Stepwise Treatment Approach for Adhesive Capsulitis
For adhesive capsulitis, begin with a 6-12 week trial of aggressive physical therapy focused on external rotation and abduction stretching combined with intra-articular corticosteroid injection, which provides superior short-term pain relief and functional improvement compared to physical therapy alone. 1, 2
Initial Conservative Management (First 6-12 Weeks)
Combined Corticosteroid Injection Plus Physical Therapy
- Intra-articular corticosteroid injection combined with physical therapy provides greater improvement than physical therapy alone and should be the first-line treatment. 1, 2
- Corticosteroid injection alone produces clinically important improvements at 7 weeks: mean pain reduction of 58 points on a 100-point scale and mean function improvement of 39 points, with 77% of patients reporting treatment success. 2
- Physical therapy with manual therapy and exercise alone produces smaller improvements: mean pain reduction of 32 points and mean function improvement of 14 points, with only 46% reporting treatment success at 7 weeks. 2
Physical Therapy Protocol
- Aggressive stretching and mobilization focusing specifically on external rotation and abduction are essential to prevent progression and restore range of motion. 3, 4
- Gentle, progressive stretching exercises should be initiated and continued throughout treatment. 5
- Avoid overhead pulley exercises, which encourage uncontrolled abduction and can worsen rotator cuff pathology. 3, 4
- Local application of heat (paraffin wax, hot pack) before exercise provides symptomatic benefit. 6, 7
Pharmacological Adjuncts
- Short-term oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) can reduce swelling and pain in early stages. 7
- NSAIDs or acetaminophen for pain control as needed. 4, 7
- Topical NSAIDs provide moderate pain relief with fewer systemic side effects for mild-to-moderate pain. 4
Second-Line Treatment (If Inadequate Response at 6-12 Weeks)
Arthrographic Joint Distension (Hydrodilatation)
- Arthrographic distension with saline and corticosteroid provides short-term benefits in pain (NNTB = 2), function (NNTB = 3), and range of movement at 3 weeks compared to placebo. 8
- This benefit is maintained at 6 and 12 weeks for function. 8
- Following arthrographic joint distension with glucocorticoid and saline, adding manual therapy and supervised exercise for 6 weeks provides greater patient-reported treatment success and active shoulder abduction at 6 weeks compared to sham ultrasound. 2
Intensified Physical Therapy
- Continue aggressive stretching and mobilization with increased frequency if not already maximized. 5
- Consider serial casting for contractures that interfere with function. 3
Surgical Intervention (If Minimal Improvement After 6 Months)
Indications for Surgery
- Failure to obtain symptomatic improvement and continued functional disability following ≥6 months of physical therapy is the general guideline for surgical intervention. 5
- Some sources suggest considering surgery after 6-12 weeks of failed nonsurgical treatment, though 6 months is more conservative. 1, 5
Surgical Options
- Manipulation under anesthesia is one surgical option for refractory cases. 1
- Arthroscopic capsule release is the alternative surgical approach. 1, 9
- Diligent postoperative therapy to maintain motion is required to minimize recurrence of adhesive capsulitis. 5
Critical Timeline and Monitoring
Re-evaluation Points
- Assess response at 6-12 weeks; if no significant improvement, advance to second-line treatments (hydrodilatation or intensified therapy). 1, 5
- Standard rehabilitation requires 12-16 weeks of skilled therapy. 4
- Re-evaluate at 12 weeks and consider alternative approaches if no significant functional improvement. 4
Natural History Considerations
- Recent evidence shows persistent functional limitations if left untreated, challenging the traditional belief that adhesive capsulitis fully resolves without treatment over 1-2 years. 1
- Early aggressive intervention is therefore warranted rather than watchful waiting. 1
Common Pitfalls to Avoid
- Do not rely on physical therapy alone without corticosteroid injection for initial treatment, as the combination is more effective. 2
- Avoid overhead pulley exercises throughout treatment, as they worsen rotator cuff pathology and increase pain. 3, 4
- Do not delay surgical referral beyond 6 months if conservative treatment fails, as prolonged stiffness leads to worse outcomes. 5
- Ensure physical therapy specifically targets external rotation and abduction, not just general shoulder exercises. 3, 4