What is the best management approach for a patient with frozen shoulder?

Management of Frozen Shoulder

Immediately initiate physical therapy with stretching and mobilization exercises focusing specifically on external rotation and abduction movements, combined with NSAIDs or acetaminophen for pain control. 1

First-Line Treatment Algorithm

Physical Therapy (Start Immediately)

• External rotation is the single most critical movement to prioritize in all physical therapy exercises, as it is the factor most significantly related to preventing and treating shoulder pain 1
• Focus on stretching and mobilization targeting external rotation and abduction movements 2, 1
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles 1
• Begin intervention as early as possible—delaying treatment leads to further motion loss and potentially permanent dysfunction if not started within 6-8 weeks 1, 3

Pain Management

• Use NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy 1, 3
• These medications provide adequate pain control for most patients to engage in therapeutic exercises 1

Critical Interventions to AVOID

• Never use overhead pulleys—this single intervention carries the highest risk of worsening shoulder pain and has the highest incidence of complications 1, 3
• Avoid shoulder immobilization, arm slings, or wraps, as these directly promote frozen shoulder development 1, 3
• Do not delay treatment initiation 1

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

Intra-Articular 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
• In diabetic patients, intra-articular corticosteroids have equivalent efficacy to NSAIDs at 24 weeks 1
• Important caveat: Peritendinous or intratendinous injections may inhibit healing and reduce tensile strength, potentially causing spontaneous rupture—ensure proper intra-articular placement 1

Additional Interventions

• Subacromial corticosteroid injections can be used when pain relates specifically to subacromial inflammation 1
• Botulinum toxin injections into subscapularis and pectoralis muscles may be considered when pain relates to spasticity 1, 3
• Acupuncture combined with therapeutic exercises shows statistically significant improvement and can be used as an adjunct 3, 4

Third-Line Interventions (For Refractory Cases)

Hydrodilatation

• For cases not responding to conservative treatment after 6-9 months, hydrodilatation of the glenohumeral joint can be considered 3, 5
• This involves gradual dilation of the glenohumeral capsule with saline and corticosteroid injection 6

Surgical Options

• Arthroscopic capsular release or manipulation under anesthesia should be reserved for resistant cases failing 6-9 months of conservative treatment 7
• Manipulation carries risk of unwarranted complications including humeral fractures and rotator cuff tears 7

Additional Supportive Modalities

Evidence-Based Adjuncts

• Low-level laser therapy is strongly recommended for pain relief and moderately recommended for improving function, but not for improving range of motion 4
• Local cold therapy provides pain relief 3
• Deep heat can be used for pain relief and improving range of motion 4
• Functional electrical stimulation may improve shoulder lateral rotation 2

Not Recommended

• Ultrasound therapy is not recommended for pain relief, improving ROM, or function 4
• Continuous passive motion is only recommended for short-term pain relief, not for improving ROM or function 4

Stage-Specific Considerations

The treatment approach should be adjusted based on disease stage, though early intervention with physical therapy and pain control remains the foundation across all stages 1, 4. Corticosteroid injections are particularly effective in stage 1 (freezing phase), while therapeutic exercises and mobilization are strongly recommended for stages 2 and 3 4.

Common Clinical Pitfalls

• Failing to prioritize external rotation exercises—this is the most critical movement pattern 1
• Using overhead pulleys, which worsen outcomes 1, 3
• Allowing shoulder immobilization 1, 3
• Delaying formal physical therapy beyond 6-8 weeks, which may result in permanent dysfunction 1, 3
• Misdiagnosis—ensure proper evaluation to rule out other shoulder pathologies 3