What is the next step in treating a patient with adhesive capsulitis who has not responded to initial conservative management?

Treatment of Adhesive Capsulitis After Failed Conservative Management

For patients with adhesive capsulitis who have not responded to initial conservative management including corticosteroid injections, the next step is intensive supervised physical therapy with a specific focus on external rotation exercises, as this is the most critical movement restriction and most strongly correlates with shoulder pain. 1

Why Physical Therapy is the Primary Next Step

• External rotation exercises are the single most important component of the treatment program, as external rotation is the most significantly affected motion and relates most strongly to shoulder pain onset 2, 1
• Supervised physical therapy (whether land-based, water-based, individual, or group) is more effective than home exercises alone and should be the preferred approach 1
• The restriction in adhesive capsulitis is present equally in both active and passive motion, distinguishing it from rotator cuff pathology which shows focal weakness 2

Critical Treatment Principles and Pitfalls

Do NOT delay intervention—adhesive capsulitis develops rapidly once immobilization occurs, and the window for effective treatment is narrow 1. Early intervention is crucial to prevent progression to more severe frozen shoulder 2.

What to Avoid:

• Avoid overhead pulley exercises as they encourage uncontrolled abduction and carry the highest risk of worsening shoulder pain 2, 1
• 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 2, 1
• Avoid immobilization devices such as arm slings, which can accelerate frozen shoulder development 2

Evidence for Combination Therapies

While corticosteroid injections provide short-term pain relief (0-8 weeks), they do not sustain long-term benefit 3. However, combining corticosteroid injections with physical therapy may provide greater improvement than physiotherapy alone 4.

• Combining suprascapular nerve block (SSNB) with physical therapy and/or intra-articular corticosteroid injection has support for improving shoulder pain, range of motion, and function 5
• Hydrodilatation combined with physical therapy offers some additive benefits for improving shoulder range of motion when used as adjunct treatment 5

Surgical Considerations

If there is minimal improvement after 6-12 weeks of intensive nonsurgical treatment, surgical options include manipulation under anesthesia and arthroscopic capsule release 4. Failure to obtain symptomatic improvement and continued functional disability following ≥6 months of physical therapy is a general guideline for surgical intervention 6.

Treatment Algorithm

1. Initiate intensive supervised physical therapy with emphasis on external rotation exercises 1
2. Consider combination therapy: Add suprascapular nerve block or repeat corticosteroid injection if pain limits participation in physical therapy 5
3. Consider hydrodilatation as an adjunct if range of motion remains severely restricted despite 4-6 weeks of therapy 5
4. Reassess at 6-12 weeks: If minimal improvement, refer for surgical consultation 4
5. Surgical intervention if no symptomatic improvement after 6 months of conservative treatment 6

Special Populations

• Breast cancer patients should be monitored for early signs of adhesive capsulitis, as early identification and treatment may prevent unnecessary pauses during exercise programming 7
• Post-surgical patients may benefit from exercises focusing on neck, rotator cuff, and posterior shoulder girdle strengthening while addressing anterior shoulder girdle flexibility 7