Pain Management for Adhesive Capsulitis of the Shoulder
Begin with acetaminophen as first-line oral analgesic, followed by NSAIDs at the lowest effective dose for the shortest duration if acetaminophen provides inadequate relief. 1
Pharmacologic Pain Management Algorithm
First-Line Oral Analgesics
- Start with acetaminophen due to its favorable safety profile 1
- If pain control is insufficient, escalate to NSAIDs at the minimum effective dose for the briefest possible duration 1, 2
- Short-term oral corticosteroids can be considered for acute pain exacerbations 2
Injectable Corticosteroid Therapy
- Intra-articular corticosteroid injections (such as Triamcinolone) have demonstrated significant effects on pain reduction in adhesive capsulitis 3
- These injections showed improvement in range of motion, though the ROM gains were not statistically significant 3
- Corticosteroid injections combined with physiotherapy may provide greater improvement than physiotherapy alone 2
Alternative Injectable Options
- Hyaluronic acid injections show equivalent clinical outcomes to corticosteroid injections for pain and ROM 4
- HA may facilitate early mobilization during initial inflammatory stages when pain causes prolonged immobilization 4
Non-Pharmacologic Pain Management
Physical Therapy Interventions
- Gentle, progressive stretching exercises focusing on external rotation and abduction are essential to prevent frozen shoulder progression 3
- Range of motion exercises should emphasize external (lateral) rotation, as this is the most severely restricted movement in adhesive capsulitis 5
- Mobilization techniques targeting the capsule can reduce pain and improve function 3, 6
Modalities for Pain Relief
- Ice, heat, and soft tissue massage are recommended adjunctive treatments 3
- Functional electrical stimulation (FES) has shown benefit for pain-free lateral rotation 3
Critical Exercise Precautions
Avoid aggressive overhead pulley exercises, which can worsen adhesive capsulitis and encourage uncontrolled abduction 3, 5. This is particularly important in post-stroke patients or those with neurologic compromise 5.
Advanced Interventions for Refractory Pain
When Conservative Management Fails
- Hydrodilatation (distension arthrography) can be considered after 6-12 weeks of unsuccessful conservative treatment 2, 7
- Suprascapular nerve block may provide pain relief in select cases 7
Surgical Options
- Manipulation under anesthesia or arthroscopic capsular release should be considered after 6 months of failed conservative management with continued functional disability 2, 8
- Surgery requires diligent postoperative therapy to maintain motion and minimize recurrence 8
Common Pitfalls to Avoid
- Do not delay formal physical therapy beyond 6-8 weeks, as this may result in permanent shoulder dysfunction 5
- Avoid prolonged immobilization, which directly contributes to capsular contracture 4
- Do not overlook systemic risk factors (diabetes, thyroid disease, post-stroke status) that may affect treatment response 5, 2
Optimal Combined Approach
The most effective strategy combines intra-articular corticosteroid injections with structured physiotherapy, as this combination demonstrates superior outcomes compared to physiotherapy alone 2. This approach addresses both the inflammatory pain component and the mechanical restriction characteristic of adhesive capsulitis.