and stiffer even though the pain is improving

    • Thawing phase: can take up to 1 year as the shoulder slowly regains its motion

Differential Diagnosis

  • Glenohumeral arthritis

  • Calcific tendonitis

Table 41–1.Shoulder examination.

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