Adhesive Capsulitis Does NOT Present with Acute Overnight Onset
Adhesive capsulitis (frozen shoulder) is characterized by gradual, progressive onset of symptoms over weeks to months, not sudden overnight development. The condition progresses through three distinct phases—freezing (painful), frozen (adhesive), and thawing—with the freezing phase alone typically lasting weeks to months 1, 2, 3.
Typical Onset Pattern
- The freezing phase involves progressive restriction of movement and spontaneous onset of pain that develops gradually, not instantaneously 4
- Patients experience increasing pain and stiffness that worsens over time, with external rotation becoming the most significantly restricted motion 5, 6
- The condition is characterized by equal restriction of both active and passive motion in all planes, which develops progressively rather than acutely 5, 6
Why Acute Overnight Onset Should Prompt Alternative Diagnoses
If a patient reports waking up with sudden shoulder pain and complete loss of motion, consider these alternative diagnoses:
- Rotator cuff tear: Can present with acute onset after trauma or even spontaneously, shows focal weakness with preserved passive motion (unlike adhesive capsulitis) 6
- Calcific tendinitis: Can cause sudden severe pain when calcium deposits rupture
- Septic arthritis: Requires urgent evaluation and exclusion 5
- Acute subacromial bursitis: Can develop rapidly with inflammation 7
- Glenohumeral osteoarthritis or crystal arthropathies: Must be excluded when evaluating shoulder pain 5
Key Distinguishing Features of True Adhesive Capsulitis
- No focal weakness on resistance testing, distinguishing it from rotator cuff pathology 6
- No swelling or atrophy on examination 6
- Equal restriction of both active and passive range of motion in all planes, particularly external rotation 5, 6
- Progressive development over weeks to months, not hours 1, 3
Clinical Pitfall to Avoid
Do not confuse adhesive capsulitis with rotator cuff pathology—the latter demonstrates focal weakness and may have preserved passive motion, whereas adhesive capsulitis shows equal active and passive restriction without focal weakness 6. If a patient presents with truly acute onset (overnight), pursue imaging and alternative diagnoses rather than assuming adhesive capsulitis 3, 7.