Management of Shoulder Sclerosis (Adhesive Capsulitis/Frozen Shoulder)
For adhesive capsulitis, initiate treatment with gentle stretching and mobilization exercises focusing on external rotation and abduction, combined with analgesics and intra-articular corticosteroid injections when indicated, reserving surgical intervention for patients who fail to improve after 3-6 months of conservative therapy. 1
Initial Conservative Management
Range of Motion Therapy (First-Line Treatment)
- Begin with gentle stretching and mobilization techniques targeting external rotation and abduction specifically, as external rotation limitation correlates most significantly with shoulder pain onset and progression to frozen shoulder 1, 2
- Progress active range of motion gradually while restoring shoulder girdle alignment and strengthening weak muscles 1
- Active, active-assisted, or passive range of motion exercises prevent progression to complex regional pain syndrome (CRPS) 1
Pharmacologic Management
- Use analgesics (acetaminophen or ibuprofen) for pain relief when no contraindications exist 1
- Administer intra-articular triamcinolone injections for significant pain reduction, as these have demonstrated significant effects on pain intensity 1
- Consider subacromial corticosteroid injections specifically when pain relates to rotator cuff or bursal inflammation in the subacromial region 1
Adjunctive Modalities
- Apply ice, heat, and soft tissue massage as supportive measures 1
- Use functional electrical stimulation to improve pain-free lateral rotation, though it may not reduce overall pain intensity 1
- Consider shoulder strapping, which shows trends toward less pain at 6 weeks and better upper limb function 1
Spasticity-Related Management
- Inject botulinum toxin into subscapularis and pectoralis muscles when hemiplegic shoulder pain relates to spasticity 1, 2
- This targets the specific muscles contributing to capsular restriction in spasticity-driven adhesive capsulitis 1
Prevention Strategies (Critical in Post-Stroke Patients)
- Avoid overhead pulley exercises, which encourage uncontrolled abduction and increase hemiplegic shoulder pain incidence 1
- Implement staff education protocols to prevent trauma to the affected shoulder 1
- Protect the hemiplegic limb from trauma, as inadequate protection increases capsulitis risk 2
Complex Regional Pain Syndrome (Shoulder-Hand Syndrome) Management
If CRPS develops (characterized by metacarpophalangeal and proximal interphalangeal joint pain, dorsal finger edema, trophic skin changes, and hyperesthesia):
- Initiate oral corticosteroids at 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 1
- Confirm diagnosis with triple phase bone scan showing increased periarticular uptake in distal upper extremity joints 1, 2
Surgical Intervention Criteria
Proceed to surgical management (manipulation under anesthesia, arthroscopic capsular release, or open release) when patients demonstrate:
- Failure to achieve symptomatic improvement after 3-6 months of conservative treatment 3, 4
- Continued functional disability despite appropriate physical therapy 4
- Individualize surgical timing based on patient symptoms and disease stage 5
Common Pitfalls to Avoid
- Never use overhead pulleys, as they demonstrate the highest incidence of developing hemiplegic shoulder pain 1
- Do not delay addressing external rotation limitation, as this is the most significant factor relating to shoulder pain onset 1, 2
- Recognize that adhesive capsulitis can mask motor function improvement and delay rehabilitation, potentially limiting assistive device use 2, 6
- Monitor for depression and sleep disturbances, as these significantly impact quality of life and require concurrent management 7, 6
Treatment Staging Considerations
The condition progresses through three stages (freezing, frozen, thawing), each lasting 4-6 months 8: