Diagnosis and Treatment of Adhesive Capsulitis
The most effective approach to adhesive capsulitis involves early diagnosis through clinical evaluation and appropriate imaging, followed by a stepwise treatment protocol starting with conservative measures (NSAIDs, physical therapy) and progressing to more invasive interventions (injections, manipulation, or surgical release) if symptoms persist beyond 6 months. 1
Diagnostic Features
- Adhesive capsulitis presents with gradual onset of shoulder pain and progressive limitation of both active and passive range of motion, particularly external rotation 2
- Bone scintigraphy may show increased activity in the affected shoulder, as reported by the American College of Radiology 3
- MRI findings of coracohumeral ligament thickening provide high specificity for diagnosis, though imaging is not always necessary 1
- Differential diagnosis must rule out other conditions that can mimic adhesive capsulitis, including rotator cuff pathology, glenohumeral arthritis, and other shoulder disorders 2
Clinical Stages and Natural History
- Traditionally considered a self-limiting condition progressing through phases of pain and stiffness over 1-2 years 1
- Recent evidence challenges this view, suggesting persistent functional limitations may occur if left untreated 1
- The condition significantly impacts quality of life, potentially contributing to depression and sleep disturbances 3
- Adhesive capsulitis can delay rehabilitation and functional recovery in patients with other conditions, such as stroke 3
Treatment Algorithm
First-Line Conservative Management (0-3 months)
- NSAIDs for pain control and inflammation reduction 1, 4
- Short-term oral corticosteroids may provide temporary relief 1
- Physical therapy focusing on gentle, progressive stretching exercises to maintain and improve range of motion 2
- Early education about the condition and expected course 1
Second-Line Interventions (3-6 months if inadequate improvement)
- Intra-articular corticosteroid injections, which may be more effective when combined with physical therapy 1
- Hyaluronate injections as an alternative to corticosteroids 5
- Suprascapular nerve blocks for pain control 5
- Distension arthrography (hydrodilatation) to expand the joint capsule 5, 1
Third-Line Interventions (>6 months with persistent symptoms)
- Manipulation under anesthesia to break adhesions and improve range of motion 1, 2
- Arthroscopic capsular release, which allows for direct visualization and targeted treatment of the contracted capsule 5
- Open surgical release for severe, recalcitrant cases 5
Evidence for Specific Modalities
- Physical therapy interventions should focus on posterior glenohumeral mobilization techniques and high-end mobilizations 6
- Ultrasound therapy has not demonstrated significant efficacy, while radial shockwave therapy and cryotherapy show more promising results 6
- Stretching exercises are mandatory components of any rehabilitation program 6
- Long-term studies support the efficacy of conservative treatment with physical therapy and NSAIDs, showing statistically significant improvements in all movement directions (elevation, external and internal rotation) 4
Special Considerations
- Patients with diabetes mellitus and hypothyroidism have increased prevalence of adhesive capsulitis and may require more aggressive management 1
- Breast cancer patients should be monitored for early signs of adhesive capsulitis, as early identification and treatment may prevent unnecessary pauses during exercise programming 7
- Post-surgical patients with adhesive capsulitis may benefit from exercises focusing on neck, rotator cuff, and posterior shoulder girdle strengthening while addressing anterior shoulder girdle flexibility 7
Treatment Pitfalls to Avoid
- Delaying diagnosis and appropriate treatment may lead to prolonged disability and persistent functional limitations 1
- Overly aggressive physical therapy in the acute painful phase can exacerbate symptoms 2
- Neglecting post-operative therapy after surgical interventions increases the risk of recurrence 2
- Failing to identify and address underlying conditions (diabetes, thyroid disorders) that may contribute to adhesive capsulitis 1