What is the recommended treatment for frozen shoulder (adhesive capsulitis)?

Treatment of Frozen Shoulder (Adhesive Capsulitis)

The recommended first-line treatment for frozen shoulder is physical therapy with stretching and mobilization exercises focusing specifically on external rotation and abduction, combined with NSAIDs or acetaminophen for pain control. 1

Initial Conservative Management

Physical Therapy - The Cornerstone of Treatment

• Therapeutic exercises and mobilization are strongly recommended for reducing pain, improving range of motion (ROM), and restoring function in stages 2 and 3 of frozen shoulder 2
• Focus exercises specifically on external rotation and abduction movements, as lateral rotation limitation is the factor most significantly related to shoulder pain onset 3, 4
• Active ROM should be increased gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 1
• Avoid overhead pulley exercises - these encourage uncontrolled abduction and are associated with the highest incidence of developing shoulder pain 3, 1, 4

Pain Management

• NSAIDs or acetaminophen should be used as first-line analgesics if no contraindications exist 1, 5
• Local cold therapy provides beneficial pain relief 1
• Short-term oral corticosteroids can be considered 5

Critical Prevention Measures

• Avoid shoulder immobilization with arm slings or wraps - immobilization promotes frozen shoulder development 3, 1
• Early exercise may prolong drainage in post-surgical cases but prevents frozen shoulder, making it the preferred approach 3
• Patient education on proper positioning and home exercises is essential 1

Advanced Interventions for Inadequate Response

Intra-articular Corticosteroid Injections

• Corticosteroid injections show significant short-term benefits and can be used particularly for stage 1 (freezing/painful phase) frozen shoulder 4, 2
• Intra-articular triamcinolone has demonstrated significant effects on pain relief 3
• Ultrasound guidance is recommended for injection-based therapy, though not absolutely required 6
• The combination of physiotherapy and corticosteroid injections may provide greater improvement than physiotherapy alone 5

Adjunctive Therapies

• Acupuncture with therapeutic exercises is moderately recommended for pain relief, improving ROM and function 2
• Acupuncture has demonstrated statistically significant improvement in shoulder symptoms and can be considered as an adjunct to physical therapy 1
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function, but not recommended for improving ROM 2
• Deep heat can be used for pain relief and improving ROM 2
• Functional electrical stimulation may improve shoulder lateral rotation 4

Hydrodilatation

• For refractory cases, hydrodilatation of the glenohumeral joint may be considered 1, 5

Treatment Algorithm

Week 0-6:

• Initiate physical therapy immediately with focus on external rotation and abduction stretching 1, 2
• Start NSAIDs or acetaminophen for pain control 1
• Educate patient on home exercises and proper positioning 1
• Apply local cold therapy as needed 1

Week 6-12 (if inadequate response):

• Continue physical therapy with increased intensity 1
• Consider intra-articular corticosteroid injection (preferably ultrasound-guided) 4, 6
• Add acupuncture as adjunctive therapy 1, 2
• Consider low-level laser therapy for pain 2

After 12 weeks (if minimal improvement):

• Consider hydrodilatation 1, 5
• Refer for surgical consultation (manipulation under anesthesia or arthroscopic capsule release) 5

Important Clinical Pearls and Pitfalls

Common Pitfalls to Avoid

• Do not use overhead pulleys - this is the single intervention most associated with worsening shoulder pain 3, 1, 4
• Do not immobilize the shoulder with slings or wraps, as this promotes adhesive capsulitis progression 3, 1
• Do not rely on ultrasound therapy - it is not recommended for pain relief, improving ROM, or function 2

Diagnostic Considerations

• Ensure proper imaging if indicated to rule out other shoulder pathologies and avoid misdiagnosis 1
• MRI without contrast is preferred for evaluating frozen shoulder as it assesses both bony morphology and soft tissue pathology 4
• Coracohumeral ligament thickening on MRI yields high specificity for adhesive capsulitis 5

Evidence Strength Considerations

Recent evidence challenges the traditional belief that frozen shoulder fully resolves without treatment within 1-2 years 5, 6. Persistent functional limitations occur if left untreated, making early intervention crucial 1, 5. While most treatments have not been shown to significantly alter the long-term natural course of the disease 6, the combination of physical therapy and corticosteroid injections provides the strongest evidence for symptom improvement 5.