The Pathogenesis and Classification of Shoulder Stiffness


The members of the Upper Extremity Committee of ISAKOS meet in Amsterdam in May 2014 with the aim to create a consensus statement on the definition, classification and treatment of the stiff shoulder. The committee recommended that the term “stiff shoulder” is used to describe the patient who presents with a restricted range of motion and that the aetiology can be due to primary or secondary causes. The term “frozen shoulder” is to be used exclusively for idiopathic stiff shoulder and “secondary stiff shoulder” for those cases with a known aetiology. We do not recommend the use of the term adhesive capsulitis.

The committee recommends that the stiff shoulder be classified as intra-articular (cartilage and synovium), capsular and extra-articular. The extra-articular components include the rotator cuff muscle and tendon, but also factors remote to the joint such as heterotopic ossification, burns contracture and neurological causes.

The “shoulder machine” is described with its neurological control, the motor and the articular components of the joint. The stiff shoulder is due to the pathoanatomical consequences of the primary insult, pathological response and secondary insult.


Stiff shoulder Frozen shoulder Pathology Aetiology ISAKOS Pathoanatomy 


  1. 1.
    Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg. 2011;19(9):536–42.PubMedGoogle Scholar
  2. 2.
    Cuomo F, Holloway GB. Diagnosis and management of the stiff shoulder. In: Iannotti JP, Williams Jr GR, editors. Disorders of the shoulder – diagnosis and management. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 541–60.Google Scholar
  3. 3.
    Bunker T. Time for a new name for frozen shoulder – contracture of the shoulder. Shoulder Elbow. 2009;1(1):4–9.CrossRefGoogle Scholar
  4. 4.
    Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg. 2011;20(2):322–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Hakim AJ, Cherkas LF, Spector TD, MacGregor AJ. Genetic associations between frozen shoulder and tennis elbow: a female twin study. Rheumatology. 2003;42:739–42.PubMedGoogle Scholar
  6. 6.
    Hertel R, Ballmer FT, Lombert SM, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5(4):307–13.CrossRefPubMedGoogle Scholar
  7. 7.
    Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl. 1969;119:1–59.CrossRefPubMedGoogle Scholar
  8. 8.
    Morrey BF. Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty. J Bone Joint Surg Am. 1990;72(4):601–18.PubMedGoogle Scholar
  9. 9.
    Watts AC, Bain GI, Shrestha K, Alexander J. Wrist arthroscopy: the future. In: Savoie III FH, Field LD, editors. AANA advanced arthroscopy: the elbow and wrist. Philadelphia: Saunders Elsevier; 2010. p. 289–98.Google Scholar
  10. 10.
    Watts AC, Bain GI. New techniques in elbow arthroscopy. In: Savoie III FH, Field LD, editors. AANA advanced arthroscopy: the wrist and elbow. Philadelphia: Saunders/Elsevier Health Sciences; 2010. p. 124–31.Google Scholar

Copyright information

© ISAKOS 2015

Authors and Affiliations

  • Gregory I. Bain
    • 1
    • 2
    • 3
    • 4
    • 5
  • Harry D. S. Clitherow
    • 3
    • 4
    • 5
  1. 1.Department of Orthopaedic SurgeryFlinders University of South AustraliaAdelaideAustralia
  2. 2.Department of Orthopaedic SurgeryFlinders Medical CentreAdelaideAustralia
  3. 3.Department of Orthopaedics and TraumaUniversity of AdelaideAdelaideAustralia
  4. 4.Department of Orthopaedics and TraumaRoyal Adelaide HospitalAdelaideAustralia
  5. 5.Department of Orthopaedics and TraumaModbury Public HospitalAdelaideAustralia

Personalised recommendations