What is the best treatment approach for a patient with shoulder capsulitis?

Treatment of Shoulder Capsulitis (Adhesive Capsulitis)

Begin with intra-articular corticosteroid injection combined with physical therapy, as this combination provides superior outcomes compared to physical therapy alone and achieves symptom resolution in approximately 90% of patients within 3-4 months. 1, 2

Initial Conservative Management (First-Line Treatment)

Pharmacological Interventions

• Intra-articular corticosteroid injections are the cornerstone of initial treatment, particularly when combined with physiotherapy, providing greater improvement than physiotherapy alone 1
• Oral NSAIDs should be prescribed for pain control in all patients 3, 2
• Short-term oral corticosteroids (prednisone) can be considered for severe pain, though evidence is limited 3, 1
• Avoid relying solely on analgesics and physical therapy without corticosteroid injection, as this approach has shown inferior therapeutic results 4

Physical Therapy and Exercise

• Supervised physical therapy with home exercise programs should be initiated immediately after corticosteroid injection 2
• Gentle passive manipulation and range-of-motion exercises should be performed multiple times daily 5, 3
• Treatment duration averages 3.8 months for successful nonoperative resolution 2

Expected Outcomes with Conservative Treatment

• 89.5% of patients achieve resolution with nonoperative treatment, including diabetic patients 2
• Forward elevation typically improves from 118° to 164°, and external rotation from 26° to 59° 2

Second-Line Interventions (If No Improvement After 6-12 Weeks)

Advanced Conservative Options

• Hydrodilatation (distension arthrography) with intra-articular injection of lidocaine and long-acting corticosteroid, followed by gentle passive manipulation under local anesthesia, achieves excellent relief in 94% of cases 4
• This approach ensures accurate intra-articular steroid delivery (versus blind injections that often miss the joint space) and has much lower morbidity than surgical options 4
• Suprascapular nerve block can be considered for pain control 5
• Acupuncture may provide additional benefit 1

Surgical Management (Reserved for Refractory Cases)

Indications for Surgery

• Minimal improvement after 6-12 months of aggressive nonoperative treatment 1, 2
• Only 10.5% of patients ultimately require surgical intervention 2
• Younger patients (average age 51 years) are more likely to require surgery compared to older patients (average age 56 years) 2

Surgical Options (In Order of Preference)

• Arthroscopic capsular release is preferred over manipulation under anesthesia to avoid complications of "blind intervention" 5
• Manipulation under anesthesia can be considered but carries higher complication risk 5, 3
• Open capsular release is reserved for severe recalcitrant cases 5

Critical Pitfalls to Avoid

• Do not simply observe and reassure patients despite the self-limited nature of the condition—recent evidence shows persistent functional limitations if left untreated, challenging the traditional theory of full spontaneous resolution 1
• Do not perform blind corticosteroid injections, as they frequently deposit medication in periarticular soft tissues rather than the joint space 4
• Do not delay treatment beyond 12 months before considering surgical options, as prolonged conservative treatment in surgical candidates averages 12.4 months without benefit 2
• Recognize that adhesive capsulitis can occur concomitantly with other shoulder pathology (rotator cuff tears, bursitis, osteoarthritis), requiring imaging to rule out alternative diagnoses 3, 1

Special Populations

Diabetic Patients

• Diabetic patients respond equally well to nonoperative treatment (89.5% success rate) 2
• Increased vigilance is warranted as adhesive capsulitis has higher prevalence in diabetes mellitus and hypothyroidism 1

Diagnostic Confirmation

• Coracohumeral ligament thickening on MRI yields high specificity for adhesive capsulitis when diagnosis is uncertain 1
• Arthrography can simultaneously confirm diagnosis and deliver therapeutic intra-articular medication 4