What is the recommended treatment for frozen shoulder?

Treatment of Frozen Shoulder (Adhesive Capsulitis)

Physical therapy, including stretching and mobilization techniques focusing especially on external rotation and abduction, is the recommended first-line treatment for frozen shoulder, combined with appropriate pain management. 1

Initial Assessment and Management

• Clinical Assessment:

  • Evaluate tone, strength, changes in soft tissue length, joint alignment, pain levels, and orthopedic changes 1
  • Identify stage of frozen shoulder (freezing/painful, frozen/adhesive, or thawing)

• First-line Treatment:

  • Pain Management:
    • Acetaminophen or NSAIDs (if no contraindications) 1
    • Ice therapy for acute pain (10-minute periods through wet towel, 3-4 times daily) 2
    • Heat therapy for chronic cases to improve tissue elasticity and enhance circulation 2

• Physical Therapy Interventions:

  • Gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction 1
  • Active range of motion exercises, gradually increased in conjunction with restoring alignment and strengthening weak muscles 1
  • Avoid overhead pulley exercises as they encourage uncontrolled abduction and can worsen symptoms 1, 2

Second-line Interventions (if symptoms persist after 4-6 weeks)

• Injection Therapy:

  • Corticosteroid injections for short-term pain relief 2
  • Intra-articular injections (Triamcinolone) have shown significant effects on pain 1
  • Subacromial corticosteroid injections when pain is related to injury or inflammation of the subacromial region 1

• Advanced Physical Therapy:

  • Scapular stabilization exercises 2
  • Neuromuscular electrical stimulation (NMES) may be considered for shoulder pain 1

For Refractory Cases

• Botulinum Toxin Injections:

  • Consider for shoulder pain related to spasticity in the subscapularis and pectoralis muscles 1
  • Has shown significant reductions in pain scores in patients with shoulder spasticity 1

• Nerve Blocks:

  • Suprascapular nerve blocks may be effective in reducing shoulder pain through reduction of both nociceptive and neuropathic pain mechanisms 1

• Surgical Options (when conservative management fails):

  • Arthroscopic capsular release
  • Manipulation under anesthesia
  • Hydrodilatation
  • Note: None of these procedures has been shown to offer superior outcomes over the others 3

Post-surgical Rehabilitation

• Physical therapy should begin immediately after surgery to prevent development of a frozen shoulder 1
• Formal exercise training to prevent frozen shoulder, avoiding shoulder immobilization, arm slings, or wraps 1
• If full shoulder function is not achieved by 6-8 weeks, intensive physical therapy should be instituted to avoid permanent dysfunction 1

Prognosis

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 2
• However, some patients may not regain full, pain-free range of motion even with treatment 4

Common Pitfalls to Avoid

1. Delaying physical therapy intervention - early treatment is crucial for better outcomes
2. Using overhead pulley exercises which can worsen symptoms 1, 2
3. Relying solely on passive treatments without active patient participation
4. Neglecting proper pain management which can inhibit participation in rehabilitation
5. Failing to recognize when to progress from conservative management to more invasive interventions

Remember that frozen shoulder is often self-limiting but can cause significant pain and disability during its course. A structured approach to treatment focusing on physical therapy and appropriate pain management can significantly improve outcomes and quality of life for patients with this condition.