What is the best treatment approach for a patient with frozen shoulder, considering their medical history, including conditions such as diabetes or thyroid disorders?

Treatment of Frozen Shoulder

First-Line Treatment: Physical Therapy Plus Analgesics

The cornerstone of frozen shoulder treatment is immediate initiation of physical therapy with stretching and mobilization exercises focusing specifically on external rotation and abduction, combined with NSAIDs or acetaminophen for pain control. 1, 2

Physical Therapy Protocol

• External rotation is the single most critical movement to prioritize in all exercise programs, as it is the factor most significantly related to preventing and treating shoulder pain 3, 2
• Stretching and mobilization should concentrate on both external rotation and abduction movements 1, 2
• Active range of motion should be increased gradually while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles 1, 2
• Strictly avoid overhead pulleys, as this intervention carries the highest risk of developing or worsening shoulder pain 3, 1, 2, 4

Pain Management

• NSAIDs (ibuprofen, naproxen) or acetaminophen are recommended as first-line analgesics to enable participation in physical therapy 1, 2
• Topical NSAIDs can be considered to eliminate gastrointestinal hemorrhage risk while maintaining pain relief efficacy 2
• Medications should be administered at bedtime for optimal pain control 5

Second-Line Treatment: Corticosteroid Injections

For patients with inadequate response to conservative therapy after 6-9 months, intra-articular triamcinolone injections provide significant pain relief, particularly in the freezing phase (stage 1). 3, 2, 5

• Intra-articular corticosteroid injections (triamcinolone or methylprednisolone) demonstrate superior pain control compared to oral NSAIDs in the acute phase 2, 5
• A single 40-mg steroid injection via intra-articular route is the preferred approach 5
• Subacromial corticosteroid injections can be used when pain relates specifically to subacromial inflammation 2
• Ultrasound guidance is recommended for injection-based therapy, though not absolutely required 6

Special Considerations for High-Risk Patients

Diabetes and Thyroid Dysfunction

• Always screen patients with frozen shoulder for diabetes and thyroid dysfunction, as these conditions are strongly associated with frozen shoulder and predict poorer outcomes 7, 8, 5
• Diabetic patients may require more aggressive treatment, as they tend to fare poorly with conservative management alone 5
• In diabetic patients, intra-articular corticosteroids have equivalent efficacy to NSAIDs at 24 weeks 2

Complex Regional Pain Syndrome Risk

• For patients developing shoulder-hand syndrome or Complex Regional Pain Syndrome, initiate an early course of oral corticosteroids (30-50 mg daily for 3-5 days, tapering over 1-2 weeks) 4
• Active, active-assisted, or passive range of motion exercises help prevent this complication 4

Surgical Intervention

For resistant cases that do not respond to conservative treatment for 6-9 months, surgical options include arthroscopic capsular release or manipulation under anesthesia. 7, 5

• Arthroscopic capsular release is broadly preferred over manipulation under anesthesia, as manipulation carries risk of humeral fracture or rotator cuff tear 7, 5
• Less than 10% of patients require surgical intervention 5
• Both procedures are not clinically superior to one another in terms of outcomes, but manipulation has higher complication rates 7

Critical Pitfalls to Avoid

• Never use overhead pulleys, as they encourage uncontrolled abduction and have the highest incidence of worsening shoulder pain 3, 1, 2, 4
• 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, 4
• If formal physical therapy is not initiated by 6-8 weeks, permanent shoulder dysfunction may result 1, 4

Expected Timeline

• Most patients respond to conservative treatment with gradual resolution of symptoms in 12-18 months 7, 9, 6
• The condition progresses through three stages (freezing, frozen, thawing) and is often self-limiting within 1-2 years 9, 6
• No current treatment has been definitively shown to alter the long-term natural course of the disease 6