What is the recommended management for a 50‑year‑old woman with diabetes who presents with adhesive capsulitis (frozen shoulder)?

Management of Adhesive Capsulitis in a 50-Year-Old Woman with Diabetes

Initiate immediate physical therapy focusing on external rotation and abduction exercises combined with oral NSAIDs or acetaminophen, and if inadequate response occurs within 6-8 weeks, add intra-articular corticosteroid injection. 1

First-Line Treatment (Start Immediately)

Physical Therapy Protocol

• External rotation exercises are the single most critical intervention and must be prioritized above all other movements, as this is the most important factor in preventing and treating shoulder pain 1
• Abduction movements should be performed alongside external rotation as the second priority 1
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles 1
• Stretching and mobilization exercises should be initiated immediately to improve shoulder function 1

Pain Control

• Start oral NSAIDs (ibuprofen or naproxen) or acetaminophen as first-line analgesics to provide adequate pain control and enable participation in physical therapy 1
• These medications should be used in conjunction with physical therapy, not as standalone treatment 1

Critical Actions to Avoid

Never use overhead pulleys, as this single intervention carries the highest risk of worsening shoulder pain 1

Additional contraindications include:

• Avoid shoulder immobilization, arm slings, or wraps, as these directly promote frozen shoulder development 1
• Do not delay treatment initiation, as this leads to further motion loss 1

Second-Line Intervention (If Inadequate Response)

Timing for Escalation

• If formal physical therapy does not achieve full shoulder function by 6-8 weeks, escalate treatment to avoid permanent shoulder dysfunction 1

Corticosteroid Injection

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

Important Caveat for Corticosteroid Use

• Peritendinous or intratendinous injections may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 1
• Ensure injection is intra-articular, not peritendinous 1

Comparison with Glucocorticoid Injection as Primary Treatment

Recent evidence suggests glucocorticoid injection may be more effective than manual therapy and exercise in the short term (up to 7 weeks), though this advantage diminishes by 6 months 2:

• At 7 weeks, glucocorticoid injection resulted in 58-point improvement in pain (0-100 scale) versus 32 points with manual therapy and exercise, representing a 26% absolute difference 2
• Function improved by 39 points with injection versus 14 points with manual therapy and exercise, representing a 25% absolute difference 2
• Treatment success was reported by 77% with injection versus 46% with manual therapy and exercise 2
• However, by 6 and 12 months, differences in pain and function were not clinically important 2
• Adverse event rates were similar: 53% with injection versus 56% with manual therapy and exercise 2

Despite glucocorticoid injection showing superior short-term results, the guideline-based approach prioritizes starting with physical therapy and NSAIDs, reserving injection for inadequate response, as this allows identification of responders to conservative treatment while maintaining injection as an effective rescue option 1

Special Considerations for Diabetic Patients

• This patient's diabetes places her at increased risk for adhesive capsulitis 3, 4
• Diabetic patients may have persistent functional limitations if left untreated, challenging the older theory that frozen shoulder fully resolves without treatment 3
• The 6-8 week window for initiating formal physical therapy is particularly critical in diabetic patients to prevent permanent dysfunction 1

Surgical Options (For Refractory Cases)

If minimal improvement occurs after 6-12 weeks of nonsurgical treatment, consider 3:

• Manipulation under anesthesia
• Arthroscopic capsule release

However, these should only be considered after exhausting conservative measures including combined physical therapy and corticosteroid injection 3