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, along with NSAIDs or acetaminophen for pain control. 1, 2

First-Line Treatment Algorithm

Physical Therapy - The Cornerstone

• Begin immediately with stretching and mobilization exercises that prioritize external rotation and abduction movements 1, 2
• External rotation is the single most critical factor in preventing and treating shoulder pain and must be the primary focus 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder alignment and strengthening weakened shoulder girdle muscles 1, 2
• Early initiation is essential to prevent further loss of motion 1

Pain Management

• Use NSAIDs (ibuprofen) or acetaminophen as first-line analgesics to enable participation in physical therapy 1, 2
• Adequate pain control is necessary for patients to engage effectively in the exercise program 2
• Consider acupuncture as an adjunct therapy, which has demonstrated statistically significant improvement in shoulder symptoms 1

Critical Interventions to AVOID

What NOT to Do

• Never use overhead pulleys - this single intervention carries the highest risk of worsening shoulder pain and encouraging uncontrolled abduction 1, 2
• Avoid shoulder immobilization, arm slings, or wraps - these promote frozen shoulder development 2
• Do not delay treatment initiation, as this leads to further motion loss 2

Treatment Timeline and Escalation

Conservative Management Duration

• Most patients respond well to conservative treatment with gradual resolution of symptoms in 12-18 months 3
• If full shoulder function is not achieved by 6-8 weeks, formal physical therapy should be instituted 1
• Resistant cases that do not respond to conservative treatment for 6-9 months may require consideration of more advanced interventions 3

Second-Line Options (If Initial Treatment Fails)

• Intra-articular triamcinolone injections provide significant pain relief, particularly effective in stage 1 frozen shoulder 2
• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 1, 4
• Oral glucocorticoids (0.5 mg/kg/day methylprednisolone, tapered over one month) combined with pregabalin and home exercises show effectiveness in early-stage frozen shoulder 5

Evidence Quality Considerations

The guidelines consistently emphasize physical therapy as the foundation of treatment 1, 2, with strong evidence supporting steroid injections and laser therapy in the short term 6. However, most studies report short-term results while frozen shoulder symptoms may persist up to 4 years 6. The combination approach of exercise, pain management, and patient education represents the current standard of care based on multiple professional society recommendations 1, 2.

Common Pitfalls

• Misdiagnosis - ensure proper imaging if indicated to rule out other shoulder pathologies 1
• Poor treatment compliance leads to suboptimal outcomes 1
• Using overhead pulleys remains the most common error with the highest incidence of worsening symptoms 1, 2
• Premature immobilization accelerates capsular adhesion formation 2