Initial Treatment for Frozen Shoulder
Begin immediate physical therapy with stretching and mobilization exercises focusing specifically on external rotation and abduction, combined with NSAIDs or acetaminophen for pain control. 1, 2
First-Line Treatment Algorithm
Physical Therapy (Primary Treatment)
- Initiate stretching and mobilization exercises immediately to prevent further loss of motion 1, 2
- Prioritize external rotation exercises as this is the single most critical factor in preventing and treating shoulder pain 2
- Focus on abduction movements in addition to external rotation 1, 2
- Gradually increase active range of motion while restoring proper shoulder girdle alignment and strengthening weak muscles 1, 2
- Patient education on proper positioning and home exercises is essential from the start 1
Pain Management (Concurrent with Physical Therapy)
- Use NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy 1, 2
- These medications provide adequate pain control necessary for exercise compliance 2
- Topical NSAIDs can be considered to eliminate gastrointestinal hemorrhage risk while maintaining efficacy 2
Critical Actions to AVOID
Never use overhead pulleys - this single intervention carries the highest risk of worsening shoulder pain and encouraging uncontrolled abduction 1, 2
Additional contraindicated interventions:
- Avoid shoulder immobilization, arm slings, or wraps as these promote frozen shoulder development 1, 2
- Do not delay treatment initiation, as this leads to further motion loss 2
Treatment Timeline and Escalation
- If full shoulder function is not achieved by 6-8 weeks with home exercises, formal physical therapy should be instituted 1
- Most patients respond to conservative treatment with gradual resolution in 12-18 months 3
- For cases not responding to conservative treatment after 6-9 months, consider escalation to intra-articular corticosteroid injections (particularly triamcinolone, which provides significant pain relief especially in stage 1 frozen shoulder) 2, 4
Additional Considerations
- Acupuncture can be considered as an adjunct to physical therapy, as it has demonstrated statistically significant improvement in shoulder symptoms 1
- Ensure proper diagnosis with imaging if indicated to rule out other shoulder pathologies before committing to this treatment pathway 1
- Monitor treatment compliance closely, as poor adherence leads to suboptimal outcomes 1
The evidence strongly supports this combined approach of immediate physical therapy with pain management, with multiple guidelines (American College of Physicians, American Academy of Physical Medicine and Rehabilitation) converging on this recommendation 1, 2. The systematic review evidence confirms moderate to strong evidence for steroid injections and mobilization techniques, though physical therapy remains the cornerstone of initial management 4.