What is the management of adhesive capsulitis?

Management of Adhesive Capsulitis

The management of adhesive capsulitis should begin with conservative treatment including physical therapy with stretching exercises, NSAIDs for pain control, and corticosteroid injections, progressing to more invasive interventions only if these fail after 3-6 months.

Understanding Adhesive Capsulitis

Adhesive capsulitis, commonly known as "frozen shoulder," is characterized by painful, gradual loss of both active and passive shoulder motion resulting from fibrosis and contracture of the joint capsule 1. It typically progresses through stages of pain and stiffness, and many patients may never fully recover 2.

Treatment Approach

First-Line Management

1. Physical Therapy

   • End-range mobilization techniques have shown significant improvements in both active and passive range of motion 3
   • Regular exercise should be encouraged as part of treatment 4
   • Physical therapy with stretching and mobilization exercises should be the cornerstone of rehabilitation 5
   • Supervised exercise programs are more effective than passive modalities 5

2. Pain Management

   • NSAIDs should be used as first-line drug treatment for pain and stiffness 4
   • Acetaminophen (up to 4g/day) can be used as first-line analgesic if NSAIDs are contraindicated 5
   • Topical NSAIDs can help reduce pain while avoiding gastrointestinal side effects 5

3. Corticosteroid Injections

   • Intra-articular corticosteroid injections provide effective short-term pain relief (0-8 weeks) 6
   • Corticosteroid injections also improve range of motion in both short and long terms 6
   • Glucocorticoid injections directed to the local site of musculoskeletal inflammation may be considered 4

Second-Line Management (if no improvement after 3-6 months)

1. Joint Distension Techniques

   • Distension arthrography may be beneficial for refractory cases 2

2. Nerve Blocks

   • Suprascapular nerve blocks can be considered for pain management 2

3. Manipulation Under Anesthesia

   • Can be considered for persistent cases not responding to conservative management 2

Surgical Intervention (for persistent cases)

1. Arthroscopic Capsular Release

   • Gradually becoming more common to avoid complications of "blind intervention" 2
   • Should be considered if pain persists despite 3-6 months of well-managed conservative treatment 5

2. Open Release

   • Useful option for recalcitrant severe cases 2

Treatment Timeline and Progression

Initial Phase (0-3 months)

• Physical therapy with stretching exercises 2-3 times per week
• NSAIDs or acetaminophen for pain control
• Consider corticosteroid injection if pain is severe

Intermediate Phase (3-6 months)

• Continue physical therapy with more aggressive stretching
• Re-evaluate for corticosteroid injection if not previously administered
• Consider joint distension techniques or nerve blocks if progress is limited

Advanced Phase (>6 months with limited improvement)

• Consider manipulation under anesthesia
• Evaluate for surgical intervention (arthroscopic capsular release)

Special Considerations

• Avoid long-term systemic glucocorticoids for patients with axial disease 4
• Patients with comorbidities like diabetes may respond differently to conservative measures 5
• Monitor progress regularly and adjust treatment plan if no improvement is seen after 8-12 weeks 5

Monitoring Effectiveness

• Regularly assess pain levels and range of motion (abduction, flexion, and rotation)
• Document functional improvements in activities of daily living
• The goal of treatment should be to maximize quality of life through control of symptoms and preservation of function 4

The evidence suggests that while many patients will improve with conservative management, some may require more invasive interventions. The treatment approach should follow a stepwise progression from conservative to more invasive options based on patient response.