What is the initial management for shoulder sclerosis or adhesive capsulitis (frozen shoulder)?

Initial Management of Adhesive Capsulitis (Frozen Shoulder)

The initial management for adhesive capsulitis (frozen shoulder) should include a combination of physical therapy, oral anti-inflammatory medications, and intra-articular corticosteroid injections as first-line conservative treatment. 1, 2

Diagnostic Approach

• Standard radiographic evaluation should include at minimum three views: anteroposterior (AP) views in internal and external rotation, and an axillary or scapula-Y view to rule out other pathologies 3, 4
• Radiographs should be performed with the patient in an upright position, as shoulder malalignment can be underrepresented on supine radiography 4, 5
• MRI or ultrasound may be appropriate if radiographs are noncontributory and there is suspicion of concomitant rotator cuff pathology 5

First-Line Conservative Management

• Oral anti-inflammatory medications (NSAIDs) should be initiated to reduce pain and inflammation 6, 7
• Intra-articular corticosteroid (IACS) injections provide significant pain relief and improved range of motion in the early painful (freezing) stage 1, 2
• Physical therapy exercises targeted at improving range of motion should be started early in the treatment process 1, 8
• The combination of IACS injections with physical therapy has stronger support in the literature for improving shoulder pain, range of motion, and function than either treatment alone 1, 6

Second-Line Interventions

• If no improvement occurs after 6-12 weeks of first-line treatment, consider:
  • Suprascapular nerve block (SSNB), which can be combined with physical therapy and/or IACS injection for improved outcomes 1, 2
  • Hydrodilatation (distension arthrography) can be used as an adjunct treatment to improve shoulder range of motion 1, 6

Surgical Management

• Surgical intervention should be considered if conservative management fails after 3-6 months 2
• Arthroscopic capsular release is preferred over manipulation under anesthesia to avoid complications of "blind intervention" 6
• Open capsular release may be considered in severe recalcitrant cases 6

Treatment Based on Stage

1. Freezing stage (painful phase):

   • Focus on pain control with NSAIDs and IACS injections 2, 7
   • Gentle range of motion exercises 8

2. Frozen stage (adhesive phase):

   • More aggressive physical therapy 1, 8
   • Consider second-line interventions if progress is limited 6, 2

3. Thawing stage:

   • Continued physical therapy focusing on strengthening 8
   • Most patients will continue to improve without surgical intervention 7

Common Pitfalls to Avoid

• Delaying treatment, which may lead to prolonged disability and decreased function 2
• Overly aggressive physical therapy in the early painful phase, which can worsen symptoms 8
• Failing to rule out other shoulder pathologies that may mimic adhesive capsulitis, such as rotator cuff tears or glenohumeral osteoarthritis 5, 7
• Not recognizing that patients with diabetes or thyroid disease are at higher risk and may have more refractory symptoms 7