What is the recommended physiotherapy management for a patient with frozen shoulder?

Physiotherapy Management for Frozen Shoulder

First-Line Treatment: Immediate Initiation of Stretching and Mobilization

Begin stretching and mobilization exercises immediately upon diagnosis, with external rotation being the single most critical movement to prioritize, followed by abduction. 1, 2

• External rotation is the most important factor in both preventing and treating frozen shoulder pain and must be the primary focus of all physical therapy interventions. 1
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles around the shoulder. 1
• Gentle stretching and mobilization techniques should specifically target increasing external rotation and abduction movements. 3, 2

Pain Management to Enable Therapy Participation

• Use NSAIDs (ibuprofen) or acetaminophen as first-line analgesics to provide adequate pain control that enables active participation in physical therapy. 1, 2
• These medications are essential for allowing patients to engage in the necessary exercises, though they may have limited effectiveness in some cases. 2

Critical Interventions to AVOID

Never use overhead pulleys for frozen shoulder treatment—this single intervention carries the highest risk of worsening shoulder pain. 1, 2, 4

• Avoid shoulder immobilization, arm slings, or wraps, as these promote frozen shoulder development and worsen outcomes. 1, 2
• Do not delay treatment initiation, as this leads to further motion loss and potentially permanent shoulder dysfunction if formal physical therapy is not started within 6-8 weeks. 2

Structured Exercise Protocol

Phase 1: Gentle Mobilization (Stages 1-2)

• Focus on passive and active-assisted range of motion exercises within the patient's pain tolerance. 3
• Place the upper limb in various appropriate and safe positions within the patient's visual field during exercises. 3
• Emphasize external rotation movements as the foundation of all exercise sessions. 1

Phase 2: Progressive Strengthening (Stage 2-3)

• Gradually increase active range of motion exercises as pain decreases. 3, 1
• Strengthen weak muscles in the shoulder girdle while maintaining proper joint alignment. 3, 1
• Continue prioritizing external rotation and abduction movements throughout this phase. 1

Adjunctive Physical Therapy Modalities

• Acupuncture can be considered as an adjunct to physical therapy, demonstrating statistically significant improvement in shoulder symptoms. 2
• Local cold therapy provides pain relief based on expert consensus. 2
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function, but not recommended for improving range of motion. 5
• Electrical stimulation may be considered as an adjunctive therapy to motor practice for improving motor control at the shoulder, particularly in acute cases. 3, 5

Evidence Quality Considerations

The strongest evidence supports therapeutic exercises and mobilization for reducing pain, improving ROM, and enhancing function in stages 2 and 3 of frozen shoulder. 5 While multiple modalities exist, the core intervention remains stretching and mobilization with emphasis on external rotation. 1, 6

When to Escalate Treatment

If adequate progress is not achieved with physical therapy and oral analgesics alone:

• Intra-articular corticosteroid injections (particularly triamcinolone) provide significant pain relief, especially effective in stage 1 (freezing phase) frozen shoulder. 1
• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation (rotator cuff or bursa involvement). 3, 1
• Botulinum toxin injections into subscapularis and pectoralis muscles may be considered when pain relates to spasticity. 3, 1

Treatment Timeline and Monitoring

• Patient education on proper positioning and home exercises is essential from the initial visit. 2
• If full shoulder function is not achieved by 6-8 weeks, formal physical therapy must be instituted to prevent permanent shoulder dysfunction. 2
• Regular reassessment is necessary to determine if treatment modifications are required or if equipment can be discontinued. 3