eMedicine Specialties > Orthopedic Surgery > Shoulder

Adhesive Capsulitis: Treatment

Author: Albert W Pearsall IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Alabama; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center
Contributor Information and Disclosures

Updated: Aug 12, 2008

Treatment

Medical Therapy

Idiopathic adhesive capsulitis affecting the glenohumeral joint is believed to be self-limiting and is often treated effectively with physical therapy and medications. However, studies on the natural history of the condition have noted long-term pain in many patients following nonoperative treatment, with as many as 10% of patients never fully recovering normal shoulder activities.

Various authors have reported an inflammatory component to frozen shoulder syndrome. Therefore, the use of nonsteroidal medications in the initial treatment phase of frozen shoulder is recommended. By diminishing inflammation and pain, the patient is better able to tolerate aggressive physical therapy. Before the patient is prescribed any medication, he or she should be queried about any contraindications to nonsteroidal medicines.

Depending on the severity of symptoms, a 3-week tapered course of oral corticosteroids should be prescribed in lieu of nonsteroidal medication (see Table 1). Due to potential side effects of this medicine, the patient should be thoroughly questioned regarding past medical history, including diabetes mellitus. Diabetes mellitus is not an absolute contraindication to the use of oral corticosteroids; however, because of the potential hyperglycemic effects of corticosteroids, it should be used judiciously and the patient's blood glucose should be closely monitored. The use of low-dose oral corticosteroids is recommended only in cases of severe refractory frozen shoulder that has either been present for an extended period (ie, longer than 2 mo) or is causing significant pain.19,10,20

Oral corticosteroids provide an even stronger anti-inflammatory effect than do nonsteroidal medications. Either type of medication may be used in conjunction with a subacromial corticosteroid injection.

Because adhesive capsulitis is rare in children, any of the previously mentioned medications rarely are used in this population. Most pediatric patients respond to conservative physical therapy without the use of medications.


Table 1                                                                                      

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Table
Corticosteroid Dosing in Patients With Refractive Frozen Shoulder Syndrome*      
Week NumberMedicationDose
1 (Days 1-7)Prednisone40 mg/d
2 (Days 8-14)Prednisone30 mg/d
3 (Days 15-18)Prednisone20 mg/d
4 (Days 19-21)Prednisone10 mg/d
5 (Days 22+)Discontinue----
Corticosteroid Dosing in Patients With Refractive Frozen Shoulder Syndrome*      
Week NumberMedicationDose
1 (Days 1-7)Prednisone40 mg/d
2 (Days 8-14)Prednisone30 mg/d
3 (Days 15-18)Prednisone20 mg/d
4 (Days 19-21)Prednisone10 mg/d
5 (Days 22+)Discontinue----

*Before oral corticosteroid medication is prescribed, the patient should be extensively questioned about pertinent medical problems that may be contraindications to taking the medicine.


Surgical Therapy

A subgroup of patients with frozen shoulder syndrome often fail to improve despite treatment with aggressive nonsurgical therapy and medication. These patients frequently are referred to as having a refractory or recalcitrant frozen shoulder. Specifically, these patients demonstrate minimal improvement in shoulder pain and motion over a 3-month period, despite the use of aggressive nonoperative measures, including medications and physical therapy. In these refractory cases, more invasive techniques (eg, manipulation, distention arthrography, open surgical release) may be needed.

Although several authors have championed the success of these therapies, significant complications, ranging from biceps tendon sheath and subscapularis tendon rupture to humeral fracture, have been reported with various nonsurgical treatments. Ogilvie-Harris and Warner have demonstrated the efficacy of arthroscopic capsular release for the refractory frozen shoulder.21,22,23 Based on these reports and work by others, a selective arthroscopic capsular release is recommended for patients with refractory frozen shoulder.

