Treatment Options for Shoulder Stiffness
Conservative management should be the first-line treatment for shoulder stiffness, with physical therapy including gentle stretching and mobilization techniques focusing on external rotation and abduction as the cornerstone of treatment. 1
Initial Conservative Management
Physical Therapy
- Early intervention with physical therapy is crucial to prevent permanent dysfunction 1
- Focus on:
- Gentle stretching exercises
- Mobilization techniques targeting external rotation and abduction
- Gradual increase in active range of motion exercises
- Eccentric strengthening exercises
- Avoid overhead pulley exercises (not recommended for shoulder pain) 2
- If full shoulder function is not achieved by 6-8 weeks, intensive physical therapy should be instituted 1
Pain Management
- NSAIDs for pain relief and anti-inflammatory effects 1
- Topical NSAIDs for fewer systemic side effects 1
- Acetaminophen if NSAIDs are contraindicated 1
- Ice application through a wet towel for 10-minute periods to reduce pain and swelling 1
Activity Modification
- Rest to prevent ongoing damage while allowing non-painful activities 1
- Avoid complete immobilization to prevent muscular atrophy 1
- Avoid shoulder immobilization with arm slings or wraps as this can lead to frozen shoulder 1
Intermediate Interventions
Injections
- Intra-articular corticosteroid injections (triamcinolone) for significant pain 1
- Methylprednisolone acetate 40mg with lidocaine 1% provides more rapid pain relief compared to triamcinolone 1
- Suprascapular nerve blocks can be effective for non-neuropathic shoulder pain with relief lasting up to 12 weeks 1
- For shoulder stiffness with spasticity, botulinum toxin injections into the subscapularis and pectoralis muscles may be beneficial 2
Diagnostic Imaging
- Plain radiography is the preferred initial imaging study 1
- Standard views: anteroposterior (AP) in internal and external rotation, axillary or scapula-Y view
- Advanced imaging only if needed:
- MRI or ultrasound for soft tissue evaluation
- Ultrasound rated highly for suspected bursitis or rotator cuff evaluation
- MRI helpful for evaluating rotator cuff quality and muscle atrophy
Advanced Interventions
Surgical Options
- Consider surgical referral if conservative management fails after 3-6 months 1
- Arthroscopic capsular release is preferred over manipulation under anesthesia due to lower risk of complications 3
- For rotator cuff tears, repair is an option for patients with chronic, symptomatic full-thickness tears 2
- Surgical tenotomy of pectoralis major, lattisimus dorsi, teres major, or subscapularis may be considered for severe cases with restricted shoulder range of motion 2
Prognosis and Monitoring
- Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 1
- Prognostic factors to consider:
Important Caveats
- Distinguish between primary (idiopathic) shoulder stiffness and secondary stiffness with a known cause 3
- Avoid relying on advanced imaging before obtaining plain radiographs 1
- The American Academy of Orthopaedic Surgeons notes insufficient evidence regarding injectable corticosteroids for glenohumeral osteoarthritis 1
- According to the most recent evidence, a high level of scientific evidence is available to guide treatment of primary shoulder stiffness 4