Frozen Shoulder – Adhesive Capsulitis: Injections, Physical Therapy and Surgery

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

A typical new patient will come into our center. They will sit on the examination table and they will tell us a story that sounds something like this:

“I have a frozen shoulder. It is not getting better. My doctor and my physical therapist tell me that if I do not treat it, it will probably go away by itself. It may be in a few months, in a few years, but maybe not at all. Physical therapy has helped me, but I yo-yo, some days my shoulder feels really good, some days it does not feel that good, some days it is really very painful.”

“I do a lot of exercises at home to keep my shoulder mobile and keep the range of motion from getting worse. I did not like the continued care choices the doctor and my therapist were offering. More painkillers, more anti-inflammatories, more physical therapy, and a schedule of 2-3 times a week is more than I can keep. I have been offered cortisone which I would like to avoid unless absolutely necessary and I have been offered to be put under (manipulation under anesthesia), but I did not like the risks my doctor told me about and she told me the frozen shoulder may just come back again anyway. I am looking for something to help me on a more permanent basis.”

There are some people with Adhesive Capsulitis of the shoulder, or more commonly a “frozen shoulder,” who get a great benefit from cortisone injections, ART or Active Release Therapy, chiropractic manipulations, and sometimes no treatment at all, the problem “thaws,” out. These are not the people we see in our clinic. We see the people whose treatments have not helped their frozen shoulders and they are thinking about manipulation under anesthesia or shoulder arthroscopic surgery and are exploring other options. Or simply we see people like this, where the frozen shoulder has become a long-term problem

I have had frozen shoulders for over four years, it is not better it is getting worse. I still have very limited mobility in my shoulders. I can’t get my hands over my head. No matter how I move my arms, my shoulders hurt.

Shoulder Adhesive Capsulitis – Frozen Shoulder Treatment: Discussion points of this article:

What caused your shoulder to freeze is open to debate

In our experience, we have seen many patients whose shoulder adhesive capsulitis or frozen shoulder started with a rotator cuff injury. This then developed into a rotator cuff tendinosis or tendinopathy of the rotator cuff tendon. Other people have no idea what caused this shoulder problem. Over time their shoulder hurt. They would get up in the morning in pain reach for some aspirin or Advil or Tylenol and be on their way hoping that their shoulder would not be a problem all day long. The common term adhesive capsulitis refers to scar tissue that forms inside a joint due to a lack of movement. In the simplest terms, “use it or lose it.” If you do not move your shoulder through its normal range of motion, you may lose your ability to do so.

Frozen Shoulder - Adhesive Capsulitis: Injections, Physical Therapy and Surgery

Frozen shoulder appears to occur in three main phases:

Frozen shoulder MRI is also controversial

A June 2022 paper (13) wrote: “Shoulder magnetic resonance imaging (MRI) is commonly performed in patients with frozen shoulder. However, the necessity of MRI and its diagnostic value is questionable.” The goal of the study was to see if MRI found anything else in the shoulder not previously suspected in the clinical examination and if any change in the treatment plan based on these additional MRI findings in frozen shoulder patients was observed.

In 403  patients a shoulder MRI was performed. An additional structural shoulder pathology was identified in 89 of 403 (22%) patients following the shoulder MRI, mostly rotator cuff tears (partial 11.4%, full-thickness: 7.4%, re-rupture following reconstruction: 2.5%, and labrum tears 0.7%. At minimum 2-year follow-up, 11 of 403 (2.7%) patients were treated surgically for the additional pathology identified on the MRI scan consisting of an arthroscopic rotator cuff reconstruction in 10 patients and a labrum refixation in one patient. Five of the 609 (0.8%) patients were treated for refractory frozen shoulder by arthroscopic capsulotomy.

Conclusions: “Although additional pathologies were identified in 22% of the patients, a change in treatment plan due to the MRI findings was only observed in 2.7% (37 MRIs needed to identify 1 patient with frozen shoulder requiring surgery for the additional MRI findings). Therefore, routine use of shoulder MRI scans in patients with a frozen shoulder but without suspicion of an additional pathology may not be indicated.”

As controversial as the origins of shoulder adhesive capsulitis are, so are the treatments. Especially treatments that may make a patient’s shoulder worse.

For some people, surgery is necessary and there will be a good improvement. This was reported by the Orthopaedic Research Institute, St George Hospital Campus, University of New South Wales, in their study, reported in the Journal of Shoulder and Elbow Surgery (1).

A November 2020 study in the journal Clinics in Shoulder and Elbow (2) suggested that surgery may not be needed and that manipulation alone could fix the problem. In this study, the doctors evaluated the need for arthroscopic capsular release in refractory (difficult, not responding) primary frozen shoulder by comparing clinical outcomes of patients treated with arthroscopic capsular release and manipulation under anesthesia.

