What is the recommended treatment for adhesive capsulitis?

Treatment for Adhesive Capsulitis

The recommended treatment for adhesive capsulitis involves a combination of physical therapy with supervised exercise as the cornerstone of management, supplemented by NSAIDs for pain control, and corticosteroid injections for accelerated recovery in the early painful phase.

Initial Management

Pharmacological Interventions

• NSAIDs: Strongly recommended as first-line treatment for pain management 1

  • Ibuprofen 1.2g daily (can be increased to 2.4g daily if needed)
  • Can be combined with acetaminophen (up to 4g daily) for inadequate relief

• Corticosteroid Injections:

  • Intra-articular corticosteroid injections provide faster pain relief and earlier improvement in the first 8 weeks compared to NSAIDs alone 2
  • More effective for short-term pain relief but benefits may not sustain long-term 3
  • Results in greater improvement in passive range of motion both in short and long term 3
  • Limit to 2-3 injections with 4-6 weeks between injections 1

Physical Therapy

• Strongly recommended over no physical therapy 4
• Active interventions (supervised exercise) are conditionally recommended over passive interventions (massage, ultrasound, heat) 4
• Land-based physical therapy is conditionally recommended over aquatic therapy 4

Phased Rehabilitation Approach

Initial Phase (0-4 weeks)

• Pain control and protected range of motion 1
• RICE protocol (rest, ice, compression, elevation) for pain and inflammation management 1
• Gentle, progressive stretching exercises 5

Intermediate Phase (4-8 weeks)

• Progressive strengthening exercises 1
• Proprioception training 1
• Low-load strengthening exercises starting with seated exercises and progressing to standing exercises 1

Advanced Phase (8-12 weeks)

• Sport-specific or occupation-specific training 1
• Functional rehabilitation 1

Treatment Algorithm

1. Start with NSAIDs and physical therapy concurrently

   • Physical therapy and corticosteroid injections combined may provide greater improvement than physical therapy alone 6

2. Consider corticosteroid injection if pain is severe or limiting progress

   • Particularly beneficial in the early "freezing" (painful) stage 2
   • Helps accelerate recovery and improve range of motion 3

3. Continue with progressive physical therapy program

   • Focus on eccentric strengthening exercises 1
   • Gradually increase intensity as pain allows 1

4. Monitor for improvement over 8-12 weeks

   • If minimal improvement after 6-12 weeks of nonsurgical treatment, consider surgical options 6

Surgical Considerations

• Consider surgical consultation if:

  • Pain persists despite 3-6 months of well-managed conservative treatment 1
  • Functional limitations significantly impact quality of life 1
  • Progressive joint degeneration is evident on follow-up imaging 1

• Surgical options include:

  • Manipulation under anesthesia 6
  • Arthroscopic capsule release 6

Important Considerations and Pitfalls

• Avoid injections around Achilles, patellar, and quadriceps tendons due to risk of tendon rupture 4
• Accurate diagnosis is crucial - other shoulder pathologies can mimic adhesive capsulitis 5
• The condition is often self-limiting but recent evidence shows persistent functional limitations if left untreated 6
• Patients with diabetes mellitus and hypothyroidism have increased prevalence of adhesive capsulitis and may require more aggressive management 6
• Criteria for return to full activity: complete resolution of pain, full range of motion, strength symmetry >90% compared to uninjured side, and successful completion of functional tests 1

By following this structured approach to treatment, most patients with adhesive capsulitis will experience significant improvement in pain and function without requiring surgical intervention.