Adhesive capsulitis, commonly known as frozen shoulder, is characterized by progressive pain and severe restriction of both active and passive shoulder movement. The underlying issue is the thickening and contraction of the joint capsule, the connective tissue surrounding the shoulder joint. Cortisone, a powerful anti-inflammatory steroid, is a frequent first-line treatment aimed at reducing inflammation and pain associated with the condition. When an intra-articular cortisone injection does not provide the expected relief, it signals a need to reassess the condition and move toward specialized treatment pathways. The focus must then shift from merely managing pain to actively restoring lost mobility.
Why the Cortisone Injection Might Have Failed
The effectiveness of a cortisone injection is often dependent on the specific stage of the disease, which progresses through “freezing,” “frozen,” and “thawing” phases. The injection is typically most beneficial during the initial, highly painful “freezing” phase, where inflammation is the dominant factor. If the condition has already progressed deeply into the “frozen” stage, the stiffness is due to dense scar tissue, or capsular contracture, which is less responsive to anti-inflammatory medication alone. High pain levels before the injection are also statistically associated with a higher rate of treatment failure.
Another possibility for failure is a misdiagnosis, where the symptoms were mistakenly attributed to frozen shoulder instead of another issue like a rotator cuff tear or tendon problem. Inaccurate placement of the medication outside the joint capsule will also render the injection ineffective, though this is less common with modern image-guided techniques. Furthermore, underlying conditions such as diabetes can make the capsular tissue more resistant to initial steroid treatment.
The Role of Physical Therapy and Rehabilitation
When the injection fails to provide adequate pain relief, the primary treatment focus shifts entirely to regaining the lost range of motion through structured physical therapy (PT). The goal of this rehabilitation is to gently stretch the contracted joint capsule without causing a pain flare that would lead to further protective tightening. A physical therapist will tailor exercises to the patient’s current stage, emphasizing a distinction between self-managed and clinical therapy.
Initial therapy involves gentle, low-load, long-duration stretches, such as the pendulum exercise or wall slides, performed within the pain-free range. The patient must maintain consistency, often performing a home exercise program several times a day, which is just as important as the supervised clinic sessions. As mobility slowly improves, the therapist may introduce more intensive manual therapy techniques and strengthening exercises to stabilize the joint. Aggressive or forceful stretching must be avoided, as it can aggravate the inflamed capsule and worsen the condition.
Specialized Non-Surgical Procedures
If a patient shows minimal or no improvement after several weeks or months of conservative physical therapy following the initial injection failure, specialized, clinic-based procedures may be introduced.
Hydrodilatation
Hydrodilatation, sometimes called distension arthrography, aims to physically stretch the joint capsule. This procedure involves injecting a large volume of fluid—a mixture of sterile saline, local anesthetic, and a corticosteroid—directly into the shoulder joint under imaging guidance. The high volume of injected fluid expands the joint capsule, effectively breaking up some of the restrictive adhesions. Studies suggest hydrodilatation provides greater improvement in range of motion and pain scores compared to a standard intra-articular steroid injection alone.
Suprascapular Nerve Block (SSNB)
Another effective intervention is the suprascapular nerve block (SSNB), which involves injecting a local anesthetic and steroid near the suprascapular nerve. This procedure is not intended to treat the capsule directly but to significantly reduce the severe shoulder pain. Reducing the pain allows the patient to tolerate more effective physical therapy immediately afterward.
When Surgery Becomes Necessary
Surgery is typically reserved as a last resort, considered only after a patient has failed to regain functional mobility despite multiple months of diligent physical therapy and specialized non-surgical procedures. The two main surgical approaches are Manipulation Under Anesthesia (MUA) and Arthroscopic Capsular Release (ACR).
Manipulation Under Anesthesia (MUA)
MUA is a less invasive technique where the patient is placed under general anesthesia. The surgeon forcibly moves the arm to break up the scar tissue and adhesions within the joint capsule. While MUA is relatively quick, it carries a small risk of complications, including potential fracture or nerve injury.
Arthroscopic Capsular Release (ACR)
ACR is a keyhole procedure where the surgeon uses small instruments guided by a camera to precisely cut and release the thickened, contracted portions of the joint capsule. ACR is often considered a more controlled and safer option, particularly for patients with co-existing conditions like diabetes. Both surgical procedures require an immediate and intensive course of post-operative physical therapy to maintain the range of motion achieved during the operation and prevent the shoulder from re-stiffening.