Here are the summary learning points:

Outcome variables at 3 months after surgery and improvements in outcome variables did not differ between groups.

It should be noted that one in eight and one in nine patients following these procedures still required multiple cortisone injections after the manipulation and surgical procedures.

How much frozen shoulder release is too much release? When less cutting is better.

Here is an interesting study published in Orthopaedics and Traumatology, Surgery and Research (3). Here, doctors took three groups of patients who had a frozen shoulder release procedure. They divided the patients by the type of procedure.

Explanatory note: Arthroscopic capsular release is considered a minimally-invasive shoulder surgery. In treating frozen shoulders, radiofrequency is used to cut through tissue that may be causing the frozen shoulder condition.

Then they compared the patient outcomes:

The researchers then suggested that less extensive releases may result in better function and pain scores. The addition of a posterior release offers increased early internal rotation, which was not sustained over time but provides early and sustained flexion improvements. A complete 360 release may not provide any further benefit. There were no significant differences in the complication rates among the 3 techniques.

Conservative care options – Non-operative Treatment of Frozen Shoulder

An April 2021 paper (4) offered an updated set of clinical guidelines in the management of frozen shoulder. We would like to reiterate that many people do very well with the treatments that are described here below. These are the people we do not see at our center, we see the people for whom these treatments were not successful. Here are the updated guidelines presented:

NSAIDs

Cortisone – “disastrous complication of avascular necrosis of femoral head has to be feared of, even with a short course of oral steroid.”

PT combined with NSAIDs and steroids

Benefits of cortisone injections combined with physical therapy in the case of a frozen shoulder

In December 2020 doctors at the University of Glasgow wrote in the JAMA Network Open from the Journal of the American Medical Association (24) about the positive effect cortisone injections could have on helping patients with Frozen Shoulder. “Based on the findings of (this study), we recommend the use of Intra-articular corticosteroid for patients with frozen shoulder (with symptoms of less than one year) because it appeared to have earlier benefits than other interventions; these benefits could last as long as 6 months. We also recommend an accompanying home exercise program with simple ROM exercises and stretches. The addition of physiotherapy in the form of an electrotherapy modality and supervised mobilizations should also be considered because it may add mid-term benefits and can be used on its own, especially when Intra-articular corticosteroid is contra-indicated. ”

A study from Faisalabad Medical University in Pakistan (5) compared the combination of corticosteroid injection with physiotherapy to physiotherapy alone in patients with frozen shoulders.

Nerve blocks and cortisone – can help, but for how long?

Researchers at the Department of Physical Medicine and Rehabilitation, Marmara University in Turkey published a December 2021 study (6)  in which they assessed and evaluated the short and long-term effects of the combination of suprascapular nerve block and intra-articular corticosteroid injection on pain, shoulder range of motion, disability, and quality of life in the management of patients with adhesive capsulitis.

There is research to suggest that suprascapular nerve block injection is beneficial for pain and range of motion. A December 2021 study (7) from Blackpool Victoria Hospital, Blackpool, United Kingdom found: that “suprascapular nerve block is associated with significant improvements in shoulder pain and range of motion in patients with frozen shoulder. Further randomized controlled trials comparing suprascapular nerve block with intra-articular injection and other nonoperative treatments are required to fully define its role in the management of frozen shoulder.”

Returning to the Marmara University study, here doctors divided forty patients (ages 30-70 years) with frozen shoulder stages 1 and 2 into two groups:

Hydrodilatation

Hydrodilatation sometimes referred to as hydrodistention, injects the shoulder with a large amount of saline, sometimes with corticosteroid and local anesthetic. The hope is that filling the shoulder up with saline will help break up the adhesions and free up the range of motion.

An April 2021 study describes Hydrodilatation this way: (8)

“In late freezing or early frozen stage, Hydrodilatation of the glenohumeral joint using saline, steroid, the local anesthetic agent is supposed to distend the capsule by breaking the ‘early intracapsular fibrosis’ which helps in improving range of motion. A single Hydrodilatation procedure is superior to placebo in improving the range of motion, pain, and function in the short term. However, more than one repeated Hydrodilatation after two weeks has no added effect over a single Hydrodilatation procedure. Nevertheless, Hydrodilatation may not offer any advantage in comparison to (corticosteroid) injection.”

A January 2021 study (9) found hydrodilatation with corticosteroid provides superior pain relief in the short term and improvement in range of motion across all time frames for frozen shoulder when compared to cortisone injection or physiotherapy.

