What are the treatment options for managing frozen shoulder (adhesive capsulitis)?

Frozen Shoulder Management

Immediate First-Line Treatment

Begin stretching and mobilization exercises immediately, prioritizing external rotation and abduction movements, combined with NSAIDs or acetaminophen for pain control. 1

• External rotation is the single most critical movement to prioritize in all physical therapy exercises, as it most strongly relates to preventing and treating shoulder pain 1
• Start NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy 1
• Gradually increase active range of motion while restoring proper shoulder girdle alignment and strengthening weakened muscles 1
• Therapeutic exercises and mobilization are strongly recommended for reducing pain, improving ROM, and restoring function in stages 2 and 3 (frozen and thawing phases) 2

Critical Actions to Avoid

Never use overhead pulley exercises—this single intervention carries the highest risk of worsening shoulder pain. 1

• 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 and prolonged disability 1
• Avoid shoulder immobilization after any shoulder surgery, as this contributes to frozen shoulder development 3

Second-Line Interventions (If Inadequate Response After 3-6 Months)

Intra-articular corticosteroid injections (triamcinolone) provide significant pain relief, particularly in stage 1 (freezing/painful phase). 1

• Intra-articular corticosteroids demonstrate superior pain control compared to oral NSAIDs in the acute phase 1
• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 1
• Botulinum toxin injections into subscapularis and pectoralis muscles may be considered when pain relates to spasticity 1
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function, but not recommended for improving ROM 2
• Acupuncture combined with therapeutic exercises is moderately recommended for pain relief, improving ROM and function 2

Additional Conservative Modalities

• Deep heat can be used for pain relief and improving ROM 2
• Electrotherapy can provide short-term pain relief 2
• Continuous passive motion is recommended for short-term pain relief but not for improving ROM or function 2
• Ultrasound is not recommended for pain relief, improving ROM, or function 2
• Hydrodilatation (capsular distension) can be considered as an interventional option 4

Surgical Management Indications

Failure to obtain symptomatic improvement and continued functional disability after 3-6 months of conservative treatment are general indications for surgical intervention. 5

• Surgical options include manipulation under anesthesia, arthroscopic capsular release, and open capsular release 5
• Conservative management leads to improvement in most cases, making surgery a last resort 5

Important Clinical Caveats

• The condition is typically self-limiting, progressing through three stages (freezing, frozen, thawing) over 1-2 years, with complete recovery as the rule 6
• No treatment is likely to shorten the natural course of the disease 6
• Peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 1
• In diabetic patients, intra-articular corticosteroids have equivalent efficacy to NSAIDs at 24 weeks 1
• Topical NSAIDs can eliminate gastrointestinal hemorrhage risk while maintaining pain relief efficacy 1
• If formal physical therapy is not initiated by 6-8 weeks post-injury or post-surgery, permanent shoulder dysfunction may result 3