How should adhesive capsulitis (frozen shoulder) be managed in a 55‑year‑old woman with diabetes mellitus?

Management of Adhesive Capsulitis in a 55-Year-Old Woman with Diabetes

Immediately initiate stretching and mobilization exercises focusing on external rotation and abduction, combined with NSAIDs or acetaminophen for pain control, and if inadequate response occurs within 6-8 weeks, add intra-articular triamcinolone injections. 1

First-Line Treatment Algorithm

Immediate Physical Therapy Interventions

• Begin stretching and mobilization exercises immediately, with external rotation as the single most critical movement to prioritize 1
• External rotation is the most significantly affected motion and relates most strongly to the onset and prevention of shoulder pain 2
• Focus exercises on both external rotation and abduction movements to prevent progression to frozen shoulder 3, 1
• Gradually increase active range of motion while restoring proper shoulder girdle alignment and strengthening weakened muscles 1

Pain Control to Enable Therapy Participation

• Start NSAIDs (ibuprofen or naproxen) or acetaminophen as first-line analgesics to provide adequate pain control 1
• Pain control is essential to enable participation in physical therapy exercises 1
• Topical NSAIDs can be considered to eliminate gastrointestinal hemorrhage risk while maintaining efficacy 1

Critical Actions to Avoid

• Never use overhead pulleys, as this single intervention carries the highest risk of worsening shoulder pain 3, 1
• Avoid shoulder immobilization, arm slings, or wraps, as these promote frozen shoulder development 1
• Do not delay treatment initiation, as this leads to further motion loss 1

Diabetes-Specific Considerations

Your patient's diabetes significantly increases her risk for adhesive capsulitis and may affect treatment response 4, 5. In diabetic patients:

• Intra-articular corticosteroids have equivalent efficacy to NSAIDs at 24 weeks 1
• The condition may be more resistant to conservative treatment 4
• Earlier consideration of corticosteroid injections may be warranted given the increased prevalence and severity in diabetic patients 4, 5

Second-Line Interventions (If Inadequate Response at 6-8 Weeks)

Corticosteroid Injection Therapy

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder 3, 1
• These injections demonstrate superior pain control compared to oral NSAIDs in the acute phase 1
• Subacromial corticosteroid injections can be used when pain relates to subacromial inflammation 1
• Short-term oral corticosteroids may be considered as an alternative 4

Combined Therapy Approach

• Physiotherapy combined with corticosteroid injections may provide greater improvement than physiotherapy alone 4
• Continue emphasizing external rotation and abduction exercises throughout treatment 1

Timeline and Monitoring

Critical Timing Considerations

• If formal physical therapy is not initiated by 6-8 weeks post-onset, permanent shoulder dysfunction may result 1
• Most patients improve with nonsurgical treatment over 6-12 months 6
• Recent evidence challenges the traditional belief of full spontaneous resolution, showing persistent functional limitations if left untreated 4

When to Consider Surgical Referral

• Failure to obtain symptomatic improvement after 6-12 months of conservative treatment 4, 6
• Continued functional disability despite adherence to physical therapy 6
• Surgical options include manipulation under anesthesia and arthroscopic capsule release 4, 6

Common Pitfalls and Caveats

Injection-Related Concerns

• Peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 1
• Ensure intra-articular placement rather than peritendinous injection 1
• The benefit-risk ratio of corticosteroids for chronic cases is debatable, as the role of inflammation in chronic tendinopathies is unclear 1

Quality of Life Impact

• Adhesive capsulitis can contribute to depression, sleeplessness, and reduced quality of life 7
• Address these psychosocial factors as part of comprehensive management 7
• Pain can delay functional recovery and limit use of assistive devices 2, 7

Alternative Therapies with Limited Evidence

Additional treatment options mentioned in the literature include acupuncture and hydrodilatation 4, though these are not prioritized in guideline recommendations. The evidence for these interventions is less robust than for the first-line and second-line treatments outlined above.