Is arthrolysis (arthrodilation) or cortisone shot more effective for treating adhesive capsulitis (frozen shoulder)?

Corticosteroid Injection is More Effective Than Arthrodilation for Frozen Shoulder

For adhesive capsulitis (frozen shoulder), corticosteroid injection is the evidence-based first-line treatment, while arthrodilation lacks sufficient quality evidence to support its use. The available guidelines and research consistently demonstrate that corticosteroid injections provide significant pain relief and functional improvement, whereas arthrodilation is not addressed in major shoulder treatment guidelines 1, 2.

Evidence Supporting Corticosteroid Injection

Efficacy and Outcomes

• Intra-articular corticosteroid injection into the glenohumeral joint provides superior outcomes compared to other injection sites or oral corticosteroids 3, 4, 5.

• Injection into the rotator interval yields the best results for early-stage frozen shoulder, with faster improvements in pain, passive range of motion, and function compared to intra-articular or subacromial injections alone 3.

• Intra-articular injection is significantly more effective than subacromial injection, with the subacromial approach showing inferior results up to 12 weeks post-treatment 4.

• Multisite corticosteroid injection (combined intra-articular and subacromial) provides superior pain relief, motion restoration, and functional status compared to single-site injection 6.

• Intra-articular injection achieves a "cure" rate 5.8 times higher at one week compared to oral corticosteroids, with 62% of patients achieving their treatment goals after one week versus only 14% with oral medication 5.

Optimal Dosing

• A dose of 40 mg triamcinolone acetonide intra-articularly provides significantly greater symptom relief than 10 mg, with more marked effects on pain and sleep disturbance than on range of motion 7.

Clinical Application Guidelines

• The American College of Physicians recommends shoulder corticosteroid injections for patients with shoulder pain lasting more than one month that has failed conservative therapy, particularly when pain intensity exceeds 4/10 or causes functional limitation 2.

• Repeat injection may be considered if a patient had ≥50% pain relief lasting at least 2 months from the first injection 2.

• 91% of patients show satisfactory improvement in pain and range of motion at 4 weeks following corticosteroid injection 2.

Absence of Evidence for Arthrodilation

• Arthrodilation (also called hydrodilatation or distension arthrography) is not mentioned in major shoulder treatment guidelines from the American Heart Association/American Stroke Association, American Academy of Orthopaedic Surgeons, or American College of Physicians 1, 2.

• No high-quality comparative studies exist directly comparing arthrodilation to corticosteroid injection for frozen shoulder in the provided evidence.

Treatment Algorithm for Frozen Shoulder

1. Initial conservative management: Physical therapy focusing on stretching and mobilization techniques, especially external rotation and abduction 1.

2. If pain persists >1 month or exceeds 4/10 intensity: Proceed with corticosteroid injection 2.

3. Optimal injection technique:

   • Use 40 mg triamcinolone acetonide 7
   • Target the rotator interval for early-stage frozen shoulder 3
   • Consider combined intra-articular and subacromial injection for maximum benefit 6, 4
   • Use ultrasound guidance for accuracy 4

4. Post-injection management:

   • Continue physical therapy 6
   • Avoid overhead pulley exercises 1
   • Assess response at 4 weeks 2

5. If inadequate response: Consider repeat injection if initial injection provided ≥50% pain relief for ≥2 months 2.

Important Caveats

• Common adverse events include injection site soreness, transient pain flare (2.5% incidence for vasovagal reaction), facial flushing, and sweating 2.

• Joint infection is extremely rare with proper aseptic technique 2.

• Short-term pain reduction is well-documented, but long-term pain reduction beyond 12 weeks has not been adequately verified 1, 4.

• The evidence specifically addresses idiopathic frozen shoulder; results may differ for secondary adhesive capsulitis 4.