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

Treatment of Frozen Shoulder

The best treatment approach for frozen shoulder is immediate initiation of physical therapy focusing on external rotation and abduction exercises combined with NSAIDs or acetaminophen for pain control, with corticosteroid injections reserved for stage 1 (freezing phase) disease or inadequate response to first-line therapy. 1, 2

First-Line Treatment Algorithm

Physical Therapy (Initiate Immediately)

• Begin stretching and mobilization exercises concentrating specifically on external rotation and abduction movements 1, 2
• External rotation is the single most critical factor in preventing and treating shoulder pain and must be prioritized 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles 1, 2
• Regular exercise programs have demonstrated effectiveness for managing symptoms 1

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

Patient Education

• Educate on proper positioning and home exercises in the initial phase 1
• If full shoulder function is not achieved by 6-8 weeks, formal physical therapy must be instituted to prevent permanent shoulder dysfunction 1, 2

Second-Line Interventions (For Inadequate Response)

Corticosteroid Injections

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder 2, 3, 4
• These demonstrate superior pain control compared to oral NSAIDs in the acute phase 2
• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 2, 3
• At 24 weeks, intra-articular corticosteroids have equivalent efficacy to NSAIDs in diabetic patients 2

Alternative Interventions

• Acupuncture combined with therapeutic exercises demonstrates statistically significant improvement in shoulder symptoms and can be considered as an adjunct to physical therapy 1, 4
• Botulinum toxin injections into subscapularis and pectoralis muscles can be considered when pain relates to spasticity 2, 3
• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 1
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function 4, 5

Critical Pitfalls to Avoid

Interventions That Worsen Outcomes

• Avoid overhead pulleys—this single intervention carries the highest risk of worsening shoulder pain and encouraging uncontrolled abduction 1, 2, 3
• Overhead pulleys are associated with the highest incidence of developing hemiplegic shoulder pain 1, 3

Immobilization

• Avoid shoulder immobilization, arm slings, or wraps as these promote frozen shoulder development 1, 2
• Avoiding immobilization after any shoulder surgery is critical to prevent frozen shoulder 2

Treatment Delays

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

Evidence Quality Considerations

The guidelines consistently recommend the same treatment algorithm across multiple professional societies (American College of Physicians, American Academy of Physical Medicine and Rehabilitation, American Academy of Orthopaedic Surgeons) 1, 2, 3. The systematic review evidence supports therapeutic exercises and mobilization with strong recommendations for reducing pain, improving ROM and function in stages 2 and 3 frozen shoulder 4. The evidence for corticosteroid injections is particularly strong for stage 1 disease 2, 4, 5, though one caveat is that peritendinous or intratendinous injections may inhibit healing and reduce tensile strength 2.