New York State Medical Treatment Guidelines for Adhesive Capsulitis / Frozen Shoulder Disorder in workers compensation patients

The guidelines formulated by the New York State Workers Compensation Board aim to assist healthcare professionals in delivering appropriate treatment for adhesive capsulitis, commonly known as frozen shoulder disorder.

Designed for medical practitioners, these Workers Compensation Board guidelines offer support in determining the right course of action for individuals with adhesive capsulitis or frozen shoulder disorder.

It’s important to emphasize that these guidelines do not replace clinical judgment or professional experience. The ultimate decision regarding treatment for adhesive capsulitis or frozen shoulder disorder should be a collaborative one, involving the patient and their healthcare provider in consultation.



Adhesive Capsulitis Overview: Adhesive capsulitis, commonly known as frozen shoulder disorder, is a condition affecting the shoulder’s soft tissues. It impacts the glenohumeral and scapulothoracic joints, leading to limitations in both passive and active range of motion.

Occupational Causes: Occupational adhesive capsulitis is often a result of chest or upper extremity trauma. Additionally, it can be associated with conditions such as stroke, traumatic brain injury, or spinal cord injury. However, primary adhesive capsulitis is seldom linked to occupational factors.


Stages of the Disorder:

Stage 1 – Initial Phase: The first stage involves acute pain and some restriction in range of motion, lasting approximately two to nine months. Notably, there is a loss of the expected 2:1 degrees of glenohumeral to scapulothoracic motion.

Stage 2 – Progressive Stiffness: Stage 2 is characterized by progressive stiffness, further loss of range of motion, and muscular atrophy. This stage can extend for an additional four to 12 months beyond Stage 1.

Stage 3 – Resolution and Recovery: The final stage sees partial or complete resolution of symptoms, along with the restoration of range of motion and strength. Typically, Stage 3 spans an additional six to nine months beyond Stage 2.

History and Mechanism of Injury:

Mechanism of Injury: Previous shoulder injuries, affecting the shoulder tendon, ligament, labrum, or other structures, are often associated with adhesive capsulitis. This condition is frequently observed in conjunction with impingement syndrome or other shoulder disorders, as indicated in the relevant subsection of this guideline.

Patient Complaints: Patients typically report pain in the sub-deltoid region, occasionally extending over the long head of the biceps or radiating down the lateral aspect of the arm to the forearm. Nighttime discomfort, particularly when sleeping on the affected side, is common. Restricted and painful motion is a notable complaint.


Physical Findings:

Restricted Range of Motion: The primary physical finding involves restricted active and passive range of motion in the glenohumeral and scapulothoracic joints. Injecting lidocaine into the glenohumeral joint and reassessing the range of motion can be a useful diagnostic step. Failure to show an increase in range of motion supports the diagnosis. Postural changes, secondary trigger points, and atrophy of the deltoid and supraspinatus muscles may also be observed.


Laboratory Tests:

General Indications: In general, laboratory tests are not typically warranted for adhesive capsulitis.

Recommendations for Select Patients: However, in specific cases where a systemic illness or disease is suspected, laboratory tests are recommended for further investigation.


Testing Procedures

X-Ray or MRI: Conventional X-rays are generally not beneficial, and MRI is usually not clinically necessary.

Recommendations for Select Patients: However, in specific cases where clinically indicated, MRI or X-ray may be recommended to rule out concomitant pathology. This is especially relevant in acute injuries or cases where nonoperative treatment has not yielded improvement, and there is a reasonably high suspicion of underlying pathology.



Recommendations for Select Patients: Arthrography is recommended in specific patients based on clinical indications. It may be beneficial in ruling out other pathology when suspected or in identifying and diagnosing a contracted joint capsule. Arthrography can also serve therapeutic purposes, as steroids and/or anesthetics may be injected, and procedures like brisement or distension arthrogram can be performed concurrently (refer to the next subsection on non-operative treatment procedures for further discussion).


Non-Operative Treatment Procedures:

Goal of Non-Operative Treatment: Non-operative treatment procedures aim to restore and maintain function. They may include:

Physical Medicine Interventions: Physical medicine interventions, such as thermal treatment, ultrasound, transcutaneous electrical nerve stimulation (TENS), manual therapy, and passive and active range-of-motion exercises, are the primary focus. As patients progress, strengthening exercises should be incorporated into the regimen.

Medications: Medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesics, can be beneficial. Narcotics are only recommended for postmanipulation or post-operative cases.


Subacromial or Intra-articular Space Injection with Steroids:

Recommendations for Select Patients: In specific cases based on clinical indications, subacromial or intra-articular space injections with steroids are recommended.

Indications: These injections may be considered when inflammation needs to be reduced, allowing therapists to enhance functional exercise and range of motion. Subacromial space injections with steroids can be beneficial if the patient positively responds to a diagnostic injection of an anesthetic. However, direct steroid injections into the tendons are not advised.

Frequency and Timing: Typically, one or two injections are sufficient, with a recommended minimum interval of three weeks between injections. The immediate effect is observed with local anesthetic, while corticosteroids may take up to three days to produce an effect. The maximum duration is limited to no more than three injections annually at the same site.


Distension Arthrography or “Brisement”:

Recommendations for Select Patients: Distension arthrography or “brisement” is recommended in specific cases based on clinical indications.

Indications: Considered in cases resistant to conservative therapy lasting at least three to six months, where range of motion remains significantly restricted. This procedure involves forcefully injecting saline, an anesthetic, and usually a steroid into the shoulder joint to disrupt the capsule.

Post-Procedure Care: Following distension arthrography or manipulation under anesthesia (MUA), early and aggressive physical medicine is crucial to maintaining range of motion and restoring strength and function. Return to work with restrictions is expected within one week, while a return to full duty is anticipated within four to six weeks.



Definition of Manipulative Treatment: Manipulative treatment, distinct from therapy, refers to the therapeutic application of manually guided forces by a physician to improve physiological function and support homeostasis altered by injury or occupational disease with clinical significance.

Recommendations for Select Patients: Manipulation is recommended in specific cases based on clinical indications.

Frequency and Duration: Frequency may range up to two to three times a week for eight to 12 weeks, depending on severity and desired effects. Subsequently, up to two treatments per week for the next four weeks may be recommended. The optimum duration is eight to 12 weeks, with a maximum duration of three months. Extended care beyond the maximum may be necessary in cases of intractable adhesions or when resumed after intra-articular injection, arthrogram, or manipulation under anesthesia (performed by a qualified surgeon).

Time to Produce Effect: For shoulder treatment, the effect is typically observed within one to six treatments.


Operative Procedures:

Manipulation Under General Anesthesia (MUA):

Recommendations for Select Patients: Manipulation under general anesthesia (MUA) is recommended for specific patients based on clinical indications.

Indications: This procedure is indicated for cases that have not responded to conservative therapy lasting at least 3-6 months and are significantly restricted in range of motion (abduction less than 90). MUA may be considered for cases with intractable restriction and can be performed by a duly qualified physician and surgeon. It may be combined with a steroid injection or distension arthrography.


Post-Operative Procedures:

Individualized Rehabilitation Program: Post-operative procedures involve an individualized rehabilitation program developed through communication among the physician, surgeon, and therapist.

Recommendations for Select Patients: These procedures are recommended for specific patients based on clinical indications.

Important Note: Early and aggressive physical medicine interventions are advised to maintain range of motion and progress strengthening. Discussions about returning to work with restrictions after surgery should be held with the treating provider. Patients are expected to approach Maximum Medical Improvement (MMI) within 8-12 weeks post-operative; however, the presence of other pathology should be taken into consideration.



Skip to content