What is the initial management for a patient with frozen shoulder (adhesive capsulitis)?

Initial Management of Frozen Shoulder (Adhesive Capsulitis)

The initial management for frozen shoulder should include physical therapy with gentle stretching and mobilization techniques focusing on external rotation and abduction, combined with analgesics such as NSAIDs or acetaminophen if not contraindicated. 1

Understanding Frozen Shoulder

Frozen shoulder (adhesive capsulitis) is characterized by painful and limited active and passive range of motion of the shoulder joint. It typically progresses through three stages:

1. Freezing stage (painful phase)
2. Frozen stage (adhesive phase)
3. Thawing stage (recovery phase)

Most patients (approximately 80%) recover completely within 3-6 months with appropriate conservative treatment 1.

Initial Assessment

• Obtain plain radiographs as the initial imaging study (anteroposterior views in internal and external rotation, and an axillary or scapula-Y view) 1
• Advanced imaging (MRI, CT) is not recommended before plain radiographs in the initial evaluation 1
• Perform a thorough musculoskeletal assessment, evaluate for spasticity, and test for regional sensory changes 1

First-Line Treatment Approach

Physical Therapy

• Begin early physical therapy intervention to prevent permanent dysfunction 1
• Focus on:
  • Gentle stretching and mobilization techniques targeting external rotation and abduction 1, 2
  • Gradually increasing active range of motion exercises 1
  • Progressive strengthening of shoulder girdle muscles 1

Pain Management

• NSAIDs (ibuprofen, naproxen) or acetaminophen if no contraindications exist 1
• Application of thermal therapy in combination with stretching 1

Second-Line Interventions

If initial management fails to provide adequate relief after 2-4 weeks:

Corticosteroid Injections

• Intra-articular corticosteroid injections (triamcinolone) for significant pain 1
• Strong evidence suggests glenohumeral intra-articular corticosteroid injections have significantly greater 4-6 week beneficial effects compared to other treatments 2
• Methylprednisolone acetate 40mg with lidocaine 1% provides more rapid pain relief compared to triamcinolone 1

Advanced Physical Therapy

• Eccentric strengthening exercises 1
• Functional exercises to restore normal movement patterns 1
• Joint mobilization techniques 2, 3

Important Cautions and Considerations

• Avoid shoulder immobilization with arm slings or wraps as this can worsen frozen shoulder 1
• Delay in physical therapy intervention should be avoided 1
• If full shoulder function is not achieved by 6-8 weeks, intensive physical therapy should be instituted 1
• Consider surgical referral if conservative management fails after 3-6 months 1
• For refractory cases, suprascapular nerve blocks may be beneficial 1

Treatment Based on Irritability Level

Treatment can be tailored based on the patient's irritability level 2:

• High irritability: Focus on pain control with analgesics and gentle range of motion exercises
• Moderate irritability: Progress to more active stretching and joint mobilization
• Low irritability: Implement more aggressive stretching and strengthening exercises

Physical therapy interventions should be progressed as the patient's irritability reduces, with the response to treatment based on significant pain relief, improved satisfaction, and return of functional motion 2.