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 management. 1

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
• Active range of motion should be increased gradually while simultaneously restoring proper alignment and strengthening weak muscles in the shoulder girdle 1, 2
• Therapeutic exercises and mobilization are strongly recommended for reducing pain, improving range of motion, 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 control if no contraindications exist 1, 2
• Local cold therapy provides pain relief and can be used as an adjunct 1

Critical Pitfalls to Avoid

• Overhead pulleys must be avoided as they encourage uncontrolled abduction and are associated with the highest incidence of worsening symptoms 1, 2
• Shoulder immobilization with arm slings or wraps should be avoided as these can worsen the condition 1

Second-Line Interventions (For Inadequate Response)

Corticosteroid Injections

• Intra-articular corticosteroid injections (such as triamcinolone) provide significant pain relief, particularly effective in stage 1 frozen shoulder 2, 3
• Subacromial corticosteroid injections can be used when pain relates to injury or inflammation of the subacromial region 2

Adjunctive Therapies

• Acupuncture combined with therapeutic exercises demonstrates statistically significant improvement in shoulder symptoms and is moderately recommended for pain relief, improving range of motion, and function 1, 3
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function, but not recommended for improving range of motion 3
• Deep heat can be used for pain relief and improving range of motion 3

Advanced Interventions (For Refractory Cases)

Hydrodilatation

• Hydrodilatation of the glenohumeral joint may be considered for cases that fail conservative management 2, 4
• This involves gradual dilation of the glenohumeral capsule with saline under ultrasound guidance 4

Surgical Options

• Arthroscopic capsular release is an effective and safe alternative to manipulation in patients with recalcitrant frozen shoulder who have failed at least 12 weeks of physical therapy 5
• Joint replacement can be considered if all conservative measures prove ineffective 6

Treatment Algorithm

Initial Phase (0-6 weeks):

• Start physical therapy with gentle stretching focusing on external rotation and abduction 1, 2
• Add NSAIDs or acetaminophen for pain control 1
• Patient education on proper positioning and home exercises 1

If inadequate response by 6-8 weeks:

• Formal physical therapy should be instituted if not already done 1
• Consider intra-articular corticosteroid injection 2, 3
• Consider adding acupuncture as adjunct therapy 1, 3

If refractory after 12+ weeks:

• Consider hydrodilatation 2, 4
• Consider arthroscopic capsular release 5

Important Clinical Considerations

• Ultrasound may be used as a diagnostic tool to evaluate shoulder soft tissue injury and rule out other pathologies 2
• Monitor treatment compliance as poor adherence leads to suboptimal outcomes 1
• The condition is often self-limiting and progresses through three stages: freezing (painful), frozen (adhesive), and thawing 7, 6