What are the imaging and management options for frozen shoulder?

Imaging and Management for Frozen Shoulder

For frozen shoulder, plain radiography is the recommended initial imaging modality, followed by a comprehensive management approach including physical therapy with stretching and mobilization techniques, pain management with NSAIDs or acetaminophen, and corticosteroid injections for refractory cases.

Diagnostic Imaging

Initial Imaging

• Plain radiography is the preferred initial study for shoulder pain evaluation 1
  • Standard shoulder radiographs should include:
    • Anteroposterior (AP) views in internal and external rotation
    • Axillary or scapula-Y view (vital for proper evaluation)
  • Radiographs should be performed upright as malalignment can be underrepresented on supine views
  • Primary purpose: rule out other conditions that may mimic frozen shoulder

Advanced Imaging

• MRI may be considered if symptoms persist after 4-6 weeks of conservative management 2
  • Helps assess for associated conditions like rotator cuff tears
  • Not routinely necessary for diagnosis of uncomplicated frozen shoulder
• CT is generally not indicated as the initial study for frozen shoulder 1
  • Better than radiography for characterizing fracture patterns but inferior to MRI for soft tissue evaluation

Management Approach

First-Line Treatment

1. Pain Management

   • NSAIDs (if no contraindications) for short-term pain relief 2
   • Acetaminophen (up to 4g/day) as first-line analgesic 2

2. Physical Therapy - Critical early intervention

   • Gentle stretching and mobilization techniques focusing on:
     • External rotation and abduction to prevent progression 1, 2
     • Active range of motion exercises gradually increased 2
   • AVOID overhead pulley exercises which can worsen symptoms 1, 2

3. Thermal Therapy

   • Heat therapy for chronic cases: improves tissue elasticity and enhances circulation 2
   • Ice therapy for acute inflammation: 10-minute periods through a wet towel, 3-4 times daily 2

Second-Line Treatment

1. Corticosteroid Injections

   • Intra-articular injections (Triamcinolone) have shown significant effects on pain 1, 2
   • Consider if symptoms persist after 4-6 weeks of conservative management 2
   • Strong evidence shows significantly greater 4-6 week beneficial effect compared to other treatments 3

2. Advanced Physical Therapy

   • Neuromuscular electrical stimulation (NMES) may be beneficial 1, 2
   • Eccentric strengthening exercises combined with thermal therapy 2

Refractory Cases (Persistent symptoms after 6-9 months of conservative treatment)

1. Surgical Options 4
   • Arthroscopic capsular release
   • Manipulation under anesthesia (with caution due to risk of complications like humeral fracture or rotator cuff tear)

Treatment Algorithm Based on Clinical Stage

1. Freezing (Painful) Stage

   • Focus on pain management: NSAIDs/acetaminophen
   • Gentle ROM exercises
   • Consider corticosteroid injection if severe pain

2. Frozen (Adhesive) Stage

   • Progressive stretching and mobilization
   • Heat therapy before exercises
   • Corticosteroid injection if not previously administered

3. Thawing Stage

   • More aggressive stretching
   • Strengthening exercises
   • Focus on functional restoration

Prognosis

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 2
• Full recovery may take 12-18 months in some cases 4

Common Pitfalls to Avoid

• Delaying physical therapy intervention (early treatment is crucial)
• Using overhead pulley exercises (can worsen symptoms) 1, 2
• Shoulder immobilization with arm slings or wraps (can lead to frozen shoulder) 1
• Neglecting to screen for associated conditions like diabetes and thyroid dysfunction 4

Remember that frozen shoulder is often self-limiting but can cause significant pain and disability during its course. A structured approach with appropriate imaging, physical therapy, pain management, and timely interventions can significantly improve outcomes and quality of life.