What is the treatment plan for frozen shoulder?

Treatment Plan for Frozen Shoulder

The most effective treatment for frozen shoulder includes gentle stretching and mobilization techniques focusing on external rotation and abduction, combined with pain management using NSAIDs or acetaminophen, and avoiding overhead pulleys which can worsen symptoms. 1, 2

Understanding Frozen Shoulder (Adhesive Capsulitis)

• A condition characterized by significant shoulder pain and progressive limitation in range of motion 1
• Can significantly impact activities of daily living and quality of life 1
• Often self-limiting but may take 12-18 months to resolve without intervention 3
• Common risk factors include diabetes, thyroid dysfunction, and dyslipidemia which should be investigated in patients with primary stiff shoulder 3, 4

Assessment Approach

• Evaluation should include assessment of:
  • Tone, strength, and changes in soft tissue length 2
  • Alignment of joints in the shoulder girdle 2
  • Pain levels and orthopedic changes in the shoulder 2
• Diagnosis is primarily clinical but ultrasound may be considered as a diagnostic tool to evaluate shoulder soft tissue injury 1, 4

Treatment Algorithm

First-Line Management

1. Physical Therapy and Exercise

   • Gentle stretching and mobilization techniques focusing on external rotation and abduction 2, 1
   • Active range of motion should be increased gradually while restoring alignment and strengthening weak muscles 2
   • Regular exercise programs have demonstrated effectiveness for managing symptoms 1, 5
   • AVOID overhead pulleys which encourage uncontrolled abduction and may worsen symptoms 2, 1

2. Pain Management

   • NSAIDs (such as ibuprofen) or acetaminophen if no contraindications exist 2, 1
   • Modalities including ice, heat, and soft tissue massage can help reduce pain 2

Second-Line Interventions

1. Injection Therapies

   • Intra-articular corticosteroid injections (Triamcinolone) for significant pain relief 2, 4
   • Botulinum toxin injections into the subscapularis and pectoralis muscles when pain is related to spasticity 2
   • Subacromial corticosteroid injections when pain is related to injury or inflammation of the subacromial region 2

2. Advanced Interventions

   • Hydrodilatation of the glenohumeral joint for refractory cases 6, 4
   • Functional electrical stimulation (FES) to improve shoulder lateral rotation 2
   • Consider shoulder strapping (sling) to prevent trauma to the affected shoulder 2

For Persistent Cases (6-9 months without improvement)

• Surgical options may be considered:
  • Arthroscopic capsular release 3
  • Manipulation under anesthesia - though this carries risk of complications including fractures or rotator cuff tears 3

Special Considerations

• For Complex Regional Pain Syndrome (CRPS) or Shoulder-Hand Syndrome:

  • Early course of oral corticosteroids (30-50 mg daily for 3-5 days, tapering over 1-2 weeks) 2
  • Active, active-assisted, or passive range of motion exercises for prevention 2

• Monitor treatment compliance as poor adherence leads to suboptimal outcomes 1

• Treatment duration may vary, but most patients respond well to conservative treatment with gradual resolution in 12-18 months 3

Treatment Pitfalls to Avoid

• Delaying treatment initiation, which may lead to further loss of motion 1
• Using overhead pulleys which can increase risk of developing hemiplegic shoulder pain 2
• Relying solely on "supervised neglect" without active intervention, which is based on studies with high risk of bias 7
• Rushing to surgical intervention before adequate trial of conservative management (minimum 6-9 months) 3