What is the recommended treatment for a patient with a frozen shoulder?

Treatment for Frozen Shoulder

Begin immediately with physical therapy focusing on stretching and mobilization exercises that emphasize external rotation and abduction, combined with NSAIDs or acetaminophen for pain control. 1, 2

First-Line Treatment Algorithm

Physical Therapy (Start Immediately)

• External rotation exercises are the single most critical intervention for preventing and treating frozen shoulder pain and should be prioritized above all other movements 2
• Stretching and mobilization exercises should concentrate on external rotation first, followed by abduction movements 1, 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder alignment and strengthening weakened shoulder girdle muscles 1, 2
• Therapeutic exercises and mobilization are strongly recommended for reducing pain, improving ROM, and function 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
• Topical NSAIDs can eliminate gastrointestinal hemorrhage risk while maintaining pain relief efficacy 2

Critical Actions to AVOID

• Never use overhead pulleys - this single intervention carries the highest risk of worsening shoulder pain and encourages uncontrolled abduction 1, 2, 4
• Never immobilize the shoulder with 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 physical 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 2, 3
• These injections demonstrate superior pain control compared to oral NSAIDs in the acute phase 2
• Adding a single intra-articular steroid injection to home exercise shows benefit in patients with frozen shoulder of <6 months duration 5
• The combination of steroid injection plus physiotherapy shows the most significant treatment effect for short-term pain relief compared to placebo 5
• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 2

Alternative Interventions

• Acupuncture with therapeutic exercises is moderately recommended for pain relief, improving ROM and function 1, 3
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function, but not recommended for improving ROM 3
• Botulinum toxin injections into subscapularis and pectoralis muscles can be considered when pain relates to spasticity 2
• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 1, 6

Treatment Considerations by Stage

Stage 1 (Freezing/Painful Phase)

• Corticosteroid injections are most effective during this stage 2, 3
• Combine with gentle stretching focusing on external rotation 2

Stages 2 and 3 (Frozen and Thawing Phases)

• Therapeutic exercises and mobilization are strongly recommended 3
• High-grade mobilization may be more effective than low-grade mobilization in patients who have already had treatment 5

Important Clinical Caveats

Diagnostic Differentiation

• Frozen shoulder shows restriction in both active and passive motion equally, distinguishing it from rotator cuff pathology 4
• Patients with frozen shoulder do not demonstrate focal weakness, swelling, or atrophy, unlike rotator cuff dysfunction 4
• The classic capsular pattern involves greatest limitation in external rotation, followed by abduction, then internal rotation 4

Corticosteroid Injection Warnings

• Peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 2
• The benefit-risk ratio of corticosteroids for chronic cases is debatable 2

Patient Education

• Educate patients on proper positioning and home exercises from the outset 1, 4
• Local cold therapy can be beneficial for pain relief 1