So once we have diagnosed adhesive capsulitis...how do we manage it?
- NSAID's - no differences in function or pain compared to placebo
- Oral corticosteroids (prednisone) - can improve night pain & pain/function in the short term (usually 6/52) but has no effect on the duration of injury
- Intra-articular corticosteroid injection - better pain relief & improved function in short term (6/52), evidence that a patient can receive up to three injections over four months without significant complications
- Sodium hyaluronate injection - significantly improved shoulder ROM and pain with equivalent results to corticosteroid injections but less harmful, however all studies looked at used repeated injections (weekly up to 5x injections)
- Hydrodilatation - a large amount of saline solution & corticosteroid is injected into the glenohumeral joint to stretch the capsule
Bell and colleagues (2003) performed 109 hydrodilatations, with 67% of patients having no pain at 3 months and the remaining having mild to moderate pain at 3 months. It has been shown as effective at early or late stage and in those with mild to severe pain.
Previously a hydrodilatation was performed until rupture, however Koh (2012) measured pressure and volume in the joint and found increased volume and a better result if they prevented the capsule rupture. If the capsule is allowed to gradually stretch, without rupture, it prevents further complications to the tendon sheaths and allows for repeat hydrodilatations. Their study found those with improved ROM and reduced pain had associated biomechanical changes in the joint of increased volume capacity and reduced capsular stiffness. This study highlights physiological changes, as well as pain relief, occur when a hydrodilatation is performed.
- Manipulation Under Anaesthetic (MUA) - only considered after 6/12, glenohumeral joint stretched into flexion/abduction/ER or IR until capsular tearing occurs, it has good results but is equivalent to less invasive methods, complications include fractures, RCuff/labral tears, dislocation, brachial plexus injuries, haematomas etc.
- Arthroscopic Release - remove scar tissue from subscapularis & inferior capsule allowing inferior and lateral translation of head of humerus
- Open Release - only after failed MUA, rare now due to arthroscope availability
There is limited evidence for physiotherapy alone, most articles agree that a combination of medical, physiotherapy and home exercise program is the most effective. Carette and associates (2003) found cortisone injections and a home exercise program were effective in reducing pain, but adding supervised physiotherapy had a faster improvement in range of motion. Although physiotherapy alone was no better. A systematic review by Blanchard (2010) found corticosteroids are better at improving pain, passive external rotation and shoulder disability in the first 6 weeks post-injection. However, physiotherapy was more beneficial at 12 weeks in reducing pain and disability, with both injections and physiotherapy more beneficial than placebo. So should we wait for it to "burn out"?
- Patient education - there is moderate evidence that "supervised neglect", consisting of knowledge of pathology, gradual stretching and return to ADL's as pain allows, is superior to intensive and aggressive physiotherapy (Diercks & Stevens, 2004)
- Joint mobilisation - although mobilisation groups show improved range and pain in RCT's, there is no significant difference compared to control, Grade I & II mobilisations may assist in pain relief but have minimal effect on range
- Stretching - there is nil to minimal improvements in ROM and pain following home stretching, however most articles employ stretching in their control groups
Clinical Practice Guidelines - For more information, a recent article by Kelley et al (2013), provides a comprehensive overview of physiotherapy, medical and surgical interventions.
Bell, S., Coghlan, J., & Richardson, M. (2003). Hydrodilatation in the management of shoulder capsulitis. Australasian radiology, 47(3), 247-251.
Blanchard, V., Barr, S., & Cerisola, F. L. (2010). The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy, 96(2), 95-107.
Carette, S., Moffet, H., Tardif, J., Bessette, L., Morin, F., Fremont, P., . . . Blanchette, C. (2003). Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis and rheumatism, 48(3), 829-838.
Kelley, M. J., Shaffer, M. A., Kuhn, J. E., Michener, L. A., Seitz, A. L., Uhl, T. L., . . . McClure, P. W. (2013). Shoulder pain and mobility deficits: adhesive capsulitis. The Journal of orthopaedic and sports physical therapy, 43(5), A1-31.
Koh, E. S., Chung, S. G., Kim, T. U., & Kim, H. C. (2012). Changes in biomechanical properties of glenohumeral joint capsules with adhesive capsulitis by repeated capsule-preserving hydraulic distensions with saline solution and corticosteroid. PM & R : the journal of injury, function, and rehabilitation, 4(12), 976-984.