Adhesive Capsulitis Treatment & Management
- Author: Albert W Pearsall IV, MD; Chief Editor: Mary Ann E Keenan, MD more...
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.[21, 22]
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.[23, 10, 24, 25]
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.[26, 27]
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. (Open Table in a new window)
| Corticosteroid Dosing in Patients With Refractive Frozen Shoulder Syndrome* | ||
| Week Number | Medication | Dose |
| 1 (Days 1-7) | Prednisone | 40 mg/d |
| 2 (Days 8-14) | Prednisone | 30 mg/d |
| 3 (Days 15-18) | Prednisone | 20 mg/d |
| 4 (Days 19-21) | Prednisone | 10 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.[28, 29, 30] Based on these reports and work by others, a selective arthroscopic capsular release is recommended for patients with refractory frozen shoulder.[31]
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, as seen in the image below. 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.
True anteroposterior view of the glenohumeral joint (left); axillary lateral view (middle); supraspinatus outlet view (right) Ahn et al developed an ultrasound-guided interventional release of the rotator interval using a round needle designed specifically for this procedure. All 13 patients experienced significant improvement.[32]
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.
Outcome and Prognosis
In the past, frozen shoulder was considered a self-limiting condition that could be treated with physical therapy and would resolve in 1-3 years. However, several studies have demonstrated long-term pain and shoulder stiffness following conservative treatment.
Several studies have noted improved symptoms following arthroscopic capsular release. Warner and colleagues reported an improvement in the Constant and Murley score of 48 points with a mean follow-up of 39 months.[33] Pearsall and colleagues found that 83% of patients reported their shoulder to be normal or near normal at an average of 22 months following capsular release.[34] Ogilvie-Harris noted that 15 of 18 patients treated with arthroscopic capsular release had an excellent result at 2-5 years following surgery. A review of the literature indicates that in patients with refractory adhesive capsulitis, a near-excellent to excellent result of 75-90% can be expected with arthroscopic capsular release and an aggressive postoperative physical therapy regimen.
Future and Controversies
Hyperthyroidism, ischemic heart disease, diabetes mellitus,[10] and cervical spondylosis have been associated with the occurrence of adhesive capsulitis. Patients with these conditions should be alerted to the increased risk of developing frozen shoulder.
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| Corticosteroid Dosing in Patients With Refractive Frozen Shoulder Syndrome* | ||
| Week Number | Medication | Dose |
| 1 (Days 1-7) | Prednisone | 40 mg/d |
| 2 (Days 8-14) | Prednisone | 30 mg/d |
| 3 (Days 15-18) | Prednisone | 20 mg/d |
| 4 (Days 19-21) | Prednisone | 10 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. | ||
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