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.
- Research suggests that frozen shoulder can simply appear spontaneously without a cause. It may disappear in that same fashion.
- Immobilization following an injury or surgery is also speculated. Many people come into our office after prolonged periods of shoulder immobilization. The capsule of tissue surrounding his/her shoulder is inflamed and shrink. This is what causes a very painful condition and to have an extremely limited range of motion. The pain may have died down after a few weeks or months but their lack of range of motion continued.
Frozen shoulder appears to occur in three main phases:
- In the first stage, shoulder pain increases with movement and gets worse at night. As the pain increases, so does the loss of motion. This phase usually lasts 2 to 9 months.
- During the second stage, the arm may be easier to move, but the range of motion is limited – close to 50 percent less than the other arm. This phase may last 4 to 12 months.
- The third stage involves a resolution of the condition. Over a 12 to 24-month period, the sufferer will experience a gradual improvement in the mobility of the shoulder. However, treatment is usually necessary to achieve proper motion.
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:
- 57 patients (group A) treated with manipulation under anesthesia and 22 patients (group B) were treated with an arthroscopic capsular release.
- In group A, manipulation under anesthesia, manipulation including a backside arm-curl maneuver was performed under interscalene brachial block (nerve block injection).
- In group B, manipulation was performed only to release the inferior capsule before arthroscopic circumferential capsular release (a standard of care procedure), which was carried out for the unreleased capsule after manipulation.
- Pain, range of shoulder motion scores were recorded at 1 week, 3 months, 6 months, and 1 year after surgery.
Outcome variables at 3 months after surgery and improvements in outcome variables did not differ between groups.
- Group A showed significantly better results than group B (surgery group) in the evaluation of pain and range of motion at 1 week.
- Eleven patients required additional steroid injections between 8 to 16 weeks after surgery: 12.2% in group A, 18.2% in group B.
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.
- Anterior-inferior capsular release (Group 1) – Smaller cutting area.
- Anterior-inferior-posterior capsular release (Group 2) – Larger tissue cutting area or releasing.
- and 360-degree capsular release (Group 3) at follow up points 3,6 and 12 months.
Then they compared the patient’s outcomes:
- Comparing ROM:
- Group 1 – Anterior-inferior capsular release -had greater early abduction, early and overall external rotation than Group 2 (Anterior-inferior-posterior capsular release), as well as greater early flexion, early abduction, early and overall internal rotation than Group 3.
- Group 2 had greater early and overall flexion than Group 1, as well as greater early and overall flexion, early abduction and early internal rotation than Group 3. Group 3 had greater overall flexion than Group 1 and greater overall external rotation than Group 2.
- Comparing VAS (visual pain scores), the less extensive releases saw the greatest significant postoperative reduction. .
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 and other analgesics: NSAIDs remain one of the most common medical intervention in treating frozen shoulder. A short course of NSAIDs for 2–3 weeks is very frequently used to minimize intense pain of the freezing stage. However, course of NSAIDs does not alter course of the frozen shoulder but enables the patient to carry out their activities of daily living in a more relaxed fashion and perform PT (retaining ROM) with ease.”
Cortisone – “disastrous complication of avascular necrosis of femoral head has to be feared of, even with a short course of oral steroid.”
- Oral steroids: In several high-quality studies, moderate evidence was found in favor of oral steroid for improving pain, ROM and function when prescribed for ‘short term’ (6 weeks) in stage 1. However, the effects were not maintained beyond 6 weeks after stopping it. Nevertheless, disastrous complication of avascular necrosis of femoral head has to be feared of, even with a short course of oral steroid.
- Steroid injection is certainly superior to PT in reducing pain but evidence is conflicting regarding restoration of ROM while comparing steroid injection with PT or manipulation under anesthesia.
PT combined with NSAIDs and steroids
- PT remains one of the cornerstones in the treatment of the frozen shoulder. The arms of PT consist of ‘pain-relieving PT’, ‘mobilization PT’ and ‘strengthening PT’. In the freezing stage, it is better to use pain-relieving PT and avoid aggressive mobilization techniques as latter can exacerbate the pain. There are various modalities of ‘pain relieving PT’ such as Laser, short wave diathermy, ultrasound and hot packs. PT, along with NSAIDs or steroid injection, is better in providing symptomatic relief than PT alone.
