What are the symptoms and treatment options for a patient with frozen shoulder?

Frozen Shoulder: Symptoms and Treatment

Clinical Presentation

Frozen shoulder presents with progressive loss of both active and passive range of motion in all planes, with external rotation being the most severely affected movement, accompanied by stage-dependent shoulder pain. 1

Key diagnostic features include:

• Significant restriction in both active and passive ROM - this distinguishes frozen shoulder from rotator cuff pathology where active motion is more limited than passive 1
• Pain that varies by disease stage - worst during the initial "freezing" phase 1
• Progressive stiffness that develops over months 1
• Functional impairment affecting activities of daily living and employment 2

The condition progresses through three distinct stages, each lasting approximately 4-6 months 1:

1. Freezing stage: Progressive loss of motion with worsening pain
2. Frozen stage: Continued stiffness but improving pain and inflammation
3. Thawing stage: Gradual return of motion 1

Treatment Algorithm

Immediate First-Line Treatment (All Stages)

Begin stretching and mobilization exercises immediately, with absolute priority given to external rotation movements, as external rotation is the single most critical factor in preventing and treating shoulder pain. 3

Physical therapy protocol:

• Focus on external rotation and abduction exercises as the primary movements 3
• Gradually increase active range of motion while restoring proper shoulder girdle alignment and strengthening weakened muscles 3
• Avoid overhead pulleys completely - this intervention carries the highest risk of worsening shoulder pain 3, 2

Pain management:

• NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy 3
• Topical NSAIDs can eliminate gastrointestinal hemorrhage risk while maintaining efficacy 3

Second-Line Interventions (Inadequate Response After 6-9 Weeks)

For patients not responding adequately to physical therapy and oral analgesics, intra-articular triamcinolone injections provide significant pain relief, particularly in stage 1 (freezing phase) frozen shoulder. 3

Injectable options:

• Intra-articular corticosteroid injections (triamcinolone) demonstrate superior pain control compared to oral NSAIDs in the acute phase 3
• Subacromial corticosteroid injections when pain relates to subacromial inflammation 3
• Botulinum toxin injections into subscapularis and pectoralis muscles when pain relates to spasticity 3, 2

Important caveats about corticosteroids:

• Peritendinous or intratendinous injections may inhibit healing and reduce tensile strength, potentially causing spontaneous rupture 3
• Efficacy is equivalent to NSAIDs by 24 weeks in diabetic patients 3
• The benefit-risk ratio for chronic cases is debatable 3

Adjunctive Therapies

• Acupuncture demonstrates statistically significant improvement in shoulder symptoms and can be considered alongside physical therapy 2
• Local cold therapy provides pain relief based on expert consensus 2

Surgical Intervention (Refractory Cases After 6-9 Months)

For patients failing conservative treatment for 6-9 months, consider 4:

• Arthroscopic capsular release (preferred due to lower complication risk)
• Manipulation under anesthesia (higher risk of humeral fractures or rotator cuff tears)
• Hydrodilatation of the glenohumeral joint 2, 5

Critical Pitfalls to Avoid

Never immobilize the shoulder, use arm slings, or apply wraps, as these interventions directly promote frozen shoulder development. 3, 2

Additional warnings:

• Avoid overhead pulleys - associated with the highest incidence of worsening shoulder pain 3, 2
• Do not delay treatment initiation - leads to further motion loss 3
• If formal physical therapy is not initiated by 6-8 weeks post-injury or post-surgery, permanent shoulder dysfunction may result 3

Special Considerations

• Screen for diabetes mellitus and thyroid dysfunction in all patients with primary frozen shoulder, as these conditions are closely associated with the disease 4, 6
• Most patients respond to conservative treatment with gradual resolution in 12-18 months 4
• The condition is self-limiting but may resolve with only partial restitution 1