Extracorporeal shock wave therapy for frozen shoulder

Extracorporeal shock wave therapy for frozen shoulder

There is limited research on this topic. A December 2015 study (11) in the Journal of Physical Therapy Science suggested a beneficial outcome for frozen shoulders with extracorporeal shock wave therapy. The researchers described the treatments and the outcomes:

A 2019 study also in the Journal of Physical Therapy Science (12) examined the effectiveness of extracorporeal shock wave therapy versus ultrasound therapy in participants with diabetic frozen shoulders.

The doctors then measured responses in pain, range of motions of the shoulder, disability, and function scores. They measured these scores weekly for four weeks.

What they found was significant improvements in pain, all active range of motions, and disability scores at the end of the 4th week in both groups. Additionally, the extracorporeal shock wave therapy group benefitted from significant pain reduction, reduced the number of therapy sessions, and thus the costs of treatment compared to the control group. The researchers concluded that: “Extracorporeal shock wave therapy significantly reduced pain in people with diabetic frozen shoulder with a reduction of treatment cost compared to the control group.”

Some patients will move onto a shoulder nerve block if surgery or other treatments are not successful

In the research just examined, we saw that cortisone was still necessary for some patients. In the journal Pain Physician, doctors noted that some patients will move onto a shoulder nerve block if surgery or other treatments are not successful. (13) 

A 2016 study recommended that some patients may “get away” with a cortisone injection that will offer temporary relief. (14) A July 2019 study suggested that “no therapeutic intervention is universally accepted as the most effective treatment for adhesive capsulitis. An intra-articular corticosteroid injection with a suprascapular nerve block (SSNB), may help with pain and restoration of the shoulder’s range of motion. (15) Again, we like to point out that these may be effective treatments for many people. These are not the people that we see in our office. We see the people who have had nerve blocks and cortisone that helped temporarily with their frozen shoulder problem but the underlying problem of shoulder instability and weakness remains.

Other treatments for frozen shoulder include shoulder exercise, manual therapy, and anti-inflammatory or NSAIDs which have been shown to produce short-term pain benefits, but both have been shown to result in long-term loss of function and even more chronic pain by inhibiting the healing process of soft tissues and accelerating cartilage degeneration.

Particular in arthroscopic frozen shoulder procedures is a significantly worse result in diabetic patients (of whom frozen shoulder can be as common as occurring in nearly 20% of diabetic patients) with a tendency towards the persistent limitation of movement two years after the operation. (16)

Is arthroscopic surgery the answer to a frozen shoulder?

Is arthroscopic surgery the answer to frozen shoulder?

Let’s look at a November 2021 study led by doctors at the Department of Orthopaedics, St Luke’s Hospital in Poland, and published in the Journal of Clinical Medicine (17). Here the doctors wrote: “Patients diagnosed with an idiopathic frozen shoulder with symptom onset of a maximum of six months receiving arthroscopic capsular release and corticosteroid injection followed by postoperative physiotherapy showed faster improvement in the involved shoulder range of motion and in the functional outcome than patients who received only the corticosteroid injection and physiotherapeutic procedure.” The short-term result is that arthroscopic surgery combined with corticosteroid and physical therapy worked better than corticosteroid and physical therapy alone. 

“Furthermore, at the early mid-term follow-up point, the early arthroscopy had a pronounced effect on the range of motion and function. Nonetheless, the arthroscopic capsular release had no beneficial effect on late mid-term clinical and functional outcomes, as both studied multimodality treatments were successful in that matter.” In the mid-term assessment (12 months after the surgery) there was no significant improvement noticed between patients who had arthroscopic capsular release and corticosteroid injection followed by postoperative physiotherapy versus the group who only had the corticosteroid and physiotherapy.

“Moreover, studied multimodality therapies were equally efficacious in reducing pain in patients with idiopathic frozen shoulders. Therefore, it seems that no recommendation for the early arthroscopic release can be given; however, conclusions should be interpreted with caution, given that they are based on a retrospective analysis.”

In other words, initially, the surgery can accelerate better shoulder range of motion and function. However, 12 months after surgery, the extra benefits of the surgery wore off and the results were just as good in patients without surgery.

Summary- what we look for in a patient with Frozen Shoulder

Extended reduced mobility in the shoulder

History of pain and severity

Determining the extent of muscle atrophy and muscle weakness.

Determining the cause of loss of range of motion

What about high-intensity laser therapy?

High-intensity laser therapy can be beneficial to some patients. An August 2020 study in the journal Lasers in Medical Science (18) offered this assessment of the treatment:

The purpose of the study is to evaluate the effects of high-intensity laser therapy (HILT) on pain, disability, and quality of life in patients with adhesive capsulitis. The study was designed as a prospective, double-blinded, and sham-controlled randomized trial.

