What is the best management approach for a patient with frozen shoulder?

Management of Frozen Shoulder

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)

• External rotation exercises are the single most critical component and should be prioritized above all other movements 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles 1, 2
• Gentle stretching and mobilization techniques should be started immediately to prevent further motion loss 1, 3
• Patient education on proper positioning and home exercises is essential; if full function is not achieved by 6-8 weeks, formal physical therapy must be instituted to prevent permanent dysfunction 1, 2

Pain Management

• NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy 1, 2
• Topical NSAIDs can be considered to eliminate gastrointestinal hemorrhage risk while maintaining efficacy 2

Adjunctive Therapies

• Acupuncture demonstrates statistically significant improvement and can be added to physical therapy 1
• Local cold therapy provides pain relief based on expert consensus 1

Second-Line Interventions (For Inadequate Response After 6-9 Months)

Injectable Therapies

• Intra-articular triamcinolone injections provide significant pain relief, particularly effective in stage 1 (freezing phase) frozen shoulder 2, 3, 4
• Subacromial corticosteroid injections when pain relates to subacromial inflammation 2, 3
• Botulinum toxin injections into subscapularis and pectoralis muscles when pain relates to spasticity 2, 3
• Hydrodilatation of the glenohumeral joint for refractory cases 1, 5

Surgical Options (After 6-9 Months of Failed Conservative Treatment)

• Arthroscopic capsular release or manipulation under anesthesia for resistant cases 6
• Manipulation carries risk of humeral fractures or rotator cuff tears, making arthroscopic release potentially safer 6

Critical Pitfalls to Avoid

Interventions That Worsen Outcomes

• Overhead pulleys must be avoided—they encourage uncontrolled abduction and carry the highest risk of worsening shoulder pain and developing hemiplegic shoulder pain 1, 2, 3
• Shoulder immobilization, arm slings, or wraps promote frozen shoulder development and must be avoided 1, 2

Timing Considerations

• Delaying treatment initiation leads to further motion loss 2, 3
• If formal physical therapy is not started by 6-8 weeks, permanent shoulder dysfunction may result 2

Special Populations

Diabetic Patients

• Screen all patients with primary stiff shoulder for diabetes and thyroid dysfunction 6
• Intra-articular corticosteroids have equivalent efficacy to NSAIDs at 24 weeks in diabetic patients 2

Complex Regional Pain Syndrome Risk

• Early oral corticosteroids (30-50 mg daily for 3-5 days, tapering over 1-2 weeks) for CRPS or Shoulder-Hand Syndrome 3
• Active, active-assisted, or passive range of motion exercises help prevent CRPS 3

Expected Timeline

• Most patients respond to conservative treatment with gradual resolution in 12-18 months 6, 7
• Symptoms may last up to 4 years in some cases 4
• Strong evidence supports steroid injections and laser therapy for short-term relief, with moderate evidence for mid-term effectiveness 4