What is the recommended treatment for adhesive (frozen) shoulder?

Treatment of Frozen Shoulder (Adhesive Capsulitis)

Intra-articular corticosteroid injection is the most effective initial treatment for frozen shoulder, providing clinically significant pain relief and functional improvement in the short-term, and should be combined with a home exercise program for optimal mid-term outcomes. 1

Initial Treatment Approach

First-Line Therapy: Corticosteroid Injection + Exercise

• Administer intra-articular corticosteroid injection as the primary intervention for frozen shoulder of less than 1-year duration, as this demonstrates both statistical and clinical superiority over other treatments 1

  • Provides approximately 1.0 point reduction on VAS pain scale compared to placebo or no treatment (95% CI: -1.5 to -0.5; P < .001) 1
  • Delivers 1.1 point greater pain reduction compared to physiotherapy alone (95% CI: -1.7 to -0.5; P < .001) 1
  • Improves function with SMD of 0.6 versus placebo (95% CI: 0.3 to 0.9; P < .001) 1

• Combine corticosteroid injection with a home exercise program to maximize recovery, particularly for mid-term outcomes 1

  • This combination achieves 1.4 point VAS pain reduction compared to no treatment (95% CI: -1.8 to -1.1; P < .001) 1
  • Simple stretching exercises focusing on external rotation and abduction are most critical 2, 3

Specific Injection Considerations

• Target subacromial space when pain relates to rotator cuff or bursa inflammation 2
• Consider glenohumeral joint injection for capsular involvement 2
• Typical regimen: corticosteroid with local anesthetic mixture 4

Therapeutic Exercise Protocol

Range of Motion Restoration

• Prioritize gentle stretching and mobilization techniques focusing on external rotation and abduction, as these are the most restricted movements 2, 5

  • External rotation is the most significantly affected motion and relates most strongly to pain onset 5
  • Progress active range of motion gradually while restoring alignment and strengthening shoulder girdle muscles 2

• Avoid aggressive passive range of motion and overhead pulley exercises, as improper technique can cause harm rather than benefit 2, 5

  • Overhead pulley exercises specifically worsen shoulder complications, particularly in post-stroke patients 5

Exercise Recommendations (Grade A Evidence)

• Therapeutic exercises combined with mobilization are strongly recommended for reducing pain, improving ROM, and restoring function in stages 2 and 3 of frozen shoulder 3
• Moist heat application with anti-inflammatory medication as adjunct therapy 6
• Physician-directed rehabilitation program with closely monitored home therapy 6

Adjunctive Treatment Options

Moderate-to-Strong Evidence

• Low-level laser therapy: Strongly recommended for pain relief, moderately recommended for function, but not for ROM improvement 3
• Acupuncture with therapeutic exercises: Moderately recommended for pain relief, ROM improvement, and functional gains 3
• Deep heat modalities: Can be used for pain relief and ROM improvement 3

Limited or Short-Term Benefit Only

• Electrotherapy provides only short-term pain relief 3
• Continuous passive motion offers short-term pain relief but does not improve ROM or function 3
• Ultrasound is not recommended for pain relief, ROM, or functional improvement 3

Pain Management Algorithm

Pharmacological Options

• Acetaminophen or ibuprofen for routine pain control (if no contraindications) 2
• Oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) specifically for Complex Regional Pain Syndrome (shoulder-hand syndrome) with edema and trophic changes 2

Interventional Options for Specific Scenarios

• Botulinum toxin injection into subscapularis and pectoralis muscles when pain is thought to be spasticity-related 2
• Manipulation under local anesthesia (approximately 20cc mixture of prilocaine + methylprednisolone at 6 injection points) is a time-saving, cost-effective option that eliminates need for general anesthesia 4

Critical Pitfalls to Avoid

• Do not confuse frozen shoulder with rotator cuff pathology: Frozen shoulder shows equal restriction in both active and passive motion in all planes, while rotator cuff tears demonstrate focal weakness on resistance testing with potentially preserved passive motion 5
• Do not use aggressive or uncontrolled passive range of motion: This can worsen shoulder complications rather than improve them 2
• Do not delay corticosteroid injection: Early use (within first year) is associated with superior outcomes 1
• Do not rely on ultrasound therapy: Evidence does not support its use for any outcome measure 3

Treatment Timeline Expectations

• Short-term (≤12 weeks): Intra-articular corticosteroid provides maximal benefit 1
• Mid-term (>12 weeks to ≤12 months): Combination of corticosteroid with home exercise program and physiotherapy demonstrates added benefits 1
• Long-term: Closely monitored home therapy with moist heat, anti-inflammatory medication, and physician-directed rehabilitation allows significant motion recovery and return to activities of daily living 6