Following a thorough preoperative assessment of the affected and unaffected shoulder's passive range of motion (PROM), standard arthroscopic shoulder portals are established. Based on the preoperative examination, the anterior and/or posterior glenohumeral joint capsule is released with electrocautery (see Image 1). Before the patient is taken from the operating room, the individual's ROM is documented and compared with his or her presurgical motion. With 24-48 hours of postoperative pain relief provided by a preoperative interscalene block, ROM exercises should be initiated on the day of surgery. A 2-week course of oral corticosteroids also should be initiated on the day of surgery.

Postoperative Details

Further inpatient care is indicated only in refractory patients. Patients receiving arthroscopic or open capsular release frequently are in the hospital for several days to permit interscalene anesthesia and aggressive, monitored physical therapy. However, patients rarely have to return to the hospital following the initial surgery. A small group of patients with adhesive capsulitis relapse, despite surgical intervention and physical therapy; admitting these patients for interscalene anesthesia and aggressive physical therapy may be appropriate.

Most patients with adhesive capsulitis use either an anti-inflammatory medication or a short course of an oral corticosteroid. Occasionally, patients may require medication for pain. A chronic-pain medication such as Neurontin or Elavil is preferred for these symptoms.

Follow-up

Patients with adhesive capsulitis—those who have been treated with conservative therapy and those who have had surgical intervention—should be closely monitored as outpatients. Usually, supervised or home physical therapy is a component of  treatment. In addition, the patient may be taking oral corticosteroids, which must be monitored for side effects. The patient should be monitored every several weeks to document progress.

The patient should be monitored at 2-week intervals for the first month after surgery. Thereafter, follow-up intervals can be increased from 6 weeks to 3 months, as needed.

Complications

The predominant complication arising from adhesive capsulitis is residual shoulder stiffness or pain. Several reports have indicated that most patients may continue to have pain and/or stiffness for up to 3 years following conservative treatment. In addition, humeral fracture, biceps tendon rupture, and subscapularis tendon rupture have been reported after shoulder manipulation.

More on Adhesive Capsulitis

Overview: Adhesive Capsulitis
Workup: Adhesive Capsulitis
Treatment: Adhesive Capsulitis
Follow-up: Adhesive Capsulitis
Multimedia: Adhesive Capsulitis
References
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References

  1. Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl. 1969;119:1-59. [Medline].

  2. Binder AI, Bulgen DY, Hazleman BL, et al. Frozen shoulder: a long-term prospective study. Ann Rheum Dis. Jun 1984;43(3):361-4. [Medline]. [Full Text].

  3. Binder AI, Bulgen DY, Hazleman BL, et al. Frozen shoulder: an arthrographic and radionuclear scan assessment. Ann Rheum Dis. Jun 1984;43(3):365-9. [Medline]. [Full Text].

  4. Lloyd-Roberts GC, French PR. Periarthritis of the shoulder. A study of the disease and its treatment. Br Med J. 1959;1:1569-71.

  5. Tveitå EK, Sandvik L, Ekeberg OM, Juel NG, Bautz-Holter E. Factor structure of the Shoulder Pain and Disability Index in patients with adhesive capsulitis. BMC Musculoskelet Disord. Jul 17 2008;9:103. [Medline].

  6. Tasto JP, Elias DW. Adhesive capsulitis. Sports Med Arthrosc. Dec 2007;15(4):216-21. [Medline].

  7. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg. Mar-Apr 2008;17(2):231-6. [Medline].

  8. Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br. Jul 2007;89(7):928-32. [Medline].

  9. Codman EA. The shoulder. Boston, Mass: Thomas Todd; 1934.

  10. Tighe CB, Oakley WS Jr. The prevalence of a diabetic condition and adhesive capsulitis of the shoulder. South Med J. Jun 2008;101(6):591-5. [Medline].

  11. Duplay ES. De la periarthritis scapulohumerale et des raiderus de l'epaule qui en son la consequence. Arch Gen Med. 1872;20:513-42.

  12. DePalma AF. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952;135:193-204.

  13. Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis. Jan 1972;31(1):69-71. [Medline]. [Full Text].

