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

Treatment of Frozen Shoulder (Adhesive Capsulitis)

Immediately initiate physical therapy with stretching and mobilization exercises focusing specifically on external rotation and abduction movements, combined with oral NSAIDs or acetaminophen for pain control. 1, 2

First-Line Treatment Protocol

Physical Therapy (Start Immediately)

• External rotation exercises are the single most critical factor in preventing and treating shoulder pain and must be prioritized 1
• Gradually increase active range of motion while simultaneously restoring proper alignment and strengthening weakened shoulder girdle muscles 1
• Focus on controlled stretching and mobilization techniques, particularly external rotation and abduction movements 2
• If full shoulder function is not achieved by 6-8 weeks, permanent shoulder dysfunction may result, making early formal physical therapy essential 1

Pain Management

• Use NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to provide adequate pain control and enable participation in physical therapy 1, 2
• These medications allow patients to tolerate the necessary physical therapy exercises 1

Critical Actions to AVOID

Never use overhead pulleys - this single intervention carries the highest risk of worsening shoulder pain and encouraging uncontrolled abduction 1, 2

Never immobilize the shoulder - avoid arm slings, wraps, or any form of shoulder immobilization as these directly promote frozen shoulder development 1, 2

Never delay treatment initiation - delaying leads to further motion loss and potential permanent dysfunction 1

Second-Line Interventions (If Inadequate Response After 3-6 Months)

Intra-articular Corticosteroid Injections

• Triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder 1
• These demonstrate superior pain control compared to oral NSAIDs in the acute phase 1
• At 24 weeks, intra-articular corticosteroids have equivalent efficacy to NSAIDs in diabetic patients 1

Alternative Injectable Options

• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 1
• Botulinum toxin injections into subscapularis and pectoralis muscles can be considered when pain relates to spasticity 1, 2

Advanced Procedures

• Hydrodilatation of the glenohumeral joint may be considered for refractory cases 2, 3

Surgical Intervention Criteria

Consider manipulation under anesthesia or arthroscopic capsular release only after 6-12 weeks of failed conservative treatment with continued functional disability 4, 5

Important Clinical Caveats

Corticosteroid Injection Warnings

• Peritendinous or intratendinous injections may inhibit healing and reduce tensile strength, potentially causing spontaneous rupture 1
• The benefit-risk ratio for chronic cases is debatable as the role of inflammation in chronic tendinopathies remains unclear 1

High-Risk Populations

• Patients with diabetes mellitus and hypothyroidism have increased prevalence of frozen shoulder 5, 6
• These patients require particularly vigilant early intervention 6

Adjunctive Therapies

• Acupuncture combined with therapeutic exercises demonstrates statistically significant improvement and can be considered as an adjunct 2, 7
• Local cold therapy provides pain relief based on expert consensus 2