Efficacy of Combined Intra-Articular Hyaluronic Acid and Ketorolac versus Ketorolac Alone in the Treatment of Adhesive Capsulitis: A Randomized Controlled Trial.

Abstract

Intra-articular corticosteroids are widely used for adhesive capsulitis, but alternatives are needed for patients with contraindications. Hyaluronic acid (HA) and ketorolac have shown individual benefits. However, evidence on their combination remains limited. To compare the efficacy of combined moderate-molecular-weight (MMW) HA and ketorolac versus ketorolac alone in adhesive capsulitis. In this randomized, double-blind, controlled trial, 56 patients were allocated to HA+ketorolac (n=28) or ketorolac-only (n=28). Each received a single intra-articular injection followed by standardized rehabilitation. Outcomes included the Thai Shoulder Pain and Disability Index (SPADI), visual analogue scale (VAS) pain score, passive range of motion (PROM), and analgesic use, assessed at baseline and 2, 6, 12, and 24 weeks. Both groups improved significantly in SPADI and VAS pain score over time, with no between-group differences at any visit (24-week SPADI: 9.8±12.5 vs 12.1±17.8; p=0.932; VAS pain score: 0.8±1.1 vs 1.4±2.2; p=0.501). The HA+ketorolac group demonstrated greater recovery in specific ROM planes, including significantly better external rotation at 24 weeks (mean difference 9°, 95% CI 0-18; p = 0.039) and greater improvement in adduction at both 2 weeks (mean difference 5°, 95% CI 0-10; p = 0.039) and 24 weeks (mean difference 8°, 95% CI 2-14; p = 0.012). Analgesic consumption was comparable between groups, and no serious adverse events were reported. Both HA+ketorolac and ketorolac alone significantly improved pain and function in adhesive capsulitis. Combination therapy provided small but statistically significant advantages in the recovery of external rotation and adduction. Both treatments are viable options, especially in patients for whom corticosteroids are contraindicated.