  14. Bruckner FE, Nye CJ. A prospective study of adhesive capsulitis of the shoulder ("frozen shoulder'') in a high risk population. Q J Med. Spring 1981;50(198):191-204. [Medline].

  15. Flannery O, Mullett H, Colville J. Adhesive shoulder capsulitis: does the timing of manipulation influence outcome?. Acta Orthop Belg. Feb 2007;73(1):21-5. [Medline].

  16. Vermeulen HM, Rozing PM, Obermann WR, et al. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther. Mar 2006;86(3):355-68. [Medline].

  17. Saeidian SR, Hemmati AA, Haghighi MH. Pain relieving effect of short-course, pulse prednisolone in managing frozen shoulder. J Pain Palliat Care Pharmacother. 2007;21(1):27-30. [Medline].

  18. De Ponti A, Viganò MG, Taverna E, et al. Adhesive capsulitis of the shoulder in human immunodeficiency virus-positive patients during highly active antiretroviral therapy. J Shoulder Elbow Surg. Mar-Apr 2006;15(2):188-90. [Medline].

  19. [Best Evidence] Bal A, Eksioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clin Rehabil. Jun 2008;22(6):503-12. [Medline].

  20. Tveitå EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord. Apr 19 2008;9:53. [Medline].

  21. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The resistant frozen shoulder. Manipulation versus arthroscopic release. Clin Orthop. Oct 1995;(319):238-48. [Medline].

  22. Warner JJ, Allen A, Marks PH, et al. Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J Bone Joint Surg Am. Dec 1996;78(12):1808-16. [Medline].

  23. Warner JJ, Allen AA, Marks PH, et al. Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am. Aug 1997;79(8):1151-8. [Medline].

  24. Warner JJ, Greis PE. The treatment of stiffness of the shoulder after repair of the rotator cuff. Instr Course Lect. 1998;47:67-75. [Medline].

  25. Pearsall AW, Osbahr DC, Speer KP. An arthroscopic technique for treating patients with frozen shoulder. Arthroscopy. Feb 1999;15(1):2-11. [Medline].

  26. Andren L, Lundberg BJ. Treatment of rigid shoulders by joint distention during arthrography. Acta Orthop Scand. 1965;36:45-53.

  27. Askey JM. The syndrome of painful disability of the shoulder and hand complicating coronary occlusion. Am Heart J. 1961;22:1-12.

  28. Baker CL, Liu SH. Comparison of open and arthroscopically assisted rotator cuff repairs. Am J Sports Med. Jan-Feb 1995;23(1):99-104. [Medline].

  29. Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES. Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am. Dec 1992;74(10):1505-15. [Medline].

  30. Bigliani LU, McIlveen SJ, Cordasco FA. Operative management of failed rotator cuff repairs. Orthop Trans. 1988;12:674.

  31. Bigliani LU, Ticker JB, Flatow EL, et al. The relationship of acromial architecture to rotator cuff disease. Clin Sports Med. Oct 1991;10(4):823-38. [Medline].

  32. Bulgen DY, Binder A, Hazleman BL, et al. Immunological studies in frozen shoulder. J Rheumatol. Nov-Dec 1982;9(6):893-8. [Medline].

  33. Bulgen DY, Binder AI, Hazleman BL, et al. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. Jun 1984;43(3):353-60. [Medline]. [Full Text].

  34. Bulgen DY, Hazleman BL, Voak D. HLA-B27 and frozen shoulder. Lancet. May 15 1976;1(7968):1042-4. [Medline].

  35. Clarke GR, Willis LA, Fish WW, et al. Preliminary studies in measuring range of motion in normal and painful stiff shoulders. Rheumatol Rehabil. Feb 1975;14(1):39-46. [Medline].

  36. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet. May 1982;154(5):667-72. [Medline].

  37. DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am. Apr 1984;66(4):563-7. [Medline].

  38. Freedman L, Munro RR. Abduction of the arm in the scapular plane: scapular and glenohumeral movements. A roentgenographic study. J Bone Joint Surg Am. Dec 1966;48(8):1503-10. [Medline].

