What are the treatment options for frozen shoulder?

Treatment of Frozen Shoulder (Adhesive Capsulitis)

Immediate First-Line Treatment

Begin stretching and mobilization exercises immediately, with external rotation being the single most critical movement to prioritize, combined with NSAIDs or acetaminophen for pain control. 1, 2

Physical Therapy Protocol

• External rotation exercises are the highest priority and should be emphasized above all other movements, as this is the single most critical factor in preventing and treating shoulder pain 1
• Focus on both external rotation and abduction movements to restore shoulder function 1, 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles 1, 2
• Therapeutic exercises and mobilization are strongly recommended for reducing pain, improving range of motion, and restoring function, particularly 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 exercise compliance 1

Critical Actions to AVOID

Never use overhead pulleys - this single intervention carries the highest risk of worsening shoulder pain and has the highest incidence of developing complications 1, 2

Additional contraindications include:

• 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 and potentially permanent dysfunction if formal therapy is not started by 6-8 weeks 1, 2

Second-Line Interventions (For Inadequate Response to First-Line)

Corticosteroid Injections

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder 1, 4
• These injections 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
• At 24 weeks, intra-articular corticosteroids have equivalent efficacy to NSAIDs in diabetic patients 1

Important caveat: Peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 1

Alternative Injectable Therapies

• 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

Adjunctive Therapies

Evidence-Based Additions

• Acupuncture demonstrates statistically significant improvement in shoulder symptoms and can be used as an adjunct to physical therapy 2
• Acupuncture combined with therapeutic exercises is moderately recommended for pain relief, improving range of motion, and function 3
• Local cold therapy is beneficial for pain relief based on expert consensus 2

Modalities with Limited Evidence

• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function, but not recommended for improving range of motion 3
• Deep heat can be used for pain relief and improving range of motion 3
• Electrotherapy can help provide short-term pain relief 3
• Ultrasound for pain relief, improving range of motion, or function is not recommended 3

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 and 3 (Frozen and Thawing Phases)

• Therapeutic exercises and mobilization are strongly recommended 3
• Continue emphasis on external rotation and abduction 1
• Progressive strengthening of shoulder girdle muscles 1, 2

Common Pitfalls

• Delaying formal physical therapy beyond 6-8 weeks post-onset may result in permanent shoulder dysfunction 1, 2
• Misdiagnosis is common - ensure proper evaluation to rule out other shoulder pathologies before initiating treatment 2
• Poor adherence to home exercise programs leads to suboptimal outcomes - patient education on proper positioning and exercises is essential 2
• The combination of physical therapy, exercise, and manual techniques is effective regardless of whether the right or left shoulder is affected 5