What is the best medical management for adhesive capsulitis?

Best Medical Management for Adhesive Capsulitis

The optimal medical management for adhesive capsulitis combines intra-articular corticosteroid injection with physical therapy as first-line treatment, followed by supervised exercise programs throughout all disease stages. 1, 2

Initial Conservative Treatment Approach

First-Line Pharmacological Management

• Intra-articular corticosteroid injection is the most effective initial intervention, providing superior short-term pain relief (0-8 weeks) and sustained improvement in range of motion both short-term and long-term (up to 24 weeks) compared to placebo 2
• NSAIDs at maximum dose should be used concurrently for pain and inflammation control, taking individual risk factors into account 3, 4
• The corticosteroid injection provides rapid pain relief and functional improvement, though pain relief benefits diminish after 8 weeks while ROM improvements persist 2

Essential Physical Therapy Component

• Active, supervised physical therapy must be initiated immediately and continued throughout all disease stages 5, 1, 6
• Physical therapy combined with NSAIDs demonstrates statistically significant long-term improvement in all movement directions: elevation, external rotation, and internal rotation 3
• Stretching techniques are mandatory in rehabilitation programs, with posterior glenohumeral mobilizations and high-grade mobilizations showing particular effectiveness 6
• Active approaches are strongly preferred over passive modalities 5

Evidence-Based Combination Strategies

Proven Effective Combinations

• Combining intra-articular corticosteroid injection with physical therapy has the strongest evidence base for improving shoulder pain, ROM, and function 1, 2
• Suprascapular nerve block (SSNB) combined with physical therapy and/or corticosteroid injection offers additive benefits for pain control and functional improvement 1
• Hydrodilatation as an adjunct to physical therapy provides additional ROM improvements when first-line treatments are insufficient 1

Treatment Timeline and Monitoring

Duration of Conservative Management

• Continue conservative treatment (corticosteroids, NSAIDs, physical therapy) for at least 3-6 months before considering invasive interventions 5, 4
• If inadequate response after 4-8 weeks of initial treatment, consider adding suprascapular nerve block or hydrodilatation 1
• Long-term follow-up (mean 9.2 years) demonstrates sustained improvement with conservative management, confirming this as an effective long-term strategy 3

Critical Clinical Pitfalls to Avoid

What NOT to Do

• Avoid long-term systemic corticosteroids - they lack efficacy and carry significant complication risks 5
• Do not rely solely on passive physical therapy modalities; active, supervised exercise is essential 5, 6
• Do not discontinue physical therapy after initial pain relief; continue throughout all disease stages for optimal outcomes 1, 6
• Ultrasound therapy has not proven effective for adhesive capsulitis and should not be prioritized 6

Patient Education and Exercise

• Educate patients that adhesive capsulitis is self-limited but requires active participation in treatment 4
• Encourage regular exercise and stretching oriented toward daily activities 5, 6
• Emphasize that conservative management provides excellent long-term results when properly implemented 3

When to Consider Advanced Interventions

• Surgical management (manipulation under anesthesia or arthroscopic capsular release) should only be considered after 3-6 months of failed conservative therapy 4
• Approximately 2-5% of the population develops adhesive capsulitis, with most responding to the conservative approach outlined above 4