  39. Grey RG. The natural history of "idiopathic" frozen shoulder. J Bone Joint Surg Am. Jun 1978;60(4):564. [Medline].

  40. Groh GI, Simoni M, Rolla P. Loss of the deltoid after shoulder operations: an operative disaster. J Shoulder Elbow Surg. 1994;3:243-53.

  41. Hawkins RJ. Impingement syndrome. Orthop Trans. 1979;3:274.

  42. Hazleman BL. The painful stiff shoulder. Rheumatol Phys Med. Nov 1972;11(8):413-21. [Medline].

  43. Hollinshead WH. Anatomy for Surgeons: The Back and Limbs. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1982.

  44. Hoppenfeld S, DeBoer P. Surgical Exposures in Orthopaedic Surgery: The Anatomic Approach. Philadelphia, Pa: Lippincott-Raven; 1984.

  45. Inmann VT, Saunders JB, Abott LC. Observations on the shoulder joint. J Bone Joint Surg Am. 1959;41:877-82.

  46. Kay NR. The clinical diagnosis and management of frozen shoulders. Practitioner. Feb 1981;225(1352):164-7. [Medline].

  47. Kelly BT, Kadrmas WR, Speer KP. Empty can versus full can exercise for rotator cuff rehabilitation: An EMG analysis (unpublished data).

  48. Kessel L. Clinical Disorders of the Shoulder. New York, NY: Churchill Livingstone; 1982.

  49. Levy HJ, Uribe JW, Delaney LG. Arthroscopic assisted rotator cuff repair: preliminary results. Arthroscopy. 1990;6(1):55-60. [Medline].

  50. McLaughlin HL. The frozen shoulder. Clin Orthop. 1961;20:126-31.

  51. Murnaghan JP. Frozen shoulder. In: Rockwood CA, Matsen FA III, eds. The Shoulder. Philadelphia, Pa: Saunders; 1990:837-62.

  52. Neviaser RJ. Painful conditions affecting the shoulder. Clin Orthop. Mar 1983;(173):63-9. [Medline].

  53. Older MW. Distention arthrography of the shoulder joint. In: Bayley I, Kessel L, eds. Shoulder Surgery. New York, NY: Springer-Verlag; 1982:123-7.

  54. Ozaki J, Nakagawa Y, Sakurai G, et al. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am. Dec 1989;71(10):1511-5. [Medline].

  55. Quigley TB. Indications for manipulation and corticosteroids in the treatment of stiff shoulders. Surg Clin North Am. 1963;43:1715-20.

  56. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975;4(4):193-6. [Medline].

  57. Rizk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum. May 1982;11(4):440-52. [Medline].

  58. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am. Jun 1992;74(5):738-46. [Medline].

  59. Speer KP. Anatomy and pathomechanics of shoulder instability. Operative Tech in Sports Med. 1993;1:252-5.

  60. Wohlgethan JR. Frozen shoulder in hyperthyroidism. Arthritis Rheum. Aug 1987;30(8):936-9. [Medline].

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Further Reading

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Keywords

adhesive capsulitis, frozen shoulder, frozen shoulder syndrome, FSS, bursitis, joint disease, capsulitis shoulder, adhesive shoulder, adhesive joint, frozen shoulder treatment, shoulder pain, stiff shoulder

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Contributor Information and Disclosures

Author

Albert W Pearsall IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Alabama; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Lynn A Crosby, MD, FACS, Chief of Shoulder Division, Professor, Department of Orthopedic Surgery, Wright State University School of Medicine
Lynn A Crosby, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American College of Surgeons, American Fracture Association, American Medical Association, American Medical Tennis Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Arthroscopy Association of North America, Mid-America Orthopaedic Association, and Orthopaedic Research Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Pekka A Mooar, MD, Professor, Department of Orthopedic Surgery, Temple University School of Medicine
Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
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