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 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
• 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

Adjunctive Therapies

• Acupuncture combined with therapeutic exercises demonstrates statistically significant improvement in shoulder symptoms and is moderately recommended for pain relief, improving range of motion, and function 1, 3
• Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function, though not recommended for improving range of motion 3, 4

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, 5, 3
• These injections 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, 5
• At 24 weeks, intra-articular corticosteroids have equivalent efficacy to NSAIDs in diabetic patients 2

Advanced Interventions

• Botulinum toxin injections into subscapularis and pectoralis muscles can be considered when pain relates to spasticity 2, 5
• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 1, 6
• Arthrographic distension alone or as an addition to active physiotherapy shows moderate evidence for effectiveness in the short term 4
• Suprascapular nerve block (SSNB) shows moderate evidence for effectiveness compared with acupuncture, placebo, or steroid injections 4

Critical Pitfalls to Avoid

Interventions That Worsen Outcomes

• Avoid overhead pulleys entirely—they encourage uncontrolled abduction and carry the highest risk of worsening shoulder pain and developing hemiplegic shoulder pain 1, 2, 5
• Never use shoulder immobilization, arm slings, or wraps as these promote frozen shoulder development 1, 2

Timing Considerations

• Delaying treatment initiation leads to further motion loss and should be avoided 2, 5
• If full shoulder function is not achieved by 6-8 weeks, formal physical therapy must be instituted to prevent permanent shoulder dysfunction 1, 2

Treatment Nuances by Stage

The evidence strongly supports stage-specific treatment approaches. Stage 1 (freezing phase) responds particularly well to corticosteroid injections combined with physical therapy 2, 3, while stages 2 and 3 (frozen and thawing phases) benefit most from therapeutic exercises and mobilization 3. This distinction is important because peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength in chronic cases, potentially predisposing to spontaneous rupture 2.

Special Considerations

• For Complex Regional Pain Syndrome (CRPS) or Shoulder-Hand Syndrome, an early course of oral corticosteroids (30-50 mg daily for 3-5 days, tapering over 1-2 weeks) is recommended 5
• Ultrasound may be considered as a diagnostic tool to evaluate shoulder soft tissue injury 1, 5
• Patient education on proper positioning and home exercises is essential throughout treatment 1, 2