What is the best treatment approach for a patient with a frozen shoulder (adhesive capsulitis) and radiating pain?

Treatment Approach for Frozen Shoulder with Radiating Pain

For frozen shoulder (adhesive capsulitis) with radiating pain, the most effective first-line treatment approach is a combination of gentle stretching and mobilization techniques focused on increasing external rotation and abduction, along with pain management strategies. 1

Initial Management

Pain Management

• First-line medications:
  • NSAIDs such as ibuprofen or acetaminophen for pain relief if no contraindications exist 1, 2
  • Local thermal interventions (ice, heat) and soft tissue massage for symptomatic relief 1, 2

Therapeutic Exercise Program

• Phase 1 (Acute Pain Phase):

  • Gentle active and passive range of motion exercises 1, 2
  • Avoid overhead pulleys which can cause uncontrolled abduction and worsen pain 1
  • Proper positioning education to prevent further injury 2

• Phase 2 (Progressive Mobility Phase):

  • Progressive ROM exercises focusing especially on external rotation and abduction 1
  • Light strengthening exercises for rotator cuff and periscapular muscles 2
  • Scapular stabilization exercises 2

Advanced Interventions

Injection Therapy

• Corticosteroid injections:

  • Intra-articular injections (Triamcinolone) for significant pain 1
  • Subacromial corticosteroid injections if pain is related to inflammation of the subacromial region 1
  • Limit to 3-4 injections per year to avoid potential tendon weakening 2

• Botulinum toxin injections:

  • Consider for cases where spasticity contributes to shoulder pain 1

Physical Therapy Modalities

• Electrical stimulation:

  • Functional electrical stimulation (FES) to improve shoulder lateral rotation 1
  • Can help with pain-free lateral rotation 1

• Proprioceptive Neuromuscular Facilitation (PNF):

  • Recent evidence shows PNF techniques can improve shoulder joint structure and function in frozen shoulder 3
  • More effective than traditional manual therapy for improving ROM and reducing pain 3

Special Considerations

For Radiating Pain

• Assessment for Complex Regional Pain Syndrome (CRPS):
  • Evaluate for edema over dorsum of fingers, trophic skin changes, hyperesthesia 1
  • If CRPS is suspected, consider early course of oral corticosteroids (30-50mg daily for 3-5 days, then tapering over 1-2 weeks) 1

Mechanical Support

• Shoulder strapping/sling:
  • Consider for preventing trauma to the affected shoulder 1
  • May help reduce frequency of shoulder-hand syndrome 1

Follow-up and Progression

• Initial follow-up at 1-2 weeks after treatment initiation 2
• Clinical reassessment at 6 weeks to evaluate progress 2
• Consider advanced imaging (MRI without contrast) if symptoms persist despite appropriate treatment 2
• Consider surgical consultation if no improvement after 3 months of appropriate rehabilitation 2, 4

Cautions and Pitfalls

• Avoid aggressive stretching during the painful freezing phase as this may increase inflammation and pain
• Don't rely solely on passive treatments - active patient participation in exercises is crucial for recovery 5
• Don't delay treatment - early intervention may prevent progression to more severe adhesive capsulitis
• Don't miss underlying pathologies - radiating pain may indicate cervical radiculopathy or other conditions that require different management approaches

The evidence strongly supports a structured rehabilitation program with appropriate pain management as the cornerstone of treatment for frozen shoulder with radiating pain, with more invasive interventions reserved for cases that fail to respond to conservative management.