What are the treatment options for frozen shoulder?

Treatment Options for Frozen Shoulder

The first-line treatment for frozen shoulder should be physical therapy with gentle stretching and mobilization exercises focusing on external rotation and abduction, combined with pain management using NSAIDs or acetaminophen. 1, 2

Initial Treatment Approach

• Physical therapy with stretching and mobilization exercises is strongly recommended for reducing pain, improving range of motion, and enhancing function in patients with frozen shoulder 1, 3
• Focus on external rotation and abduction movements which are particularly effective for preventing progression of frozen shoulder 2, 4
• NSAIDs or acetaminophen should be used for pain control if there are no contraindications 1, 2
• Avoid overhead pulleys as they encourage uncontrolled abduction and may worsen symptoms 1, 4
• Early intervention with physical therapy is crucial to prevent further loss of motion 2

Treatment Algorithm Based on Stage

Freezing Stage (Painful Phase)

• Pain neuroscience education, tactile discrimination, and graded motor imagery may be beneficial in this early painful stage 5
• Aggressive physical therapy during this phase may prolong recovery and should be avoided 5
• Intra-articular corticosteroid injections can provide significant pain relief in this stage 2

Frozen Stage (Adhesive Phase)

• Therapeutic exercises and joint mobilization techniques are strongly recommended 3
• Active range of motion should be increased gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 1, 2
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function 3

Thawing Stage (Recovery Phase)

• Progressive stretching and strengthening exercises to restore full range of motion 6
• Functional training to improve activities of daily living 1

Second-Line Interventions

• Intra-articular corticosteroid injections for significant pain relief 2
• Acupuncture with therapeutic exercises is moderately recommended for pain relief, improving range of motion and function 1, 3
• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 1
• Botulinum toxin injections can be used when pain is related to spasticity 1, 2
• Deep heat therapy can be used for pain relief and improving range of motion 3

Surgical Options (for Refractory Cases)

• Manipulation under anesthesia has been associated with joint damage and may be no more effective than physiotherapy 7
• Capsular release is supported by expert opinion but lacks high-quality research evidence 7
• Moderate mobilization has shown better results than mobilization under anesthesia 8

Treatment Pitfalls to Avoid

• Delaying treatment initiation can lead to further loss of motion 2
• Using overhead pulleys can increase the risk of developing shoulder pain 2, 4
• Aggressive physical therapy in the early freezing stage may prolong recovery 5
• Ultrasound therapy is not recommended for pain relief, improving range of motion, or function 3
• Continuous passive motion is recommended only for short-term pain relief but not for improving range of motion or function 3

Special Considerations

• For Complex Regional Pain Syndrome (CRPS) or Shoulder-Hand Syndrome, an early course of oral corticosteroids (30-50 mg daily for 3-5 days, tapering over 1-2 weeks) is recommended 2
• Patient education on proper positioning and home exercises is crucial in the initial phase 1
• Regular monitoring of progress and adjustment of treatment plan is essential 2