What is the initial treatment for frozen shoulder?

Initial Treatment for Frozen Shoulder

The initial treatment for frozen shoulder should include physical therapy with stretching and mobilization exercises, focusing especially on external rotation and abduction, combined with pain management using NSAIDs or acetaminophen. 1

Understanding Frozen Shoulder (Adhesive Capsulitis)

Frozen shoulder, also known as adhesive capsulitis, is characterized by:

• Stiffness and pain in the shoulder joint that significantly limits range of motion 1
• Typically progresses through three stages: freezing (painful), frozen (adhesive), and thawing 2
• Can lead to decreased ability to perform activities of daily living and impact employment 1
• Prevalence of limited shoulder range of motion affects 1.5-50% of patients following certain conditions like breast cancer treatment 1

Initial Treatment Approach

First-Line Interventions

1. Physical Therapy

   • Stretching and mobilization exercises focusing on external rotation and abduction 1
   • Regular exercise programs have been shown to be effective for managing musculoskeletal symptoms 1
   • Should be initiated early to prevent further loss of motion 1

2. Pain Management

   • NSAIDs or acetaminophen for pain control 1
   • Note that for some conditions (like aromatase inhibitor-associated shoulder pain), these medications may have limited effectiveness 1

Second-Line Interventions

If first-line treatments are insufficient, consider:

1. Corticosteroid Injections

   • Intra-articular steroid injections (Triamcinolone) can significantly reduce pain 1, 3
   • Strong evidence supports effectiveness in short-term and moderate evidence for mid-term follow-up 3

2. Acupuncture

   • Has demonstrated statistically significant improvement in shoulder symptoms 1
   • Can be considered as an adjunct to physical therapy 1

Treatment Algorithm

1. Initial Assessment

   • Determine if pain is traumatic or non-traumatic in nature 4
   • Assess for red flags requiring urgent referral (significant trauma, joint instability, neurological symptoms) 4

2. Conservative Management (First 4-6 weeks)

   • Physical therapy with specific stretching exercises 1
   • Pain management with oral medications 1
   • Patient education about the condition and expected course 5

3. If Limited Improvement (After 4-6 weeks)

   • Consider corticosteroid injection 1, 3
   • Intensify physical therapy program 1
   • Consider acupuncture as adjunctive therapy 1

4. For Persistent Cases (After 3 months)

   • Consider hydrodilatation (arthrographic distension) 3
   • Evaluate for suprascapular nerve block 3
   • Surgical consultation may be warranted for refractory cases 5

Evidence Quality and Considerations

• Most studies report short-term results, whereas frozen shoulder symptoms may last up to 4 years 3
• Moderate evidence supports mobilization techniques for both short and long-term effectiveness 3
• Strong evidence exists for steroid injections and laser therapy in the short term 3

Common Pitfalls and Caveats

• Avoid overhead pulleys which encourage uncontrolled abduction and may worsen symptoms 1
• Don't delay treatment as this can lead to prolonged disability and more difficult recovery 5
• Don't rely solely on passive treatments - active patient participation in exercise programs is essential for recovery 2
• Beware of misdiagnosis - ensure proper imaging (if indicated) to rule out other shoulder pathologies 4
• Monitor for treatment compliance as poor adherence can lead to suboptimal outcomes 1