What is the initial treatment for adhesive capsulitis?

Initial Treatment for Adhesive Capsulitis

The initial treatment for adhesive capsulitis should include physical therapy combined with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line management to reduce pain and improve range of motion. 1, 2

Understanding Adhesive Capsulitis

Adhesive capsulitis, commonly known as "frozen shoulder," is characterized by:

• Painful, gradual loss of shoulder motion, especially external rotation
• Inflammation and thickening of the shoulder capsule
• Progression through three phases: freezing (painful), frozen (adhesive), and thawing

First-Line Treatment Approach

1. Pain Management

• NSAIDs: First-line medication for pain and inflammation 3, 1
  • Options include oral NSAIDs (ibuprofen, naproxen) or topical NSAIDs for localized pain
  • Acetaminophen (up to 4g/day) if NSAIDs are contraindicated 3

2. Physical Therapy

• Begin early to prevent further loss of motion 1, 4
• Focus on:
  • Gentle, progressive stretching exercises
  • Range of motion exercises, particularly for external rotation
  • Graded activity to increase functional use of the affected shoulder 5
  • Postural alignment correction to reduce muscle overactivity 5

3. Heat Therapy

• Apply moist heat before exercises to improve tissue extensibility 5
• Consider thermal interventions such as alternating heat and cold 5

Second-Line Interventions

If symptoms persist after 4-6 weeks of first-line treatment:

1. Corticosteroid Injections

• Intra-articular corticosteroid injections provide better short-term pain relief (0-8 weeks) compared to placebo 6
• Also improve range of motion in both short and long term 6
• Should be limited to 2-3 injections with 4-6 weeks between injections 5

2. Advanced Physical Therapy Techniques

• Deep transverse friction massage 5
• Ultrasound therapy to increase collagen synthesis 5
• Joint mobilization techniques

Treatment Algorithm

1. Weeks 0-4: NSAIDs + physical therapy + heat therapy
2. Weeks 4-8: If inadequate improvement, add corticosteroid injection while continuing physical therapy
3. Weeks 8-12: Reassess progress; consider second injection if needed
4. Beyond 12 weeks: If minimal improvement, consider surgical options (manipulation under anesthesia or arthroscopic capsule release) 1

Important Considerations

• Avoid prolonged immobilization as it leads to muscle deconditioning 5
• Limit splinting as it may prevent restoration of normal movement 5
• Reassess pain and function every 4-6 weeks 5
• Adjust treatment plan if no improvement after 8-12 weeks 5

Common Pitfalls to Avoid

• Rushing to invasive procedures before adequate trial of conservative measures 5
• Overreliance on passive treatments without active patient participation 5
• Focusing only on pain relief without addressing range of motion 5
• Using corticosteroid injections as first-line treatment 5

Recent evidence challenges the traditional belief that adhesive capsulitis always resolves spontaneously within 1-2 years, as some patients may develop persistent functional limitations if left untreated 1. Therefore, early and appropriate intervention is essential to optimize outcomes and prevent long-term disability.