What is the best treatment approach for a patient with frozen shoulder, considering their individual needs and medical history, such as diabetes or other underlying conditions?

Frozen Shoulder Treatment

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

First-Line Treatment Algorithm

Physical Therapy (Primary Intervention)

• Begin stretching and mobilization exercises immediately targeting external rotation and abduction movements, as external rotation is the single most critical factor in preventing and treating shoulder pain 1, 2
• Gradually increase active range of motion while restoring proper shoulder girdle alignment and strengthening weakened muscles 1, 2
• Avoid overhead pulley exercises—these carry the highest risk of worsening shoulder pain and encouraging uncontrolled abduction 1, 2
• If full shoulder function is not achieved by 6-8 weeks, permanent dysfunction may result, so early formal physical therapy is essential 1, 2

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 efficacy 2
• Local cold therapy provides pain relief based on expert consensus 1

Critical Actions to Avoid

• Never use shoulder immobilization, arm slings, or wraps—these promote frozen shoulder development 1, 2
• Do not delay treatment initiation, as this leads to further motion loss 2
• Avoid overhead pulleys, which have the highest incidence of worsening hemiplegic shoulder pain 1, 2

Second-Line Interventions (For Inadequate Response After 3-6 Months)

Injectable Therapies

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder, demonstrating superior pain control compared to oral NSAIDs in the acute phase 2, 3
• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 2
• Botulinum toxin injections into subscapularis and pectoralis muscles may be considered when pain relates to spasticity 1, 2
• Important caveat: Peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 2

Advanced Interventions

• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 1, 3
• Acupuncture has demonstrated statistically significant improvement in shoulder symptoms and can be considered as an adjunct to physical therapy 1

Surgical Management (For Persistent Symptoms After 6-9 Months of Conservative Treatment)

• Arthroscopic capsular release or manipulation under anesthesia are options when conservative treatment fails 4, 5
• Both procedures are not clinically superior to one another, but manipulation could result in complications like humeral fractures or rotator cuff tears 5
• Most patients respond well to conservative treatment with gradual resolution in 12-18 months 5

Special Considerations for High-Risk Patients

Diabetes

• Frozen shoulder is strongly associated with diabetes and should always be investigated in patients with primary stiff shoulder 5
• Intra-articular corticosteroids have equivalent efficacy to NSAIDs at 24 weeks in diabetic patients 2
• Diabetic patients with peripheral neuropathy may have reduced pain sensation, which could mask both initial injury and treatment response 6

Thyroid Dysfunction

• Frozen shoulder is associated with thyroid dysfunction and should be investigated in patients presenting with primary stiff shoulder 5

Common Pitfalls

• Misdiagnosis: Ensure proper imaging (if indicated) to rule out other shoulder pathologies before committing to frozen shoulder treatment 1
• Poor treatment compliance: Monitor adherence as this leads to suboptimal outcomes 1
• Delayed formal physical therapy: Waiting beyond 6-8 weeks without formal therapy may result in permanent shoulder dysfunction 1, 2
• Using overhead pulleys: This single intervention carries the highest risk of worsening symptoms 1, 2