What is the recommended treatment for a 52-year-old male with left frozen shoulder (adhesive capsulitis)?

Treatment of Frozen Shoulder in a 52-Year-Old Male

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

First-Line Treatment Algorithm

Physical Therapy (Mandatory Foundation)

• Begin stretching and mobilization exercises immediately, with external rotation as the single most critical movement to prioritize 1
• Progress to active range of motion exercises while restoring proper shoulder girdle alignment and strengthening weakened muscles 1
• External rotation is the most significantly affected motion and relates most strongly to preventing and treating shoulder pain 2
• Abduction exercises should be incorporated as the second priority movement 1, 2
• Therapeutic exercises combined with mobilization provide strong evidence (Grade A recommendation) for reducing pain, improving ROM, and restoring function in stages 2 and 3 frozen shoulder 3

Pain Management

• Use NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy 1
• These medications provide adequate pain control necessary for effective rehabilitation 1

Critical Actions to Avoid

• Never use overhead pulley exercises—this carries the highest risk of worsening shoulder pain 1, 4
• Avoid shoulder immobilization, arm slings, or wraps, as these promote frozen shoulder progression 1
• Do not delay treatment initiation, as this leads to further motion loss and potentially permanent dysfunction if formal therapy is not started within 6-8 weeks 1

Second-Line Interventions (If Inadequate Response After 3-6 Weeks)

Intra-Articular Corticosteroid Injections

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing/painful phase) frozen shoulder 1
• These injections demonstrate superior pain control compared to oral NSAIDs in the acute phase 1
• Corticosteroid injections combined with physiotherapy may provide greater improvement than physiotherapy alone 5
• In diabetic patients, intra-articular corticosteroids show equivalent efficacy to NSAIDs at 24 weeks 1

Alternative Injectable Options

• 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 muscle spasticity 1

Additional Conservative Modalities

• Low-level laser therapy is strongly recommended for pain relief and moderately recommended for improving function, though not for ROM improvement 3
• Acupuncture combined with therapeutic exercises is moderately recommended for pain relief, improving ROM and function 3
• Hydrodilatation (distension arthrography) can be considered as an adjunctive treatment 6, 7
• Deep heat modalities can provide pain relief and improve ROM 3

Surgical Intervention (If Conservative Treatment Fails)

• Consider manipulation under anesthesia or arthroscopic capsular release if minimal improvement occurs after 6-12 weeks of nonsurgical treatment 5
• Failure to obtain symptomatic improvement and continued functional disability after 3-6 months of conservative treatment are general indications for surgical management 6

Important Clinical Caveats

Corticosteroid Injection Risks

• Peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 1
• The benefit-risk ratio of corticosteroids for chronic tendinopathies remains debatable, as the role of inflammation in chronic cases is unclear 1

Natural History Considerations

• Traditional teaching suggested frozen shoulder resolves spontaneously in 1-2 years, but recent evidence demonstrates persistent functional limitations if left untreated 5
• This challenges the "wait and see" approach and supports early aggressive treatment 5

Differential Diagnosis

• Ensure exclusion of degenerative joint disease, crystal arthropathies, and septic arthritis—the key distinguishing feature of adhesive capsulitis is equal restriction of both active and passive motion in all planes, particularly external rotation 2