Adhesive Capsulitis (Frozen Shoulder)

Who: Peak 40–65, more often women. Diabetes is the big one. It also happens in older adults, where glenohumeral OA is the competing pattern.
What: Deep ache in the shoulder and upper arm, may refer to the neck or biceps region. Rarely below the elbow.
How it behaves: Pain first, stiffness second. Everything hurts at end range, there's no comfortable position, and night pain is prominent early.

The illness script in one line: progressive loss of active and passive range, external rotation worst, with a firm end-feel — in a shoulder that hurt before it stiffened.

The numbers that matter:

(Prevalence: [1], German general practice, 1,207 practices. Diabetes: [2], six case-control studies, 5,388 people.)

It's much less common than rotator cuff-related shoulder pain — but you will meet it on a five-week block, and it's the one students most often mislabel as a cuff.

⚠️ No Australian guideline exists for this presentation, and the guideline situation is worse than that. Anchored to the JOSPT Adhesive Capsulitis CPG [3] — still the only physio-facing guideline, and now thirteen years old. The 2025 international Delphi consensus [4] exists precisely because the available guidelines are few and outdated. Quote both.

Pattern > Label. The whole diagnosis is one comparison: does the passive range go too?

Five stages, in the order your course teaches them. Insidious onset, so run BEHAVIOUR before HISTORY.

MAIN PROBLEM

Listen for the function, because it's specific and it's brutal: hair washing, bra strap, back pocket, seatbelt, reaching into the back seat, and sleep. If they lead with "I can't sleep on it and I can't do my hair", you're already most of the way there.

BODY CHART

• Deep, poorly localised ache over the deltoid and upper arm. They rub it with a whole hand.
• May refer to the neck or the biceps region. Rarely below the elbow — symptoms into the hand are a cervical question until cleared.
• Clear the cervical and thoracic spine, the elbow, and both upper limbs for neurological symptoms.

BEHAVIOUR

• Aggs: every end-range movement. Reaching behind, overhead, across the body, quick unguarded movements, and lying on it.
• Eases: arm supported and still. Note what's different from a cuff — there often isn't a good easing position, especially early.
• 24-hr pattern: stiff and sore first thing, loosens a little with movement, worse again by evening.
• Night: prominent, early, and a major driver of why they've come. Don't skip past it — sleep loss is what makes this presentation feel unbearable, and patients describe exactly that [5].
• Severity: VAS 0–10 at best / at worst / right now.
• Irritability: vigour of the provoking activity, severity provoked, and time to settle. All three. In this pattern irritability doesn't just set your O/E depth — it sets whether stretching is treatment or provocation.

HISTORY

• Insidious onset over weeks. Pain came first; the stiffness crept in after.
• Ask about diabetes, every time. Odds of frozen shoulder are 3.69× higher with diabetes (Dyer 2023). Also ask about thyroid disease, and about a previous frozen shoulder on the other side (Kelley 2013).
• Recent immobilisation, shoulder or upper arm injury, thoracic injury, or surgery — in the 65+ data the strongest associations after OA were injury to the shoulder and upper arm (OR 1.85) and to the thorax (OR 1.47) (Jacob 2023).
• What have they been told, and what do they believe? Fear matters here more than most patterns — see below.

SPECIAL / SCREENING QUESTIONS

General health, weight loss, night sweats, fever, malignancy history (including breast and any axillary surgery or radiotherapy), inflammatory features, medications, and neurological symptoms in the arm. See §4.

The bit most students skip

Fear and expectation are prognostic here, not just pleasant to ask about. In a 120-patient cohort on 12 weeks of multimodal care, baseline kinesiophobia predicted shoulder-specific disability afterwards, baseline DASH predicted upper-limb disability, and comorbidities predicted quality of life [6]. Across the wider prognostic literature, pain-related fear, depression and catastrophising track with outcome [7].

So the question "what are you most worried this is?" is doing diagnostic and prognostic work at the same time.

On the three phases

Freezing → frozen → thawing is a useful teaching model and you should know it. Treat the boundaries as fuzzy: they're a description, not a staging system with criteria, and nobody will grade you on declaring a phase. What matters clinically is irritability today.

Top competing patterns, one discriminating feature each.

The discriminator that does the most work: passive external rotation with the arm by the side. Frozen shoulder loses it, and it's the direction it loses first (ER > ABD > flexion). A cuff keeps it. A big tear keeps it. Test it before you test anything else.

And measure it against the other shoulder, because that comparison has numbers behind it. In 77 adhesive capsulitis and 57 calcific tendinitis patients, passive glenohumeral range was compared with the contralateral unaffected side [8]:

Read the right-hand column twice. Calcific tendinitis loses a bit of abduction and keeps its external rotation completely. That is the cleanest separation on this page, and it takes one movement on each side.

(Retrospective, level 3, single surgical-referral institution — but the effect is large and the test is free.)

Jones' hypothesis categories that change your plan here: sources of symptoms (capsule vs cuff vs joint surface), pathophysiology (this one genuinely matters — see §6), precautions (irritability decides whether you stretch at all), and patient perspectives (fear is prognostic).

Same end-feel, different story. Firm and capsular = capsule. Hard and grating = the joint. Guarded and pain-limited = neither.