Adhesive Capsulitis in Physical Medicine and Rehabilitation Medication
- Author: André Roy, MD, FRCPC; Chief Editor: Stephen Kishner, MD, MHA more...
The goal of pharmacologic intervention in FS is uniquely the control of pain in the 2 first stages of the disease because no drug affects the underlying disease process. Medication does not affect the duration of disease or the severity or duration of glenohumeral joint contracture. Most of the time, patients with FS can manage their pain with analgesics, such as acetaminophen, as needed. However, during the most painful months of the condition, when rest pain and night pain are most bothersome, appropriate use of narcotic agents is warranted.
Pain control should be aimed at relieving pain in the following order of priority:
- Rest pain and night pain: The preferred agent should be a long-acting, centrally acting agent (eg, calcitonin) or a sustained-release narcotic preparation (eg, low-dose oxycodone HCl [OxyContin]).
- Activity-related pain: Some physicians advocate the use of short-acting analgesic agents, such as oxycodone, before sessions of physical therapy to improve shoulder mobilization. The authors' opinion is that this regimen should be used with care because of the risk of causing a flare-up after physiotherapeutic mobilization due to an excessively vigorous mobilization session.
Attaining the favorable prognosis requires patience on the part of the physician and the patient.
Endocrine metabolic agents
Agents in this class may have analgesic effects.
Can relieve some back pain associated with adhesive capsulitis. A prospective, randomized study was conducted to compare calcitonin SC for 3 wk with manual therapy and physical therapy with physical therapy alone. Pain decreased more in patients with posttraumatic capsulitis who were receiving calcitonin, manual therapy, and physical therapy than it did in others. The speed of recovery was comparable in both groups.
Given the absence of histopathologic evidence of capsular inflammation, NSAIDs must be used for their analgesic effects. To our knowledge, no researchers have compared the efficacy of NSAIDs with that of placebo in adhesive capsulitis. Comparisons of the efficacy of different NSAIDs in the treatment of adhesive capsulitis show a positive effect regardless of the NSAID used.
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well; examples are inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
COX-2 – selective NSAIDs are recommended in cases of FS. Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than it is with traditional NSAIDs. Ongoing analysis of the cost of preventing GI bleeds will help in further defining the patient populations who are most likely to benefit from COX-2 inhibitors.
Two randomized, controlled studies were conducted to compare oral (PO) corticosteroids with placebo. One study showed an improvement only of night pain at 4 weeks. The other study showed an improvement of pain and function at 3 weeks. Therapeutic effects of PO corticosteroids after these periods have not been demonstrated.
PO corticosteroid therapy is significantly less effective than intra-articular corticosteroid injection in the short term.
Given the systemic adverse effects, one should question the indication for PO corticosteroids in the treatment of FS. Other drugs with fewer adverse effects are available; alternatively, corticosteroids can be administered intra-articularly with fewer adverse effects.
Inhibits primarily COX-2, an isoenzyme induced during pain and by inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; therefore, GI toxicity may be decreased. Seek the lowest dose for each patient.
In rare cases, narcotic analgesia may be needed for adequate pain control if the patient's condition is refractory to the judicious use of bupivacaine or bupivacaine suprascapular nerve blocks or in situations in which these nerve-block procedures and/or steroid injections (which are most often performed with fluoroscopic guidance) are not readily available. When combined with anti-inflammatory agents and physical modalities, analgesics should result in good pain control.
In the occasional patient whose condition does not respond to the aforementioned therapies, the use of a long-acting narcotic agent, such as codeine, morphine sulfate (MS Contin), oxycodone HCl (OxyContin), or hydromorphone, should be considered, along with rescue doses of short-acting drugs every 4-6 hours.
Should be first-line drug of choice. In most patients, 3 g/d suffices to control the pain of FS during all but the most painful months. Narcotics and NSAIDs should be used only if the regular use of acetaminophen 1 g tid fails to adequately control pain. The authors prefer to be conservative and limit the prescription to 75% of the maximal daily dosage because patients may be prone to liver toxicity if they take the maximal dosage for many consecutive months.
Indicated for relief of moderate to severe pain.
Staples MP, Forbes A, Green S, et al. Shoulder-specific disability measures showed acceptable construct validity and responsiveness. J Clin Epidemiol. 2009 Aug 13. [Medline].
Wohlgethan JR. Frozen shoulder in hyperthyroidism. Arthritis Rheum. 1987 Aug. 30(8):936-9. [Medline].
Hazleman B. Why is a frozen shoulder frozen?. Br J Rheumatol. 1990 Apr. 29(2):130. [Medline].
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].
Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975. 4(4):193-6. [Medline].
Walmsley S, Rivett DA, Osmotherly PG. Adhesive capsulitis: establishing consensus on clinical identifiers for stage 1 using the DELPHI technique. Phys Ther. 2009 Sep. 89(9):906-17. [Medline].
Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, et al. The resistant frozen shoulder. Manipulation versus arthroscopic release. Clin Orthop Relat Res. 1995 Oct. 238-48. [Medline].
