Beyond Corticosteroids: Ultrasound-Guided Regenerative and Hydrodissection Therapies for Adhesive Capsulitis

Adhesive capsulitis (AC) is a common fibroinflammatory shoulder disorder, affecting 2–5% of the general population and up to 20% of people with diabetes mellitus. Although historically considered self-limiting, the course frequently exceeds two years and imposes a substantial functional burden. Intra-articular corticosteroids remain the predominant first-line option, but their benefit is often short-lived and is offset by transient hyperglycemia in diabetic patients, potential tissue toxicity with repeated use, and limited durability. These limitations have prompted interest in non-steroidal, ultrasound-guided alternatives. This narrative review appraises two complementary strategies: ultrasound-guided regenerative injectates (hyaluronic acid, hypertonic dextrose prolotherapy, and platelet-rich plasma) and ultrasound-guided perineural hydrodissection of the suprascapular, axillary, and subscapular nerves. We summarize comparative efficacy with corticosteroids, durability, injection anatomy, and the subgroups most likely to benefit. We then propose—explicitly as a clinically defensible framework rather than a validated guideline—a phase-specific paradigm in which a timely non-steroidal injection provides early pain control while stage-appropriate rehabilitation drives functional recovery. The hypothesis that this sequence may compress the symptomatic course to approximately three to six months is supported by preliminary evidence and requires prospective validation. Because no head-to-head trial has compared the proposed paradigm with the corticosteroid-first standard, these recommendations warrant corresponding caution.