What are the treatment options for frozen shoulder?

Treatment of Frozen Shoulder (Adhesive Capsulitis)

Begin immediately with stretching and mobilization exercises focusing on external rotation and abduction movements, combined with NSAIDs or acetaminophen for pain control. 1, 2

First-Line Treatment Protocol

Physical Therapy (Initiate Immediately)

• External rotation exercises are the single most critical intervention and should be prioritized above all other movements, as this is the key factor in preventing and treating shoulder pain 1
• Abduction movements should be performed alongside external rotation to maximize functional improvement 1, 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder alignment and strengthening weakened shoulder girdle muscles 1
• Physical therapy combined with therapeutic exercises demonstrates strong evidence for reducing pain, improving ROM, and enhancing function in stages 2 and 3 of frozen shoulder 3

Pain Management

• 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 patients to engage in the critical exercise component 1

Additional First-Line Adjuncts

• Acupuncture combined with therapeutic exercises shows moderate evidence for pain relief, improving ROM and function, and can be added to the treatment regimen 2, 3
• Local cold therapy provides pain relief based on expert consensus 2
• Deep heat modalities can be used for pain relief and improving ROM 3

Second-Line Interventions (When First-Line Inadequate)

Corticosteroid Injections

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder, demonstrating superior pain control compared to oral NSAIDs in the acute phase 1
• Subacromial corticosteroid injections can be utilized when pain relates specifically to subacromial inflammation 1
• At 24 weeks, intra-articular corticosteroids show equivalent efficacy to NSAIDs in diabetic patients 1
• Avoid peritendinous or intratendinous injections as these may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 1

Advanced Interventions

• Botulinum toxin injections into subscapularis and pectoralis muscles can be considered when pain relates to spasticity 1, 2
• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 2, 4
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function, though not recommended for improving ROM 3

Critical Pitfalls to Avoid

Harmful Interventions

• Never use overhead pulleys - this single intervention carries the highest risk of worsening shoulder pain and is associated with the highest incidence of developing hemiplegic shoulder pain 1, 2
• Avoid shoulder immobilization, arm slings, or wraps as these promote frozen shoulder development and worsen outcomes 1, 2

Timing Considerations

• Do not delay treatment initiation - delaying leads to further motion loss and potentially permanent dysfunction 1
• If formal physical therapy is not initiated by 6-8 weeks post-injury or post-surgery, permanent shoulder dysfunction may result 1, 2

Treatment Algorithm by Stage

Stage 1 (Freezing/Painful Phase)

• Intra-articular corticosteroid injections are most effective at this stage 1, 3
• Combine with immediate physical therapy focusing on external rotation 1
• NSAIDs or acetaminophen for pain control 1

Stages 2-3 (Frozen/Adhesive and Thawing Phases)

• Therapeutic exercises and mobilization are strongly recommended 3
• Continue emphasis on external rotation and abduction 1
• Consider acupuncture as adjunct therapy 2, 3

Evidence Quality Considerations

The strongest evidence supports therapeutic exercises and mobilization as the cornerstone of treatment 3. While multiple modalities exist, the combination of physical therapy emphasizing external rotation with appropriate pain management represents the most evidence-based approach 1, 2. Corticosteroid injections have clear benefit in early-stage disease but should be used judiciously given potential complications 1. Ultrasound therapy alone is not recommended for pain relief, improving ROM, or function 3.