What is the recommended treatment for adhesive capsulitis (frozen shoulder) in patients with Chronic Kidney Disease (CKD)?

From the Guidelines

The recommended treatment for adhesive capsulitis (frozen shoulder) in patients with Chronic Kidney Disease (CKD) involves a multimodal approach with careful medication adjustments, prioritizing physical therapy and minimal use of NSAIDs due to their potential to worsen kidney function.

Treatment Approach

The cornerstone of treatment is physical therapy, focusing on gentle stretching and range-of-motion exercises to prevent further stiffness and gradually restore shoulder mobility.

• Physical therapy should be tailored to the individual's needs and CKD stage.
• For pain management, acetaminophen is preferred at standard doses (500-1000mg every 6 hours, not exceeding 3000mg daily in CKD patients) as it has minimal renal effects 1.

Medication Considerations

• NSAIDs should be avoided or used with extreme caution due to their potential to worsen kidney function, especially in patients with chronic kidney disease stage IV or V (estimated glomerular filtration rate below 30 cc/minute) 1.
• Intra-articular corticosteroid injections (such as methylprednisolone 40mg or triamcinolone 40mg) can provide significant pain relief with minimal systemic absorption, making them relatively safe in CKD.
• Hydrodilatation (capsular distension) may be considered for resistant cases.
• Opioids should be used sparingly and with dose adjustments based on CKD stage.

Surgical Interventions

Surgical interventions like manipulation under anesthesia or arthroscopic capsular release are reserved for cases that fail conservative management after 6-12 months.

• This cautious approach is necessary because CKD patients have altered drug metabolism, increased risk of medication side effects, and often have comorbidities like diabetes that can complicate frozen shoulder management and healing 1.

Key Considerations

• CKD patients are particularly susceptible to hemodynamic insults and at higher AKI risk with exposure to nephrotoxins such as aminoglycosides, amphotericin B, non-steroidal anti-inflammatory agents, and radiocontrast 1.
• Reducing or holding CNI therapy pre- and post-contrast exposure should be considered with a temporary increase in other non-nephrotoxic immunosuppressive medications dictated by immunologic risk.

From the Research

Adhesive Capsulitis Treatment in CKD

• Adhesive capsulitis is a common problem in patients with Chronic Kidney Disease (CKD), characterized by joint stiffness and painful joint movement 2.
• Conservative treatments for adhesive capsulitis in CKD patients include non-steroid anti-inflammatory drugs, intraarticular injections, and physical therapy 2, 3.
• Platelet-rich plasma injections (PRP) have been applied as a newer approach, but there is little evidence for its effectiveness in patients with adhesive capsulitis 2.
• A study on a 70-year-old woman with CKD and adhesive capsulitis showed that PRP injections improved range of motion, but did not improve function and pain based on DASH and VAS scores 2.

Rehabilitative Treatments

• A systematic review of rehabilitative treatments for adhesive capsulitis found that multimodal therapies, including instrumental physical therapy, exercise, and anti-inflammatory drug therapy, are effective in managing the condition 4.
• The review also found that joint mobilizations, techniques adopting posterior glenohumeral approaches, and high-end mobilizations are effective, both manually and instrumentally 4.
• Stretching is a mandatory implementation in rehabilitation programs, and supervised group or home therapeutic exercises can be effective in multimodal rehabilitation programs 4.

Corticosteroid Injections

• A meta-analysis found that intra-articular corticosteroid injections lead to fast pain relief and improvement of range of motion (ROM) in patients with adhesive capsulitis 5.
• The study found that corticosteroid injections were more effective in reducing pain scores at 0 to 8 weeks, but the pain relief did not sustain in the long term 5.
• Intra-articular corticosteroid injections resulted in greater improvement in passive ROM both in the short and long terms 5.

Diagnosis and Management

• Adhesive capsulitis is characterized by pain and decreased range of motion, especially in external rotation, and has an increased prevalence in patients with diabetes mellitus and hypothyroidism 3.
• The most effective treatment for adhesive capsulitis is uncertain, but nonsurgical treatments, including nonsteroidal anti-inflammatory drugs, short-term oral corticosteroids, intra-articular corticosteroid injections, physiotherapy, acupuncture, and hydrodilatation, can be effective 3.
• Surgical treatment options, such as manipulation under anesthesia and arthroscopic capsule release, can be considered for patients who have minimal improvement after six to 12 weeks of nonsurgical treatment 3.