In a patient with adhesive capsulitis who has failed physiotherapy, NSAIDs, and corticosteroid injection, is intra‑articular hyaluronic‑acid injection appropriate and effective?

Hyaluronic Acid for Adhesive Capsulitis

Intra-articular hyaluronic acid injection is not recommended for adhesive capsulitis, as it provides no additional benefit beyond physical therapy alone and lacks the robust evidence supporting corticosteroid injections.

Evidence Against Hyaluronic Acid in Adhesive Capsulitis

The available evidence specifically examining hyaluronic acid for adhesive capsulitis demonstrates no meaningful clinical benefit:

• A randomized controlled trial directly comparing HA plus physical therapy versus physical therapy alone found no significant differences in pain, disability, quality of life, or range of motion between groups 1
• This study concluded that intra-articular HA injections should be carefully assessed to reduce unnecessary medical expenditures in patients with adhesive capsulitis 1
• A systematic review of shoulder capsulitis treatments found only expert opinion-level evidence to guide hyaluronic acid injection for adhesive capsulitis, indicating insufficient high-quality data 2

Corticosteroid Injections: The Evidence-Based Alternative

When your patient has failed physiotherapy and NSAIDs, corticosteroid injection is the appropriate next step, not hyaluronic acid:

• Intra-articular corticosteroid injections provide superior short-term pain relief (0-8 weeks) and improve passive range of motion both short-term and long-term (9-24 weeks) 3
• Meta-analysis of 5 studies with 225 patients demonstrates corticosteroids are more effective than placebo for pain reduction in the initial 8 weeks 3
• Corticosteroids require only a single injection versus 3-5 weekly injections for hyaluronic acid, making them more practical 4
• The evidence base for corticosteroids in adhesive capsulitis includes 7 studies, compared to only 3 studies for hyaluronic acid 2

Comparative Effectiveness: HA vs. Corticosteroids

A recent 2024 meta-analysis directly comparing these two treatments in adhesive capsulitis provides critical guidance:

• Corticosteroid injections demonstrate superior pain reduction and functional improvement at 2-4 weeks compared to hyaluronic acid 5
• By 6 and 12 weeks, outcomes become comparable between the two treatments 5
• Active and passive shoulder ROM showed no significant differences between HA and corticosteroid groups 5

Why the Guideline Evidence Doesn't Apply Here

The ACR/Arthritis Foundation guidelines strongly recommend against hyaluronic acid for osteoarthritis of the knee, hip, and hand, citing that high-quality, low-bias trials show effect sizes approaching zero 6. However, adhesive capsulitis is a fundamentally different pathology than osteoarthritis—it involves capsular inflammation and fibrosis rather than cartilage degeneration. Despite this distinction, the limited evidence specific to adhesive capsulitis still fails to support HA use 1.

Clinical Algorithm for Your Patient

Given your patient has already failed physiotherapy, NSAIDs, and corticosteroid injection:

1. Verify the corticosteroid injection was performed correctly (intra-articular glenohumeral joint injection, not subacromial) 3
2. Consider repeating corticosteroid injection if the first injection provided temporary benefit, as the evidence supports its efficacy 5, 3
3. Intensify physical therapy with focus on passive ROM exercises, as this remains the cornerstone of treatment 1
4. Consider hydrodilatation (distension arthrography) as an alternative intervention before resorting to HA 7
5. Hyaluronic acid may be discussed only in the context of shared decision-making when the patient understands it provides no proven additional benefit over continued physical therapy alone 1

Critical Caveats

• Do not extrapolate the weak evidence for HA in knee osteoarthritis to adhesive capsulitis—these are distinct pathologies with different treatment responses 6, 1
• The heterogeneity of HA formulations, injection protocols (1-3 injections), and treatment combinations in adhesive capsulitis studies makes definitive conclusions difficult 7, 5
• HA injections may theoretically facilitate early mobilization by reducing inflammation, but this has not been proven to improve final outcomes 7
• Cost-effectiveness is poor, as HA requires multiple weekly injections with significant expense and no demonstrated superiority over single corticosteroid injections 4, 1

When HA Might Be Considered (With Caution)

The only scenario where HA could be discussed is:

• Patient requires repetitive injections but has contraindications to repeated corticosteroids (diabetes with poor glycemic control, concern for tendon weakening) 5
• Patient must understand that HA provides comparable outcomes to corticosteroids only after 6-12 weeks, with inferior early pain relief 5
• This represents off-label use without strong supporting evidence 2, 1