This paper by Neviaser and Neviaser argues that 'frozen shoulder' is a clinically overused term applied to two distinct entities requiring different management. It defines true adhesive capsulitis by its pathology, arthrographic findings, and four arthroscopic stages, then lays out a stepwise treatment algorithm from gentle stretching through manipulation to open capsulotomy.
The key clinical decision point this paper addresses is one you will face in every shoulder clinic: does this patient have adhesive capsulitis, or a stiff and painful shoulder from some other pathology?
The distinction matters because the treatments diverge completely. Manipulation is appropriate for true adhesive capsulitis but is not appropriate for the stiff and painful shoulder — where the motion restriction is pain-mediated, not structural.
Arthrography resolves the question: less than 10 mL capacity with axillary fold obliteration confirms capsular contracture. Radiographs and physical exam alone cannot make this call reliably.
The four-stage classification shapes the treatment arc. Stage I disease. Minimal motion loss, pure synovitis. Is a trap: it looks like impingement, and operating on it as impingement is an error. The authors explicitly state that if synovitis is seen at diagnostic arthroscopy before a planned decompression, you should stop and reframe the diagnosis.
For residents, the board-testable framework is: gentle stretching first, manipulation under anesthesia (as an inpatient) if no progress past 90° elevation after months of therapy, and open anterior capsulotomy only when manipulation is contraindicated or has failed.
This paper by Neviaser and Neviaser argues that 'frozen shoulder' is a clinically overused term applied to two distinct entities requiring different management. It defines true adhesive capsulitis by its pathology, arthrographic findings, and four arthroscopic stages, then lays out a stepwise treatment algorithm from gentle stretching through manipulation to open capsulotomy.
The key clinical decision point this paper addresses is one you will face in every shoulder clinic: does this patient have adhesive capsulitis, or a stiff and painful shoulder from some other pathology?
The distinction matters because the treatments diverge completely. Manipulation is appropriate for true adhesive capsulitis but is not appropriate for the stiff and painful shoulder — where the motion restriction is pain-mediated, not structural.
Arthrography resolves the question: less than 10 mL capacity with axillary fold obliteration confirms capsular contracture. Radiographs and physical exam alone cannot make this call reliably.
The four-stage classification shapes the treatment arc. Stage I disease. Minimal motion loss, pure synovitis. Is a trap: it looks like impingement, and operating on it as impingement is an error. The authors explicitly state that if synovitis is seen at diagnostic arthroscopy before a planned decompression, you should stop and reframe the diagnosis.
For residents, the board-testable framework is: gentle stretching first, manipulation under anesthesia (as an inpatient) if no progress past 90° elevation after months of therapy, and open anterior capsulotomy only when manipulation is contraindicated or has failed.