Rizk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum. 1982 May. 11(4):440-52. [Medline].
Sano H, Hatori M, Mineta M, et al. Tumors masked as frozen shoulders: A retrospective analysis. J Shoulder Elbow Surg. 2009 Jun 30. [Medline].
Lequesne M, Dang N, Bensasson M, et al. Increased association of diabetes mellitus with capsulitis of the shoulder and shoulder-hand syndrome. Scand J Rheumatol. 1977. 6(1):53-6. [Medline].
Mao CY, Jaw WC, Cheng HC. Frozen shoulder: correlation between the response to physical therapy and follow-up shoulder arthrography. Arch Phys Med Rehabil. 1997 Aug. 78(8):857-9. [Medline].
Carette S, Moffet H, Tardif J, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum. 2003 Mar. 48(3):829-38. [Medline]. [Full Text].
Green S. Physiotherapy and injection better than injection alone or physiotherapy alone for improving range of motion in adhesive capsulitis. Aust J Physiother. 2003. 49(2):145. [Medline].
Pajareya K, Chadchavalpanichaya N, Painmanakit S, et al. Effectiveness of physical therapy for patients with adhesive capsulitis: a randomized controlled trial. J Med Assoc Thai. 2004 May. 87(5):473-80. [Medline].
Ulusoy H, Sarica N, Arslan S, Olcay C, Erkorkmaz U. The efficacy of supervised physiotherapy for the treatment of adhesive capsulitis. Bratisl Lek Listy. 2011. 112(4):204-7. [Medline].
Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am. 2000 Oct. 82-A(10):1398-407. [Medline].
Rizk TE, Christopher RP, Pinals RS, et al. Adhesive capsulitis (frozen shoulder): a new approach to its management. Arch Phys Med Rehabil. 1983 Jan. 64(1):29-33. [Medline].
Rizk TE, Gavant ML, Pinals RS. Treatment of adhesive capsulitis (frozen shoulder) with arthrographic capsular distension and rupture. Arch Phys Med Rehabil. 1994 Jul. 75(7):803-7. [Medline].
Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving joint range of motion: A systematic review. J Hand Ther. 2004 Apr-Jun. 17(2):118-31. [Medline].
Russell S, Jariwala A, Conlon R, et al. A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder. J Shoulder Elbow Surg. 2014 Apr. 23(4):500-7. [Medline].
Vermeulen HM, Obermann WR, Burger BJ, et al. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: A multiple-subject case report. Phys Ther. 2000 Dec. 80(12):1204-13. [Medline].
Liaw SC. The effect and timing of physiotherapy on change in range of motion and function in frozen shoulder. Physiother Singapore. Sep 2000. 3(3):82-6.
Klç Z, Filiz MB, Çakr T, Toraman NF. Addition of Suprascapular Nerve Block to a Physical Therapy Program Produces an Extra Benefit to Adhesive Capsulitis: A Randomized Controlled Trial. Am J Phys Med Rehabil. 2015 Oct. 94 (10 Suppl 1):912-20. [Medline].
Williams RM, Westmorland MG, Schmuck G, et al. Effectiveness of workplace rehabilitation interventions in the treatment of work-related upper extremity disorders: a systematic review. J Hand Ther. 2004 Apr-Jun. 17(2):267-73. [Medline].
Hazleman BL. The painful stiff shoulder. Rheumatol Phys Med. 1972 Nov. 11(8):413-21. [Medline].
Jacobs LG, Smith MG, Khan SA, et al. Manipulation or intra-articular steroids in the management of adhesive capsulitis of the shoulder? A prospective randomized trial. J Shoulder Elbow Surg. 2009 May-Jun. 18(3):348-53. [Medline].
Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: the effectiveness of conservative and surgical interventions--systematic review. Br J Sports Med. 2011 Jan. 45(1):49-56. [Medline].
Yoon SH, Lee HY, Lee HJ, et al. Optimal dose of intra-articular corticosteroids for adhesive capsulitis: a randomized, triple-blind, placebo-controlled trial. Am J Sports Med. 2013 May. 41(5):1133-9. [Medline].
Lorbach O, Anagnostakos K, Scherf C, et al. Nonoperative management of adhesive capsulitis of the shoulder: oral cortisone application versus intra-articular cortisone injections. J Shoulder Elbow Surg. 2009 Sep 30. [Medline].
Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis. 1997 Jan. 56(1):59-63. [Medline]. [Full Text].
Esenyel CZ, Esenyel M, Yesiltepe R, et al. [The correlation between the accuracy of steroid injections and subsequent shoulder pain and function in subacromial impingement syndrome]. Acta Orthop Traumatol Turc. 2003. 37(1):41-5. [Medline].
Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol. 2004 Feb. 31(2):308-14. [Medline].
Ryans I, Montgomery A, Galway R, et al. A randomized controlled trial of intra-articular triamcinolone and/or physiotherapy in shoulder capsulitis. Rheumatology (Oxford). 2005 Apr. 44(4):529-35. [Medline]. [Full Text].
