PT Classroom - Manual Therapy vs. Glucocorticoid Injections for Patients with Adhesive Capsulitis  ׀ by Casey Griebel, SPT


Adhesive capsulitis, or a frozen shoulder, is a condition that affects 3-5% of the general population, generally females between 40 and 70 years old. (2, 3) Adhesive capsulitis is an inflammatory condition of the synovium within the glenohumeral joint that is characterized by the spontaneous onset of pain and progressive loss of range of motion that affects activities of daily living. Patients tend to limit the use of the shoulder causing weakness, loss of motion, development of adhesions in the capsule, and increased pain. Adhesive capsulitis comes in multiple stages and the severity of the condition depends on the pain level and restrictions present. Stage I occurs in the first three months, accompanied by gradual pain (increased at night) and decreased external rotation. (2) Stage II, also known as the freezing stage, usually occurs after 3-9 months with the patient experiencing pain at rest with a loss of all glenohumeral motions. (2) The shoulder is considered frozen at stage III, with significant adhesions in the capsule, very limited motion, and atrophy to the rotator cuff, deltoid, biceps and triceps brachii. (2) The final stage is considered the thawing stage, stage IV, with minimal pain and the gradual improvement in range of motion. (2) This stage can occur between 15 and 24 months. The stage of the frozen shoulder will determine the treatment necessary.

The desired outcome of any treatment for adhesive capsulitis is to relieve the pain and restore range of motion. There are two main treatments that have been known to decrease pain for patients with this condition: manual therapy performed by a physical therapist and glucocorticoid injections. Manual therapy for adhesive capsulitis consists of therapist applied mobilizations and manipulations to the glenohumeral joint. These mobilizations are used to help gait the pain, break adhesions, and circulate synovial fluid through the joint to provide nutrition. In most cases, physical therapy is the first line of treatment for this condition. For pain relief, grade I and II joint mobilizations are the best option. With a patient in later stages with distinct restrictions, grades III and IV mobilizations will be necessary. The higher mobilizations are used to break the adhesions of the capsule. Glucocorticoid injections are often offered to patients who have chronic adhesive capsulitis. Since adhesive capsulitis is ultimately an inflammatory condition, the steroid injections help to decrease the inflammation present in the joint, as well as decrease the pain levels.

A Chocrine systematic review analyzed 32 studies, 30 of which were randomized control trials, of patients who were diagnosed with adhesive capsulitis. There were a total of 1836 participants with the average age of 55 years old. The long term and short term effects of manual therapy and exercise verses glucocorticoid injections for patients with adhesive capsulitis were reviewed. Although most of the evidence was deemed low to moderate, the results showed glucocorticoid injections portrayed better outcomes faster than manual therapy and exercise. (4) For short term treatments, glucocorticoid injections had a 25% greater functional improvement and a 26% decrease in pain over the manual therapy. (4) However, with long term treatments, there was no significant difference between the injections and the manual therapy, meaning the results were equally effective at increasing function and decrease the pain in patients. (4) Since the results of the two treatments showed the same long term effects of the condition, the pros and cons of each treatment should be discussed between the patient and physical therapist to determine the best option for the individual.

A randomized control study performed by Hsu et al. directly compared the effects Lidocaine has on a physical therapy treatment for patients with adhesive capsulitis. This study included participants with unilateral frozen shoulder with greater than 50% limitation in passive range of motion as compared to the uninvolved side in three or more directions (flexion, abduction, internal rotation, and external rotation) and symptoms that have lasted more than 3 months. (1) There were two groups: a PT only group and an INJPT (injection + PT) group. (1) For the participants in the injection group, Lidocaine was injected into their shoulder 10-20 minutes prior to undergoing physical therapy. (1) The injections were only done if a patient was experiencing severe pain that day (7cm or higher on a 10cm visual analog scale). (1) The outcome measures for this study include: active & passive ROM (primary outcome), the Shoulder Disability Questionnaire, the Shoulder Pain and Disability Index, and the Short-Form 36 survey. Participants were evaluated at baseline, 1, 2, 3, 4, and 6 months after the start of treatment. (1) The results showed that both groups improved in active and passive ROM independently. (1) When comparing between groups, the INJPT group showed greater improvement over the PT only group for active ROM in flexion and external rotation at 3, 4, and 6 months. (1) The INJPT group showed a significant difference over the PT only group for passive ROM in flexion at 3, 4, and 6 months, and external rotation at 4 and 6 months. (1) There was no significant difference for internal rotation between the groups noted. (1) Overall, this study showed that Lidocaine was successful at relieving pain during physical therapy sessions, which enabled the physical therapist to enhance the treatment effects. This study performed by Hsu et al. was the first to directly compare injections prior to physical therapy. However, the injections that were used were not glucocorticoid based. Lidocaine was used as an analgesic for this study, but this drug has the potential to be paired with a glucocorticoid. Therefore, more research is needed to conclude the overall benefit of the Lidocaine treatment paired with glucocorticoid.

In conclusion, both glucocorticoid injections and manual therapy were able to show improved range of motion and decreased pain for patients with adhesive capsulitis. The treatment chosen may depend on cost, co-morbidities present, or other underlying conditions of the patient. More research is necessary to determine if one method is overall more efficient and effective than the other for treating adhesive capsulitis of the glenohumeral joint.

Last revised: August 21, 2015
by Casey Griebel, SPT

1) Hsu, W., Wang, T., Lin, Y., Hsieh, L., Tsai, C., & Huang, K. (2015). Addition of lidocaine injection immediately before physiotherapy for frozen shoulder: a randomized controlled trial. PLoS One. 10(2): e0118217. Retrieved from:
2) Kisner, Carolyn and Colby, Lynn Allen. Therapeutic Exercise-Foundations and Techniques. Philadelphia: Jaypee Brothers Medical Publishers, 2012. Print.
3) Manske, R. & Prohaska, D. (2008). Diagnosis & management of adhesive capsulitis. Current Reviews in Musculoskeletal Medicine. 1(3-4): 180-189. Retrieved from:
4) Page, M.J., Green, S., Kramer, S., Johnston, R.V., McBain, B., Chau, M., & Buchbinder, R. (2014). Manual therapy and exercise for adhesive capsulitis (frozen shoulder). The Cochrane Library. Issue 8.

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