Initial Treatment for Adhesive Capsulitis
The initial treatment for adhesive capsulitis should be a combination of physical therapy and NSAIDs, with consideration for intra-articular corticosteroid injection to provide additional short-term benefit, particularly in the early painful phase. 1, 2
First-Line Conservative Management
NSAIDs and Physical Therapy
- NSAIDs combined with physical therapy form the foundation of initial conservative treatment and have demonstrated statistically significant long-term improvement in shoulder elevation, external rotation, and internal rotation 3
- This combination is effective across all phases of the disease, with sustained benefits documented at mean 9.2-year follow-up 3
- Physical therapy should focus on stretching exercises targeting the capsular pattern: external rotation (most limited), followed by abduction, then internal rotation 1
Corticosteroid Injections
- Intra-articular corticosteroid injections show significant short-term benefits and should be considered as an adjunct to physical therapy 1
- The combination of physiotherapy and corticosteroid injections provides greater improvement than physiotherapy alone 2
- Short-term oral corticosteroids are an alternative option but less commonly used than intra-articular injection 2
Timing and Early Intervention
Early diagnosis and treatment are crucial - patients treated in phase 1 (freezing stage) achieve better outcomes than those treated in phase 2 (frozen stage), particularly for regaining internal rotation 4
Phase-Specific Considerations
- Phase 1 patients benefit most from early intervention with combined approaches 4
- Avoiding immobilization (such as arm slings) helps prevent progression to more severe frozen shoulder 1
- Patient education on proper positioning and movement should begin immediately 1
Additional Treatment Options
Hydrodilatation
- Ultrasound-guided glenohumeral hydrodilatation combined with physical therapy shows significant improvement in pain relief, disability reduction, and range of motion 4
- This intervention is particularly effective when performed before phase 2 4
Suprascapular Nerve Block
- SSNB combined with physical therapy and/or corticosteroid injection demonstrates additive benefits for improving shoulder pain, ROM, and function 5
- Consider this as an adjunct when pain is limiting participation in physical therapy 5
Exercise Prescription Specifics
Avoid overhead pulleys as they encourage uncontrolled abduction 1
Key exercise components include:
- Stretching is mandatory in all rehabilitation programs 6
- Focus on external rotation and abduction movements given the capsular pattern 1
- Posterior glenohumeral mobilization techniques and high-grade mobilizations are effective 6
- For post-surgical patients or those with comorbidities, emphasize neck, rotator cuff, and posterior shoulder girdle strengthening while addressing anterior shoulder girdle flexibility 7
Common Pitfalls to Avoid
- Do not assume the condition is self-limiting - recent evidence shows persistent functional limitations if left untreated, challenging the traditional "wait and see" approach 2
- Do not delay treatment waiting for imaging - diagnosis is clinical, though MRI showing coracohumeral ligament thickening has high specificity if imaging is obtained 2
- Recognize that adhesive capsulitis significantly impacts quality of life and may contribute to depression and sleep disturbances 8
When to Escalate Treatment
If minimal improvement occurs after 6-12 weeks of conservative treatment, consider surgical options including manipulation under anesthesia or arthroscopic capsule release 2