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

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

Shoulder Adhesive Capsulitis – Frozen Shoulder Treatment

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 my continued care choices the doctor and my therapist were offering. More painkillers, more anti-inflammatories, more physical therapy, the 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 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 for who treatments have not helped their frozen shoulder 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 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.

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 with 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 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 appears to occur in three main phases:

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 release is too much release? When less cutting is better.

Here is an interesting study published in the Orthopaedics and traumatology, surgery and research (x). 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 shoulder, radiofrequency is used to cut through tissue that may be causing the frozen shoulder condition.

Then they compared the patient’s outcomes:

The researchers then suggested that less extensive releases may result in better functional and pain scores. 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 amongst the 3 techniques.

Conservative care options – Non-operative Treatment of Frozen Shoulder

An April 2021 paper (3) 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

Hydrodilatation

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. (6

A 2016 study recommended that some patients may “get away” with a cortisone injection that will offer temporary relief. (7) A July 2019 study suggested while “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 shoulder range of motion. (8) 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 benefit, 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. (9)

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 (10) 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 improve 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

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.

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 (11) 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 (12) 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 (13) commented on a case history of a patient treated with Platelet Rich Plasma injections for frozen shoulder.

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

A July 2019 study in the American Journal of Physical Medicine & Rehabilitation (14)  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 (15) found that one injection of PRP was more effective than procaine in treating frozen shoulderPRP had a more prolonged efficiency than the procaine control.

Summary and contact us. Can we help you?

We hope you found this article informative and 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

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

1 Barnes CP, Lam PH, Murrell GA. Short-term outcomes after arthroscopic capsular release for adhesive capsulitis. J Shoulder Elbow Surg. 2016 Sep;25(9):e256-64. [Google Scholar]
2 Lee SJ, Jang JH, Hyun YS. Can manipulation under anesthesia alone provide clinical outcomes similar to arthroscopic circumferential capsular release in primary frozen shoulder (FS)?: the necessity of arthroscopic capsular release in primary FS. Clinics in Shoulder and Elbow. 2020 Dec;23(4):169. [Google Scholar]
3 Pandey V, Madi S. Clinical Guidelines in the Management of Frozen Shoulder: An Update!. Indian Journal of Orthopaedics. 2021 Feb 1:1-1. [Google Scholar]
4 Lädermann A, Piotton S, Abrassart S, Mazzolari A, Ibrahim M, Stirling P. Hydrodilatation with corticosteroids is the most effective conservative management for frozen shoulder. Knee Surgery, Sports Traumatology, Arthroscopy. 2021 Jan 9:1-1.
5 Paruthikunnan SM, Shastry PN, Kadavigere R, Pandey V, Karegowda LH. Intra-articular steroid for adhesive capsulitis: does hydrodilatation give any additional benefit? A randomized control trial. Skeletal radiology. 2019 Dec 17:1-9. [Google Scholar]
6 Chang KV, Wu WT, Hung CY, Han DS, Yang RS, Chang CH, Lin CP. Comparative Effectiveness of Suprascapular Nerve Block in the Relief of Acute Post-Operative Shoulder Pain: A Systematic Review and Meta-analysis. Pain Physician. 2016 Sep-Oct;19(7):445-56. [Google Scholar]
7 Koh KH. Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials. Singapore Med J. 2016 Aug 29.  [Google Scholar]
8 Jung TW, Lee SY, Min SK, Lee SM, Yoo JC. Does Combining a Suprascapular Nerve Block With an Intra-articular Corticosteroid Injection Have an Additive Effect in the Treatment of Adhesive Capsulitis? A Comparison of Functional Outcomes After Short-term and Minimum 1-Year Follow-up. Orthopaedic journal of sports medicine. 2019 Jul 19;7(7):2325967119859277. [Google Scholar]
9 Mehta SS, Singh HP, Pandey R. Comparative outcome of arthroscopic release for frozen shoulder in patients with and without diabetes. Bone Joint J. 2014 Oct;96-B(10):1355-8. doi: 10.1302/0301-620X.96B10.34476.  [Google Scholar]
10 Atan T, Bahar-Ozdemir Y. Efficacy of high-intensity laser therapy in patients with adhesive capsulitis: a sham-controlled randomized controlled trial. Lasers in Medical Science. 2020 Aug 18:1-1.  [Google Scholar]
11 Ünlü B, Çalış FA, Karapolat H, Üzdü A, Tanıgör G, Kirazlı Y. Efficacy of platelet-rich plasma injections in patients with adhesive capsulitis of the shoulder. International Orthopaedics. 2020 Nov 18:1-0. [Google Scholar]
12 Thu AC, Kwak SG, Shein WN, Htun LM, Htwe TT, Chang MC. Comparison of ultrasound-guided platelet-rich plasma injection and conventional physical therapy for management of adhesive capsulitis: a randomized trial. Journal of International Medical Research. 2020 Dec;48(12):0300060520976032. [Google Scholar]
13 Aslani H, Nourbakhsh ST, Zafarani Z, et al. Platelet-Rich Plasma for Frozen Shoulder: A Case Report. Archives of Bone and Joint Surgery. 2016;4(1):90-93. [Google Scholar]
14 Barman A, Mukherjee S, Sahoo J, Maiti R, Rao PB, Sinha MK, Sahoo D, Tripathy SK, Patro BK, Bag ND. Single Intra-articular Platelet-Rich Plasma Versus Corticosteroid Injections in the Treatment of Adhesive Capsulitis of the Shoulder: A Cohort Study. American journal of physical medicine & rehabilitation. 2019 Jul 1;98(7):549-57. [Google Scholar]
15 Lin J. Platelet-rich plasma injection in the treatment of frozen shoulder: A randomized controlled trial with 6-month follow-up. International journal of clinical pharmacology and therapeutics. 2018 Aug 1;56(8):366. [Google Scholar]

This article was updated February 8, 2021

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