Vad VB, Sakalkale D, Warren RF. The role of capsular distention in adhesive capsulitis. Arch Phys Med Rehabil. 2003 Sep. 84(9):1290-2. [Medline].
de Jong BA, Dahmen R, Hogeweg JA, et al. Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Clin Rehabil. 1998 Jun. 12(3):211-5. [Medline].
van der Windt DA, Koes BW, Devillé W, Boeke AJ, de Jong BA, Bouter LM. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ. 1998 Nov 7. 317(7168):1292-6. [Medline]. [Full Text].
Ranalletta M, Rossi LA, Bongiovanni SL, Tanoira I, Elizondo CM, Maignon GD. Corticosteroid Injections Accelerate Pain Relief and Recovery of Function Compared With Oral NSAIDs in Patients With Adhesive Capsulitis: A Randomized Controlled Trial. Am J Sports Med. 2016 Feb. 44 (2):474-81. [Medline].
Buchbinder R, Green S, Forbes A, Hall S, Lawler G. Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomised, double blind, placebo controlled trial. Ann Rheum Dis. 2004 Mar. 63(3):302-9. [Medline]. [Full Text].
Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br. 1995. 77(5):677-83.
Neer CS 2nd, Satterlee CC, Dalsey RM, et al. The anatomy and potential effects of contracture of the coracohumeral ligament. Clin Orthop. 1992 Jul. (280):182-5. [Medline].
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. 1989 Dec. 71(10):1511-5. [Medline].
Andrieu V, Dromer C, Fourcade D, et al. Adhesive capsulitis of the shoulder: therapeutic contribution of subacromial bursography. Rev Rhum Engl Ed. 1998 Dec. 65(12):771-7. [Medline].
Calis M, Demir H, Ulker S, et al. Is intraarticular sodium hyaluronate injection an alternative treatment in patients with adhesive capsulitis?. Rheumatol Int. 2006 Apr. 26(6):536-40. [Medline].
Itokazu M, Matsunaga T. Clinical evaluation of high-molecular-weight sodium hyaluronate for the treatment of patients with periarthritis of the shoulder. Clin Ther. 1995 Sep-Oct. 17(5):946-55. [Medline].
Rovetta G, Monteforte P. Intraarticular injection of sodium hyaluronate plus steroid versus steroid in adhesive capsulitis of the shoulder. Int J Tissue React. 1998. 20(4):125-30. [Medline].
Hsieh LF, Hsu WC, Lin YJ, Chang HL, Chen CC, Huang V. Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: a randomized controlled trial. Arch Phys Med Rehabil. 2012 Jun. 93(6):957-64. [Medline].
Corbeil V, Dussault RG, Leduc BE, et al. [Adhesive capsulitis of the shoulder: a comparative study of arthrography with intra-articular corticotherapy and with or without capsular distension]. Can Assoc Radiol J. 1992 Apr. 43(2):127-30. [Medline].
Gam AN, Schydlowsky P, Rossel I, et al. Treatment of "frozen shoulder" with distension and glucorticoid compared with glucorticoid alone. A randomised controlled trial. Scand J Rheumatol. 1998. 27(6):425-30. [Medline].
Bell S, Coghlan J, Richardson M. Hydrodilatation in the management of shoulder capsulitis. Australas Radiol. 2003 Sep. 47(3):247-51. [Medline].
Piotte F, Gravel D, Moffet H, et al. Effects of repeated distension arthrographies combined with a home exercise program among adults with idiopathic adhesive capsulitis of the shoulder. Am J Phys Med Rehabil. 2004. 83(7):537-46; quiz 547-9.
Dahan TH, Fortin L, Pelletier M, et al. Double blind randomized clinical trial examining the efficacy of bupivacaine suprascapular nerve blocks in frozen shoulder. J Rheumatol. 2000 Jun. 27(6):1464-9. [Medline].
Gado K, Emery P. Modified suprascapular nerve block with bupivacaine alone effectively controls chronic shoulder pain in patients with rheumatoid arthritis. Ann Rheum Dis. 1993 Mar. 52(3):215-8. [Medline]. [Full Text].
Shanahan EM, Ahern M, Smith M, Wetherall M, Bresnihan B, FitzGerald O. Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain. Ann Rheum Dis. 2003 May. 62(5):400-6. [Medline]. [Full Text].
Lin ML, Huang CT, Lin JG, et al. [A comparison between the pain relief effect of electroacupuncture, regional never block and electroacupuncture plus regional never block in frozen shoulder]. Acta Anaesthesiol Sin. 1994 Dec. 32(4):237-42. [Medline].
Buchbinder R, Hoving JL, Green S, et al. Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial. Ann Rheum Dis. 2004 Nov. 63(11):1460-9. [Medline].
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. 2006 Mar. 86(3):355-68. [Medline].
Widiastuti-Samekto M, Sianturi GP. Frozen shoulder syndrome: comparison of oral route corticosteroid and intra-articular corticosteroid injection. Med J Malaysia. 2004 Aug. 59(3):312-6. [Medline].