All groups received 25 minutes of exercises to the shoulder joint supervised by a physiotherapist.

High-intensity laser therapy plus therapeutic exercises showed significant differences in pain scores. Fifteen sessions of High-intensity laser therapy are superior to improving pain and quality of life but not superior in terms of disability or function in patients with adhesive capsulitis.

Pain relief is always a good thing. Pain relief with functional improvement would be better.

Prolotherapy for Frozen Shoulder

Prolotherapy of the shoulder. Frequent sites of injection are demonstrated including the coracoid process, the subscapularis tendon, and the greater tuberosity also seen are the transverse humeral ligament the bronchial plexus.

Prolotherapy for frozen shoulder

After we do a physical examination to access the amount of damage from osteoarthritis and the possibility of bone spurs causing limitations in range of motion, we may also perform an ultrasound to look for rotator cuff tear. Then we typically inject a shoulder capsule with a large amount of Prolotherapy numbing solution to stretch out the shoulder joint. The numb shoulder can then be gently manipulated. Often several sessions of this treatment regimen are needed to achieve the shoulder’s original full range of motion.

In our clinical observations, we have seen Prolotherapy offer good results as a frozen shoulder treatment at getting the shoulder more motion, eliminating pain, and restoring the structures of the joint.

Prolotherapy combined with physical therapy

An October 2022 paper in the American Journal of Case Reports (25) examined the effectiveness of Prolotherapy combined with physical therapy versus physical therapy only for frozen shoulder. In this paper, doctors detailed the cases of two patients with frozen shoulder. Here is what they wrote: “Prolotherapy injects certain compounds into articular spaces, ligaments, and/or tendons to relieve pain and disability around joint spaces and to stimulate a proliferation cascade to enhance tissue repair and strength. This case report aims to describe functional outcome changes in 2 patients with frozen shoulder, comparing prolotherapy combined with physical therapy vs physical therapy only.”

In the first patient, doctors described treatment outcomes in a 66-year-old man with right shoulder pain and limited ROM that had worsened in the past three months. The patient complained his shoulder problems disrupted his daily life and he reported a visual analog scale (VAS) of 6 out of 10. The patient underwent prolotherapy combined with physical therapy and had significantly improved ROM after 2 weeks, with relieved pain and improved shoulder function.

In the second patient, the doctors described treatment outcomes in a 65-year-old man with right shoulder pain and limited ROM that had worsened in the past two months. The symptoms affected his general quality of life, with a VAS of 5 out of 10. Patient B underwent physical therapy only and showed similar ROM and no significant pain improvement.

The doctors concluded: “Initial treatment with prolotherapy combined with physical therapy for patients with frozen shoulder achieved a fast improvement of active and passive ROM, significantly decreased pain, and improved quality of life compared to physical therapy intervention only.”

Manipulation Under Anesthesia and Prolotherapy

A case report in the Journal of chiropractic medicine (26) was presented by doctors at the Natural Wellness and Pain Relief Center in Grand Blanc, Michigan. In this case the doctors described treatments for a 50-year-old man who had a 6-month history of chronic shoulder pain. They noted that the patient had a “markedly reduced” range of motion.  His shoulder pain was not responding to traditional treatments or medications including chiropractic manipulation, physical therapy, and steroid injections. Further he was taking hydrocodone 5/325 every 8 hours for pain without pain relief.

An MRI revealed adhesive capsulitis and distal (in the shoulder away from the scapula) infraspinatus partial-thickness tendon tear.

During treatment the the patient received a 3-day serial Manipulation Under Anesthesia. He participated in a course of post-Manipulation Under Anesthesia therapy for 4 weeks and thereafter received 6 total dextrose-based prolotherapy injections of the infraspinatus tendon over the subsequent 8 weeks. His self-rated pain rating scale dropped from a 77 out of 100 (extreme pain) to 11 out of 100. His range of motion returned to within normal limits. The doctors summarized: “This patient with adhesive capsulitis and rotator cuff tear responded favorably to Manipulation Under Anesthesia and dextrose-based prolotherapy. Results were maintained 7 years after treatment.”

Prolotherapy, frozen shoulder, diabetes mellitus and hypertension

An April 2023 paper (27) cited the cases of three patients with frozen shoulder treated with Prolotherapy. The main focus was on the comorbidities of diabetes mellitus and hypertension present in two of the patients and if Prolotherapy could help the patient’s frozen shoulder with these two diseases. Physical therapy was also added to the treatment regiment.

