What is the recommended treatment for frozen shoulder?

Frozen Shoulder Treatment

The recommended initial treatment for frozen shoulder is physical therapy with stretching and mobilization exercises focusing on external rotation and abduction, combined with NSAIDs or acetaminophen for pain control, with intra-articular corticosteroid injections reserved for refractory cases or early-stage disease. 1, 2

First-Line Treatment Approach

Physical Therapy (Strongly Recommended)

• Gentle stretching and mobilization techniques targeting external rotation and abduction are the cornerstone of treatment 1, 2, 3
• Active range of motion should be increased gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 1, 2
• Therapeutic exercises and mobilization have strong evidence (Grade A) for reducing pain, improving ROM, and restoring function in stages 2 and 3 of frozen shoulder 3
• Treatment should be initiated early to prevent further loss of motion 1

Pain Management

• NSAIDs (such as ibuprofen) or acetaminophen should be used for pain relief if no contraindications exist 1, 2
• These medications provide symptomatic relief while physical therapy addresses the underlying capsular restriction 1

Critical Pitfall to Avoid

• Overhead pulleys should be avoided as they encourage uncontrolled abduction and may worsen symptoms 4, 1, 2
• The highest incidence of developing hemiplegic shoulder pain occurred with patients who used overhead pulleys 4

Second-Line Interventions

Intra-Articular Corticosteroid Injections

• Triamcinolone intra-articular injections provide significant pain relief and have strong evidence for short-term effectiveness 4, 2, 5
• Moderate evidence supports their use for mid-term follow-up 5
• Dosing: 5-15 mg for larger joints, with doses up to 40 mg for larger areas 6
• These injections are particularly useful for stage 1 (freezing/painful phase) frozen shoulder 3

Hydrodilatation (Arthrographic Distension)

• For refractory cases, hydrodilatation of the glenohumeral joint with corticosteroid provides superior outcomes compared to corticosteroid injection alone or physiotherapy 2, 7
• This intervention shows moderate evidence for short-term effectiveness and provides medium-term and long-term improvements in ROM over intra-articular CSI and physiotherapy alone 5, 7
• The technique involves gradual dilation of the glenohumeral capsule with approximately 50 mL of normal saline combined with corticosteroid 8

Adjunctive Therapies

Acupuncture

• Acupuncture combined with therapeutic exercises is moderately recommended for pain relief, improving ROM and function 1, 3
• It demonstrates statistically significant improvement in shoulder symptoms 1

Low-Level Laser Therapy

• Strongly suggested for pain relief with strong evidence (Grade A) 3, 5
• Moderately suggested for improving function but not recommended for improving ROM 3

Modalities

• Ice, heat, and soft tissue massage can be used as adjuncts 4, 2
• Deep heat can help with pain relief and improving ROM 3
• Local cold therapy is beneficial for pain relief based on expert consensus 4

Treatment Algorithm by Stage

Stage 1 (Freezing - Painful Phase):

• Corticosteroid injections for pain control 3
• Gentle ROM exercises 2
• NSAIDs/acetaminophen 1

Stage 2 (Frozen - Adhesive Phase):

• Physical therapy with aggressive stretching and mobilization focusing on external rotation and abduction 1, 3
• Consider hydrodilatation if inadequate response 2, 7

Stage 3 (Thawing Phase):

• Continue physical therapy with progressive strengthening 3
• Maintain ROM gains 9

Special Considerations

Complex Regional Pain Syndrome Prevention

• If shoulder-hand syndrome develops, an early course of oral corticosteroids (30-50 mg daily for 3-5 days, tapering over 1-2 weeks) is recommended 2
• Active, active-assisted, or passive ROM exercises help prevent this complication 2

Positioning and Education

• Avoid shoulder immobilization, arm slings, or wraps as these contribute to frozen shoulder development 4
• Patient education on proper positioning and home exercises is crucial 1
• If full shoulder function is not achieved by 6-8 weeks, formal physical therapy should be instituted 4

Evidence Quality Note

The evidence base shows that most studies report short-term results (less than 3 months), whereas frozen shoulder symptoms may persist for up to 4 years 5. Hydrodilatation with corticosteroid emerges as the most effective conservative management based on recent systematic reviews, providing superior outcomes across all time frames compared to other conservative interventions 7.