What are the next steps in treating a patient with adhesive capsulitis (frozen shoulder) who has not responded to steroid injections?

Treatment of Adhesive Capsulitis After Failed Steroid Injections

When steroid injections fail in adhesive capsulitis, the next step is intensive physical therapy with a structured four-direction stretching program, which successfully treats 90% of patients, though hydrodilatation (glenohumeral joint distension) combined with targeted exercise shows superior outcomes if initiated early, particularly before complete range of motion loss occurs. 1, 2, 3

Immediate Next Steps: Physical Therapy as Primary Treatment

Structured Stretching Program

• Implement a specific four-direction shoulder-stretching exercise program focusing on external rotation, abduction, forward elevation, and internal rotation 3
• External rotation exercises are the single most important component, as external rotation is the most significantly affected motion and relates most strongly to shoulder pain onset 4
• This approach achieves satisfactory outcomes in 90% of patients with phase II adhesive capsulitis, with significant improvements in pain (from mean 4.12 to 1.33 points with activity) and range of motion (average increases: 43° forward elevation, 25° external rotation, 72° glenohumeral rotation arc) 3

Supervised vs. Home Exercise

• Supervised physical therapy (land or water-based, individual or group) is more effective than home exercises alone and should be preferred 5
• Manual glenohumeral mobilizations, particularly posterior glenohumeral approaches and high-grade mobilizations, appear effective when incorporated into multimodal programs 6
• Stretching is mandatory in all rehabilitation programs regardless of other interventions 6

Alternative Intervention: Hydrodilatation

When to Consider Hydrodilatation

• Ultrasound-guided glenohumeral joint hydrodilatation (hydrodistension) combined with targeted exercise should be strongly considered, especially if the patient is still in stage 1 (freezing phase) or early stage 2 (frozen phase) 2
• This intervention shows significant improvement in shoulder range of motion in all planes except extension, with better outcomes when performed before complete range of motion reduction occurs 2
• Stage 1 patients achieve superior recovery compared to stage 2 patients, who have more difficulty recovering internal rotation 2

Hydrodilatation Outcomes

• Provides significant improvement in pain relief, reduced disability, and increased range of motion at 2,4, and 6-month follow-ups 2
• Most effective when diagnosed and treated before phase 2, when range of motion becomes completely reduced 2

Additional Therapeutic Modalities to Consider

Adjunctive Physical Therapy Techniques

• Radial extracorporeal shockwave therapy (rESWT) shows effectiveness, unlike ultrasound therapy which has not proven effective 6
• Whole body cryotherapy (WBC) demonstrates efficacy as an adjunctive treatment 6
• Manual stretching techniques should be incorporated alongside mechanical approaches 6

Oral Corticosteroids

• Short-term oral corticosteroids can be considered as an adjunct to physical therapy, though evidence is limited 1
• The combination of physiotherapy and corticosteroid injections may provide greater improvement than physiotherapy alone, suggesting oral steroids might have similar benefit 1

Timeline for Surgical Consideration

When Conservative Treatment Fails

• Surgical options (manipulation under anesthesia or arthroscopic capsular release) should be considered only after 6-12 weeks of intensive nonsurgical treatment shows minimal improvement 1
• Only 7% of patients in prospective studies required manipulation or capsular release after structured stretching programs 3
• Prior physical therapy treatment and Workers' Compensation claims/pending litigation are the only variables associated with eventual need for surgical intervention 3

Critical Prognostic Factors and Pitfalls

Predictors of Worse Outcomes

• Male gender and diabetes mellitus are associated with worse motion at final evaluation 3
• Greater severity of pain with activity at initial evaluation predicts lower functional scores at outcome 3
• Lower initial Simple Shoulder Test scores predict comparatively lower scores at final evaluation 3

Common Pitfalls to Avoid

• Do NOT delay intervention—adhesive capsulitis develops rapidly once immobilization occurs, and the window for effective treatment is narrow 7
• Avoid overhead pulley exercises as they encourage uncontrolled abduction and carry the highest risk of worsening shoulder pain 7, 4
• Do not confuse adhesive capsulitis with rotator cuff pathology; adhesive capsulitis shows equal restriction in both active and passive motion in all planes, whereas rotator cuff tears demonstrate focal weakness with specific resistance testing 4

Expected Outcomes and Patient Counseling

• Despite significant improvements and high patient satisfaction (90%), measurable limitations persist when comparing the affected shoulder to the contralateral side 3
• The mean duration of treatment is approximately 22 months, though most improvement occurs within the first 6 months 3
• Recent evidence challenges the traditional theory that adhesive capsulitis fully resolves without treatment; persistent functional limitations occur if left untreated 1

Treatment Algorithm Summary

1. First-line after failed steroid injection: Intensive supervised physical therapy with four-direction stretching program, emphasizing external rotation 3
2. Consider early: Ultrasound-guided hydrodilatation if patient is in stage 1 or early stage 2 2
3. Adjunctive options: Radial shockwave therapy, cryotherapy, manual mobilizations 6
4. Reassess at 6-12 weeks: If minimal improvement, consider surgical consultation for manipulation under anesthesia or arthroscopic capsular release 1