Shoulder Pain Without Surgery: Adhesive Capsulitis and the 3-in-1 Block

The nerve cannot truly regenerate in the clinical sense. When there is nerve injury, the patient can go into complex regional pain syndrome Type II. Nerve regeneration takes a very long time and the results are poor — if you believe you can treat a patient through nerve regeneration, in present-day practice that is a myth.

For nerve blocks we use ropivacaine. For steroids, we primarily use dexamethasone in spinal procedures. For joint injections, we usually use Kenacort (triamcinolone).

In India, opioids are scheduled drugs — you need a prescription from a competent doctor: a pain specialist, anaesthesiologist or neurologist, not a general surgeon or ENT. For morphine and fentanyl specifically, the hospital needs a government licence to hold a certain quantity, and we use a special designated government form that we stamp, with patients required to bring a consumption chart we submit to the drug controller. Tramadol, tapentadol and buprenorphine don't need special licensing, but you do need a valid prescription from a competent doctor.

The first issue is simply diagnosis — ninety per cent of doctors not trained for this kind of spinal pain can't diagnose facetogenic pain. We call it axial pain, which includes facetogenic and discogenic pain, and gabapentinoids are of no use for it whatsoever — yet eight out of ten patients with axial pain are given these drugs with no results. It's a diagnostic challenge first: specific questions in the history, a specific examination, then a diagnostic block to confirm the pain is coming from the facet before proceeding to facet joint RFA.

If the femoral head is involved, we can perform radiofrequency ablation of the hip joint, ablating the articular nerves supplying the joint — it's a very rewarding procedure. But if the pain is arising from the bone itself or visceral involvement, the best approach is opioid analgesics rather than high-dose NSAIDs, which will damage the kidneys. Primary management is opioid-based — morphine or tramadol with paracetamol and a neuropathic agent — and where there is a specific anatomical target, we address that interventionally as well.

For adhesive capsulitis, a spinal needle is passed through the acromioclavicular joint down to the shoulder capsule, which is then expanded under fluoroscopy. A corticosteroid injection follows into the released capsule.

Not necessarily. Tears under 50% generally do not require surgery in current practice. Tears above 50% need the tendon repaired first, and patients who still have pain afterward often respond well to suprascapular nerve radiofrequency ablation.

It is a single approach that injects the supraspinatus muscle, the acromioclavicular joint, and the subacromial bursa in one sitting, letting several common sources of shoulder pain be treated together, often combined with suprascapular nerve radiofrequency ablation for a more durable result.

Suprascapular nerve radiofrequency ablation is used for patients who continue to have pain after their torn tendon has been surgically fixed.