What is the recommended treatment for frozen shoulder?

Treatment of Frozen Shoulder

The recommended treatment for frozen shoulder is immediate initiation of physical therapy focusing on external rotation and abduction exercises combined with NSAIDs or acetaminophen for pain control, with intra-articular corticosteroid injections reserved for stage 1 (freezing phase) disease or inadequate response to first-line therapy. 1, 2

First-Line Treatment Algorithm

Physical Therapy (Mandatory Foundation)

• Begin stretching and mobilization exercises immediately, with external rotation being the single most critical movement to prioritize 1, 2
• Focus specifically on external rotation and abduction movements, as these are the most important factors in preventing progression and restoring function 1, 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles 1, 2
• Strictly avoid overhead pulley exercises—this intervention carries the highest risk of worsening shoulder pain and symptoms 1, 2, 3

Pain Management

• Use NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy 1, 2
• Topical NSAIDs can be considered to eliminate gastrointestinal hemorrhage risk while maintaining efficacy 2
• Local cold therapy provides additional pain relief based on expert consensus 1

Adjunctive Therapies

• Acupuncture combined with therapeutic exercises demonstrates statistically significant improvement and can be considered as an adjunct 1, 4

Second-Line Interventions (For Inadequate Response)

Injectable Corticosteroids

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder 2, 4
• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 2
• Note: Peritendinous or intratendinous injections may inhibit healing and reduce tensile strength, potentially causing spontaneous rupture 2

Advanced Interventions for Refractory Cases

• Hydrodilatation of the glenohumeral joint may be considered for cases not responding to conservative management 1
• Botulinum toxin injections into subscapularis and pectoralis muscles can be considered when spasticity contributes to pain 1, 2
• Arthroscopic capsular release is an option for recalcitrant cases after at least 12 weeks of failed conservative treatment 5

Critical Pitfalls to Avoid

• Never immobilize the shoulder with arm slings or wraps—this directly promotes frozen shoulder development and worsening 1, 2, 3
• Avoid overhead pulleys as they encourage uncontrolled abduction and have the highest incidence of worsening symptoms 1, 2, 3
• Do not delay treatment initiation, as this leads to further motion loss and potentially permanent dysfunction 2
• If full shoulder function is not achieved by 6-8 weeks, formal physical therapy must be instituted to prevent permanent shoulder dysfunction 1, 2

Treatment Considerations by Stage

Stage 1 (Freezing/Painful Phase)

• Intra-articular corticosteroid injections are most effective during this phase 2, 4
• Aggressive pain control is essential to enable participation in physical therapy 2

Stages 2-3 (Frozen/Thawing Phases)

• Therapeutic exercises and mobilization are strongly recommended for reducing pain, improving ROM, and restoring function 4
• Low-level laser therapy can be considered for pain relief but is not recommended for improving ROM 4
• Continuous passive motion may provide short-term pain relief but does not improve ROM or function 4

Evidence Quality Note

The evidence strongly supports physical therapy with external rotation emphasis combined with analgesics as first-line treatment 1, 2, 4. While the 2010 AAOS guideline on glenohumeral osteoarthritis found insufficient evidence for corticosteroid injections in that specific condition 6, more recent evidence specifically for frozen shoulder demonstrates clear benefit, particularly in stage 1 disease 2, 4. The condition is often self-limiting but can cause significant morbidity if not treated appropriately 7, 8.