# Frozen Shoulder > Frozen shoulder (adhesive capsulitis) for NEET-PG Orthopaedics: three phases, capsular pattern of restriction, diabetes link, hydrodilatation and release. - Canonical URL: https://prepelephant.com/topics/neet-pg/orthopaedics/frozen-shoulder - Exam / course: NEET-PG · Subject: Orthopaedics - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Frozen Shoulder", PrepElephant, https://prepelephant.com/topics/neet-pg/orthopaedics/frozen-shoulder ## Direct answer Three phases — freezing, frozen and thawing — define adhesive capsulitis, an idiopathic contracture of the joint capsule producing global restriction of both active and passive shoulder motion in a capsular pattern: external rotation worse than abduction worse than internal rotation. It hits people between 40 and 60, women more than men, and travels strongly with diabetes mellitus (more severe, more bilateral and slower there), thyroid disease, immobilisation, and overlap with early rotator cuff disease. Pain at rest and at night dominates the freezing months, stiffness dominates the frozen phase, and the thawing phase unwinds slowly; the whole natural history spans one to three years, leaving a minority with permanent restriction. Diagnosis is clinical — loss of passive external rotation is the key finding separating it from cuff tears — and treatment escalates from physiotherapy stretching and intra-articular steroid or hydrodilatation to manipulation under anaesthesia and arthroscopic capsular release, with diabetic control addressed throughout. ## What you must remember - **Phases with timelines:** freezing (roughly 3-9 months, pain dominant), frozen (4-12 months, stiffness dominant, sleep disturbance), thawing (12-42 months, gradual return of motion). - **Capsular pattern:** external rotation lost first and most, then abduction, then internal rotation — passive restriction equal to active, distinguishing capsulitis from cuff tear at the bedside. - **Associations:** diabetes mellitus (bilateral in up to a third, often sequential), thyroid disorders, dyslipidaemia, immobilisation, and post-surgical or post-traumatic capsulitis. - **Treatment ladder:** analgesia and structured stretching physiotherapy first; intra-articular corticosteroid early in the painful phase; hydrodilatation for persistent restriction; manipulation under anaesthesia or arthroscopic capsular release for refractory stiffness after months of failed conservative care. - **Diabetic caveat:** slower recovery, frequent recurrence or bilaterality, so glycaemic control and realistic counselling about the 18-24 month horizon are part of management; forceful manipulation in osteoporotic diabetics risks fracture. - **Differential anchors:** cuff tear (full passive range), glenohumeral arthritis (radiograph), locked posterior dislocation, cervical radiculopathy. ## Walking through a diabetic's stiff shoulder A 55-year-old woman with type 2 diabetes of twelve years reports eight months of right shoulder pain — night pain that wakes her, inability to reach her back hook, and progressive loss of overhead reach. Passive external rotation at 90 degrees abduction is about 10 degrees (normal 70-90), abduction 90 degrees with scapular hitching, internal rotation to the sacrum: global passive restriction in the capsular pattern. Cuff tests are limited by stiffness rather than weak, and a radiograph is unremarkable. The diagnosis is adhesive capsulitis in transition from freezing to frozen, and the first prescription is honesty about time: she is months into a one-to-three year condition; physiotherapy is a daily stretching habit, not a weekly ritual. She starts a structured home programme — pendulum exercises, passive external rotation with a stick, pulley abduction, behind-the-back internal rotation — with an intra-articular steroid injection to blunt the inflammatory pain that blocks stretching. Her glycated haemoglobin is addressed with the physician. At four months sleep has improved but external rotation is unchanged; hydrodilatation follows, and if months of diligent stretching still leave her restricted, arthroscopic capsular release with gentle manipulation frees the anterior capsule and rotator interval, with supervised physiotherapy the same day — the window after release is when motion is won. ## How the exam frames it Two discriminations carry most marks. First, frozen shoulder versus rotator cuff tear: both hurt at night and limit active motion, but passive external rotation is preserved (cuff) or globally lost (capsulitis) — the single finding that settles a stem. Second, the phase timeline: steroid injections work best early, while release surgery belongs to the established stiff phase after conservative failure, not the acute painful one. Diabetes is the most-tested association, with the triple of severity, bilaterality and slow recovery. In Indian clinics "periarthritis shoulder" labels every painful stiff shoulder, and the exam-relevant correction is that it is an umbrella term — capsulitis, cuff tears and impingement are distinct entities with different treatments; the other Indian reality is the heavy burden of undiagnosed diabetes, so a stiff shoulder in a middle-aged adult deserves a blood glucose check as part of the workup. ## Frequently asked questions ### What is the capsular pattern of restriction? External rotation lost first and most, followed by abduction and then internal rotation, with passive and active limitation equal — unlike cuff tears, where passive range stays full. ### What are the three phases of adhesive capsulitis? Freezing (pain-dominant, 3-9 months), frozen (stiffness-dominant, 4-12 months) and thawing (gradual recovery, 12-42 months), with the whole history often spanning 1-3 years. ### Why is diabetes mellitus the classic association? Capsular fibrosis is more aggressive in diabetics — shoulders stiffer, recovery slower, and involvement bilateral or sequential in a substantial proportion — making glycaemic control part of treatment. ### When is arthroscopic capsular release indicated? Established refractory stiffness after months of failed physiotherapy, injections and often hydrodilatation — releasing the rotator interval, coracohumeral ligament and anterior capsule, with immediate rehabilitation. ### How does hydrodilatation work? Fluid injected under pressure distends the contracted capsule, disrupting adhesions and improving compliance — a middle rung between injection and formal release.