Treatment of Frozen Shoulder (Adhesive Capsulitis)
The most effective initial treatment for frozen shoulder combines physical therapy with stretching and mobilization exercises focusing specifically on external rotation and abduction, paired with NSAIDs or acetaminophen for pain control, while strictly avoiding overhead pulleys. 1, 2
First-Line Treatment Algorithm
Physical Therapy (Mandatory Foundation)
- Initiate stretching and mobilization exercises immediately, concentrating on external rotation and abduction movements 1, 2
- Gradually increase active range of motion while simultaneously restoring proper alignment and strengthening weakened shoulder girdle muscles 2
- External rotation is the single most critical factor related to preventing and treating shoulder pain 3
- Strictly avoid overhead pulley exercises—these encourage uncontrolled abduction and are associated with the highest incidence of shoulder pain development 3, 1, 2
Pain Management
- Use NSAIDs (ibuprofen) or acetaminophen as first-line analgesics 1, 2
- These medications provide adequate pain control to enable participation in physical therapy 1
Adjunctive Therapy
- Acupuncture combined with therapeutic exercises demonstrates statistically significant improvement in shoulder symptoms and should be considered alongside physical therapy 1, 4
- Apply local cold therapy for additional pain relief 1
Second-Line Interventions (For Inadequate Response)
Corticosteroid Injections
- Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 frozen shoulder 3, 2, 4
- These injections improve range of motion, though improvements may not reach statistical significance 3
- Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 2
Hydrodilatation (Most Effective Conservative Treatment)
- Arthrographic distension/hydrodilatation with corticosteroid provides superior outcomes compared to corticosteroid injection alone or physiotherapy alone 5
- Delivers short-term pain relief advantages over placebo 5
- Provides medium-term and long-term improvements in range of motion that exceed both intra-articular corticosteroid injection and physiotherapy 5
- A modified technique involves gradual glenohumeral capsule dilation with approximately 50 mL of normal saline under ultrasound guidance, preceded by injection of lidocaine mixed with triamcinolone through an anterior approach 6
Specialized Interventions
- Botulinum toxin injections into subscapularis and pectoralis muscles when pain relates to spasticity 2
- For Complex Regional Pain Syndrome or Shoulder-Hand Syndrome: oral corticosteroids 30-50 mg daily for 3-5 days, tapering over 1-2 weeks 2
Evidence Quality Considerations
The guideline evidence strongly converges on physical therapy with specific exercise parameters as the foundation 1, 2. The 2021 meta-analysis provides the highest quality evidence for hydrodilatation superiority, though it was rated low quality by AMSTAR-2 criteria—however, its data synthesis remains valid 5. The 2014 systematic review supports therapeutic exercises and mobilization with strong recommendations (Grade A) for pain reduction, range of motion improvement, and functional gains in stages 2 and 3 4.
Critical Pitfalls to Avoid
- Never use overhead pulleys—this single intervention carries the highest risk of worsening shoulder pain 3, 1, 2
- Avoid shoulder immobilization, arm slings, or wraps, as these promote frozen shoulder development 1
- Do not delay treatment initiation, as this leads to further motion loss 2
- Ensure proper diagnosis with ultrasound evaluation if indicated to rule out other shoulder pathologies 2