What is the initial treatment for a patient with frozen shoulder?

Initial Treatment for Frozen Shoulder

The initial treatment for frozen shoulder should combine physical therapy with stretching and mobilization exercises focusing on external rotation and abduction, paired with NSAIDs or acetaminophen for pain control. 1, 2

First-Line Treatment Algorithm

Physical Therapy - The Foundation

• Begin immediately with stretching and mobilization exercises concentrating on external rotation and abduction movements 1, 2
• External rotation is the single most critical factor for preventing and treating shoulder pain and must be prioritized 2
• Gradually increase active range of motion while simultaneously restoring proper alignment and strengthening weakened shoulder girdle muscles 1, 2
• Early initiation prevents further loss of motion 1

Pain Management

• Use NSAIDs (ibuprofen) or acetaminophen as first-line analgesics to provide adequate pain control and enable participation in physical therapy 1, 2
• These medications allow patients to engage more effectively in the exercise program 2

Adjunctive Therapy

• Acupuncture can be considered as an adjunct to physical therapy, as it has demonstrated statistically significant improvement in shoulder symptoms 1
• Local cold therapy is beneficial for pain relief based on expert consensus 1

Critical Pitfalls to Avoid

What NOT to Do

• Absolutely avoid overhead pulley exercises - they encourage uncontrolled abduction and carry the highest risk of worsening shoulder pain 1, 2
• Do not use shoulder immobilization, arm slings, or wraps - these promote frozen shoulder development 1, 2
• Do not delay treatment initiation - this leads to further motion loss 2

When to Escalate Treatment

Second-Line Interventions (If Inadequate Response)

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 frozen shoulder 2, 3
• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 2
• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 1, 4

Timing for Formal Physical Therapy

• If full shoulder function is not achieved by 6-8 weeks with home exercises, institute formal physical therapy 1
• Most patients respond to conservative treatment with gradual resolution of symptoms in 12-18 months 5
• Consider surgical options (arthroscopic capsular release or manipulation under anesthesia) only for resistant cases that do not respond to conservative treatment for 6-9 months 5

Important Clinical Considerations

Diagnostic Vigilance

• Ensure proper imaging if indicated to rule out other shoulder pathologies and avoid misdiagnosis 1
• Ultrasound may be considered as a diagnostic tool to evaluate shoulder soft tissue injury 1

Patient Education

• Patient education on proper positioning and home exercises is crucial in the initial phase 1, 2
• Monitor for treatment compliance as poor adherence leads to suboptimal outcomes 1