All three patients were treated with Prolotherapy. “The injection point on the rotator cuff includes the supraspinatus, infraspinatus, teres minor, and subscapularis. Intraarticular injection of the glenohumeral joint, subacromial bursa, long head biceps tendon, and acromioclavicular joint (were also given). Injections were administered four times every other week. ”

Summary findings: “The presence of comorbidities in the frozen shoulder causes a worsening prognosis in the treatment process. Using prolotherapy in a patient with comorbidities has been shown to reduce pain and increase the quality of life, which is almost the same as in patients without comorbidities. . . In a patient with a comorbid frozen shoulder, prolotherapy, and physical therapy exhibited the same potential benefits for improved range of motion, dramatically reduced discomfort, and improved quality of life. A patient with a comorbid frozen shoulder may benefit from prolotherapy, which has effects that last till full recovery. However, it takes longer to complete recovery compared to non-comorbid patients.”

In this video, a general demonstration of Prolotherapy and PRP treatment is given.
Danielle Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:

PRP injections in the management of adhesive capsulitis of the shoulder

A January 2021 (19) study published in the journal International Orthopaedics investigated whether PRP injections are effective in the management of adhesive capsulitis of the shoulder. This study was PRP alone. At our center, we recommend a combined Prolotherapy and PRP treatment as discussed in the above video.

How did the patients do? According to the researchers: “PRP injections were found to be effective in both pain and disability, and showed improvements in a restricted shoulder due to adhesive capsulitis. These findings might point out PRP as a therapeutic option in the management of adhesive capsulitis.”

Comparison of ultrasound-guided platelet-rich plasma injection and conventional physical therapy

A December 2020 study (20) published in The Journal of International Medical Research looked at how effective PRP injections could be for patients with adhesive capsulitis in comparison to conventional physical therapy. The conventional physical therapy included short-wave diathermy (heat) and exercise therapy performed at three sessions a week for 6 weeks for a total of 18 sessions). The PRP treatment was one injection.

Treatment outcomes evaluated therapeutic effectiveness before and at one, three, and six weeks after PRP injection and conventional physical therapy initiation. How did these patients do?

In independent research, doctors writing in the journal The Archives of Bone and Joint Surgery (21) commented on a case history of a patient treated with Platelet Rich Plasma injections for a frozen shoulder.

The doctors noted that Platelet-rich plasma can produce collagen and growth factors, which increases stem cells and consequently enhances healing.

A July 2019 study in the American Journal of Physical Medicine & Rehabilitation (22)  found that patients who were given a single PRP injection versus a single cortisone injection had better results from the PRP in terms of improving pain, disability, and shoulder range of movement at a 12 week follow up.

An August 2018 study in the International Journal of Clinical Pharmacology and Therapeutics (23) found that one injection of PRP was more effective than procaine in treating a frozen shoulder. PRP had a more prolonged efficiency than the procaine control.

Recap and contact us. Can we help you?

Caring Medical Research

Ross Hauser, MD discusses the Prolotherapy treatment results that were published a few years ago as part of our article series on the use of Hackett-Hemwall dextrose Prolotherapy, as well as shows a treatment demonstration from a Prolotherapy symposium he taught in 2021

A frozen shoulder is treatable with Prolotherapy and Platelet Rich Plasma Therapy but healing occurs over a longer period of time. The term adhesive capsulitis refers to scar tissue that forms inside the joint due to a lack of movement. If a joint is not moved through its full range of motion every day, scar tissue will form inside the joint. Generally, physical therapy exercises must accompany Prolotherapy and PRP to restore proper motion to the shoulder.  The first line of treatment for a frozen shoulder is physiotherapy. Physical therapy modalities, such as myofascial release, massage, range-of-motion exercises, and ultrasound, can often release scar tissue. If these do not relieve the problem, then the scar tissue can be broken up within the joint by the physician by injecting the shoulder full of a solution made up of sterile water mixed with an anesthetic. The numb shoulder can then be gently manipulated. Often several sessions of this treatment regimen are needed to achieve the shoulder’s original full range of motion.

Since the initial cause of the adhesive capsulitis was supraspinatus (rotator cuff) weakness, Prolotherapy injections to strengthen the rotator cuff can be performed in conjunction with the above techniques. Complete to near-complete resolution can be accomplished using this combined approach.

It is important that the other therapists know you are receiving Prolotherapy and PRP and they understand how it works in order to not interrupt or stop the progress made with Prolotherapy and PRP. It is also wise to make the Prolotherapist aware of exactly what type of therapies are being done between Prolotherapy visits and even to have some communication with the other therapist.

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your shoulder problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References

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This article was updated March 31, 2023

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