What is the recommended treatment approach for a patient with adhesive capsulitis (frozen shoulder) of the shoulder?

Treatment of Adhesive Capsulitis (Frozen Shoulder)

Begin immediately with stretching and mobilization exercises prioritizing external rotation and abduction movements, combined with oral NSAIDs or acetaminophen for pain control. 1

First-Line Treatment Approach

Immediate Physical Therapy Initiation

• External rotation exercises are the single most critical intervention and must be prioritized above all other movements to prevent and treat shoulder pain 1
• Start stretching and mobilization exercises immediately, focusing on external rotation and abduction movements to restore shoulder function 1
• Gradually increase active range of motion while simultaneously correcting alignment and strengthening weakened shoulder girdle muscles 1
• Critical timing: Formal physical therapy must begin within 6-8 weeks post-injury or post-surgery to prevent permanent shoulder dysfunction 2

Pain Control to Enable Therapy

• Use NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to provide adequate pain control that enables participation in physical therapy 1
• Topical NSAIDs can eliminate gastrointestinal hemorrhage risk while maintaining pain relief efficacy 1

Critical Actions to Avoid

• Never use overhead pulley exercises—this single intervention carries the highest risk of worsening shoulder pain 3, 1
• Avoid shoulder immobilization, arm slings, or wraps, as these directly promote frozen shoulder development 1, 2
• Do not delay treatment initiation, as this leads to further motion loss and potentially permanent dysfunction 1, 2

Second-Line Interventions (For Inadequate Response After 6-8 Weeks)

Intra-articular Corticosteroid Injections

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder 1, 4
• These injections demonstrate superior pain control compared to oral NSAIDs in the acute phase and provide greater improvement in passive range of motion both short-term (0-8 weeks) and long-term (9-24 weeks) 1, 4
• Pain relief is most pronounced at 0-8 weeks but does not sustain as effectively at 9-24 weeks, though range of motion improvements persist 4
• In diabetic patients, intra-articular corticosteroids have 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
• Suprascapular nerve block may be considered as an adjunctive treatment for hemiplegic shoulder pain and can be combined with physical therapy for additive benefits 3, 5
• Botulinum toxin injections into subscapularis and pectoralis muscles can be considered when pain relates to spasticity 1

Evidence for Combination Therapy

• Combining intra-articular corticosteroid injection with physical therapy provides greater improvement than physiotherapy alone 5, 6
• Combining suprascapular nerve block with physical therapy and/or corticosteroid injection improves shoulder pain, range of motion, and function 5
• Hydrodilatation with physical therapy offers additive benefits for improving shoulder range of motion 5

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 is debatable for chronic cases, as the role of inflammation in chronic tendinopathies remains unclear 1

High-Risk Populations

• Patients aged 40-65 years are at peak risk, with adhesive capsulitis rarely occurring under age 40 2
• Up to 67% of stroke patients with combined motor, sensory, and visuoperceptual deficits develop shoulder-hand-pain syndrome that may progress to adhesive capsulitis 2
• Improper handling during stroke rehabilitation, particularly overhead pulley exercises, significantly increases adhesive capsulitis risk 2

Surgical Considerations (For Refractory Cases After 6-12 Weeks)

• Manipulation under anesthesia or arthroscopic capsular release should be considered for patients with minimal improvement after 6-12 weeks of nonsurgical treatment 7, 6
• Surgical tenotomy of pectoralis major, latissimus dorsi, teres major, or subscapularis may be considered for patients with severe hemiplegia and restrictions in shoulder range of motion 3