What is the recommended duration of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) treatment for a patient with frozen shoulder?

NSAID Duration for Frozen Shoulder

NSAIDs for frozen shoulder should be used for a limited duration of 2-4 weeks, preferably on-demand rather than continuously, at the lowest effective dose, with careful attention to cardiovascular, gastrointestinal, and renal risk factors.

Evidence-Based Duration Recommendations

The available evidence does not provide frozen shoulder-specific NSAID duration guidelines, but extrapolating from high-quality musculoskeletal guidelines provides clear direction:

Recommended Treatment Duration

• Oral NSAIDs should be prescribed for 2-4 weeks maximum as initial therapy, based on evidence from osteoarthritis trials showing efficacy at this timeframe 1
• On-demand dosing is preferable to continuous daily use when symptoms fluctuate, minimizing cumulative exposure and adverse event risk 2
• Extended courses beyond 4 weeks should only continue if patients demonstrate clear ongoing benefits without major adverse events 2

Topical NSAIDs as Preferred Alternative

• Topical NSAIDs (particularly diclofenac gel) are strongly preferred over oral NSAIDs due to superior safety profile while maintaining comparable pain relief 1
• Topical formulations can be used for up to 8 weeks based on osteoarthritis data showing sustained efficacy with minimal systemic absorption 1
• A 2024 randomized trial demonstrated that topical loxoprofen for 14 days combined with physiotherapy achieved 66.67% effectiveness in frozen shoulder with minimal adverse events 3

Critical Safety Considerations

Cardiovascular Risks

• All NSAIDs carry increased risk of myocardial infarction, stroke, and cardiovascular death, which can occur even with short-term use 1, 2
• Use the absolute lowest effective dose for the shortest necessary duration to minimize cardiovascular thrombotic events 1, 2
• Avoid NSAIDs entirely in patients with established cardiovascular disease, heart failure, or elevated cardiovascular risk 2

Gastrointestinal Risks

• Risk of serious GI bleeding, ulceration, and perforation increases with duration of use 1, 2
• Elderly patients face dramatically higher risk: 1 in 110 adults over 75 versus 1 in 2,100 adults under 45 2

Renal Considerations

• Avoid NSAIDs in patients with renal disease or when combining with ACE inhibitors and beta blockers 2

Treatment Algorithm for Frozen Shoulder

Stage 1 (Freezing/Painful Phase)

• Start with topical NSAIDs (diclofenac gel or loxoprofen patch) applied daily for 2-4 weeks combined with physiotherapy 3, 4
• If topical therapy insufficient, add oral NSAIDs at lowest effective dose for maximum 2-4 weeks 1
• Consider corticosteroid injection for stage 1 frozen shoulder as alternative to prolonged NSAID use 5

Stage 2-3 (Frozen/Thawing Phases)

• Prioritize therapeutic exercises and mobilization over pharmacotherapy, as these show strongest evidence for improving ROM and function 5
• Use NSAIDs only for breakthrough pain on as-needed basis rather than scheduled dosing 2
• Reassess benefit versus risk every 2 weeks; discontinue if no clear improvement 1, 2

Refractory Cases (6-9 months)

• If conservative treatment including limited NSAID use fails after 6-9 months, consider surgical options (arthroscopic capsular release or manipulation under anesthesia) 6

Common Pitfalls to Avoid

• Do not prescribe NSAIDs for the entire 12-18 month natural course of frozen shoulder - this dramatically increases adverse event risk without proven benefit 6, 7
• Do not use continuous daily NSAIDs when intermittent dosing would suffice - on-demand use reduces cumulative exposure 2
• Do not ignore topical formulations - they provide comparable efficacy with far superior safety profile 1, 3
• Do not combine aspirin with ibuprofen without proper timing - ibuprofen must be taken 30 minutes after or 8 hours before aspirin to avoid interference with cardioprotection 1

Practical Implementation

• Week 1-2: Topical NSAID (diclofenac gel or loxoprofen patch) daily + physiotherapy 3
• Week 3-4: Continue topical; add oral NSAID only if inadequate response, lowest dose 1
• Week 5+: Discontinue scheduled NSAIDs; transition to as-needed dosing for breakthrough pain only 2
• Month 2+: Focus on physiotherapy and exercises; NSAIDs only for acute flares 5, 4

The evidence strongly supports short-duration NSAID use (2-4 weeks) rather than prolonged courses, with topical formulations preferred whenever feasible 1, 3.