- Hydrodilatation: In late freezing or early frozen stage, Hydrodilatation of the glenohumeral joint using saline, steroid, local anesthetic agent is supposed to distend the capsule by breaking the ‘early intracapsular fibrosis’ which helps in improving ROM. A single HD procedure is superior to placebo in improving ROM, pain, and function in the short term. However, more than one repeated Hydrodilatation after 2 weeks has no added effect over a single Hydrodilatation procedure.
- A January 2021 study (4) 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.
- A May 2020 study in the journal Skeletal radiology (5) presented an opposing point-of-view: “Shoulder joint hydrodilatation offered no additional benefit compared to intra-articular steroid injections for shoulder adhesive capsulitis. Outcome for diabetics and non-diabetics were similar and there was no correlation between duration of symptoms and outcome.”
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
- Frozen shoulder is an interesting entity, we are not really sure why it happens it seems to be more prevalent in people with diabetes. There appears also to be a connection with some type of autoimmune reaction (inflammation) in the shoulder.
Extended reduced mobility in the shoulder
- In some patients, they have a shoulder injury like a rotator cuff tendon tear. They then stop using that shoulder because of pain and function issues. With this lack of movement, the soft tissue of the shoulder capsule compresses or shrinks down. This is the body’s natural way to limit injury, by limiting motion, as it does with bone spurs however, this is also painful.
History of pain and severity
- We are looking for extremely painful shoulder episodes with a very limited range of motion. We are also looking for a patient history where this pain may have been significantly reduced on its own 8 – 12 weeks after the onset. This will help determine how we will progress with treatment.
Determining the extent of muscle atrophy and muscle weakness.
- Many patients we see have had frozen shoulder problems for years. They have developed significant muscle atrophy and weakness. It has also impacted neck and arm movements.
Determining the cause of loss of range of motion
- In a physical examination, we are going to try to determine the cause of the loss of range of motion. Is it from advancing osteoarthritis and bone spur formation? If needed an ultrasound examination of the shoulder will be performed to make sure a rotator cuff or other problems such as a shoulder impingement is not hiding from us.
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.
- Thirty-six patients diagnosed with adhesive capsulitis were randomized into
- high-intensity laser therapy plus therapeutic exercises,
- sham-laser plus therapeutic exercises,
- and control-therapeutic exercises only groups.
All groups received 25 minutes of exercises to the shoulder joint supervised by a physiotherapist.
- Patients in both the high-intensity laser therapy and the sham-laser group were blinded to their group randomization. The interventions were performed five times a week for 3 weeks (a total of 15 sessions).
- The primary outcome measure was pain scores. The secondary outcome measures were disability and range of motion of the shoulder joint.
- Assessments were performed at pre-intervention, post-intervention, and 12-week follow-up by an investigator who was blinded.
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.
- Prolotherapy is the simple injection of dextrose (sugar) into the shoulder joint. Many studies have documented Prolotherapy treatment’s effectiveness in treating the problems of chronic pain.
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 or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- In the shoulder procedure, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
- This patient, in particular, came to us for a history of repeated shoulder dislocations. His MRI findings showed multiple shoulder labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and shoulder tendon damage multiple dislocations can do.
- With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
- PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
- PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments, in this case, it was in his anterior shoulder attachments to address the chronic dislocations.
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.
- In this study 32 patients, 21 female and 11 male, average age 57.
- The patients in this study had to have shoulder pain and restrictions in movements (at least 25% when compared to the other side, and at least in two directions) for three months minimum and nine months maximum.
- Patients were randomized to two groups, and one group took PRP injections for three times every two weeks, while the other group took saline injections in same frequency and volume. A standardized exercise program was also applied to all patients.
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?
- “Subjects in both groups showed a significant decrease in the visual analogue scale score for pain and shoulder and hand scores, and they a significant increase in shoulder passive range of motion at all evaluation time points. There was no significant difference in the measured outcomes between the two groups. However, there was less acetaminophen consumption after PRP injection compared with that after conventional physical therapy.
- Conclusions: “PRP injection is a useful option for treating patients with adhesive capsulitis, particularly those who have low therapeutic compliance for exercise therapy or have contraindications for corticosteroid injection or oral pain reduction medication.”
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 45-year-old man with shoulder adhesive capsulitis underwent two consecutive platelet-rich plasma injections at the seventh and eighth months after initiation of symptoms. He was measured for pain, function, and Range of Motion ROM.
- After the first injection, the patient reported a 60% improvement regarding shoulder pain and no night pain.
- Also, two-fold improvement for ROM and more than 70% improvement for function were reported.
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 shoulder. PRP 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
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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