Initial Treatment for Adhesive Capsulitis
Start with combined intra-articular corticosteroid injection and physical therapy, as this combination provides superior outcomes compared to either treatment alone. 1, 2
First-Line Treatment Algorithm
Immediate Management
- Begin with intra-articular corticosteroid injection combined with physical therapy - this combination demonstrates the strongest evidence for improving pain, range of motion, and shoulder function 1, 2
- Add NSAIDs for pain control during the initial treatment phase 3, 2
- Consider short-term oral corticosteroids as an adjunct if pain is severe 2
Physical Therapy Components
- Initiate gentle, progressive stretching exercises immediately after corticosteroid injection 4
- Focus on external rotation first, as this is the most significantly affected motion and relates strongly to pain onset 5
- Progress to abduction exercises, which become severely restricted in the frozen stage 5
- For post-surgical patients or those with specific risk factors, include neck, rotator cuff, and posterior shoulder girdle strengthening while addressing anterior shoulder girdle flexibility 6
Treatment Timing Considerations
Stage 1 (Freezing Phase) - Optimal Treatment Window
- Treat aggressively during stage 1 before complete range of motion loss occurs - patients diagnosed and treated in stage 1 achieve better outcomes than those treated in stage 2 7
- Ultrasound-guided glenohumeral hydrodistention combined with targeted exercise shows significant success when initiated early 7
Stage 2 (Frozen Phase)
- Patients in stage 2 can still regain shoulder range of motion in most planes, though internal rotation recovers with more difficulty 7
- Continue combined corticosteroid injection and physical therapy approach 1
Additional Treatment Options
Suprascapular Nerve Block (SSNB)
- Consider adding SSNB to physical therapy and/or corticosteroid injection for enhanced pain relief and functional improvement 1
- SSNB combined with other conservative treatments shows additive benefits 1
Hydrodilatation
- May be added as an adjunct treatment to improve shoulder range of motion 1, 7
- Particularly effective when combined with physical therapy in early-stage disease 7
Critical Pitfalls to Avoid
- Do not delay treatment waiting for spontaneous resolution - recent evidence shows persistent functional limitations if left untreated, contradicting the traditional belief of full self-resolution 2
- Avoid overhead pulley exercises in post-stroke patients - improper handling during rehabilitation increases risk of hemiplegic shoulder pain 5
- Do not rely on physical therapy alone - combination with corticosteroid injection provides greater improvement than physiotherapy as monotherapy 2
Monitoring and Escalation
- Evaluate response at 2,4, and 6 months after initial treatment 7
- If minimal improvement occurs after 6-12 weeks of conservative treatment, consider surgical options including manipulation under anesthesia or arthroscopic capsule release 2
- General guideline for surgical intervention: failure to obtain symptomatic improvement and continued functional disability following ≥6 months of physical therapy 4