What is the recommended pharmacologic and non‑pharmacologic treatment for adhesive capsulitis (frozen shoulder)?

Treatment of Adhesive Capsulitis (Frozen Shoulder)

Begin immediately with stretching and mobilization exercises focusing on external rotation and abduction, combined with oral NSAIDs or acetaminophen for pain control; if inadequate response after several weeks, add intra-articular corticosteroid injection. 1

First-Line Treatment Algorithm

Non-Pharmacological Management (Start Immediately)

• Initiate stretching and mobilization exercises immediately, with external rotation being the single most critical movement to prioritize. External rotation limitation correlates most strongly with shoulder pain onset and is essential for both prevention and treatment. 1, 2

• Supervised physical therapy is superior to home exercises alone. While home exercises improve function in the short term, supervised programs—whether individual or group-based—result in better patient global assessment and should be preferred when available. 3

• Gradually increase active range of motion while simultaneously restoring proper shoulder alignment and strengthening weakened shoulder girdle muscles. Focus exercises on the rotator cuff and posterior shoulder girdle while addressing anterior shoulder girdle flexibility. 1, 4

• Avoid overhead pulley exercises entirely. This intervention carries the highest risk of worsening shoulder pain and can cause permanent dysfunction, particularly in neurologically compromised patients. 1, 2

Pharmacological Management (Concurrent with Exercise)

• Use oral NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics. These provide adequate pain control to enable participation in physical therapy. 1, 3

• Consider topical NSAIDs to eliminate gastrointestinal hemorrhage risk while maintaining pain relief efficacy. 1

• Ensure cardiovascular, gastrointestinal, and renal risks are assessed before prescribing NSAIDs. Elderly patients are at particularly high risk for adverse effects including GI bleeding, platelet dysfunction, and nephrotoxicity. 3

Second-Line Interventions (For Inadequate Response After 3-6 Weeks)

Corticosteroid Injections

• Intra-articular triamcinolone injections provide significant pain relief and are particularly effective in stage 1 (freezing phase) frozen shoulder. These demonstrate superior pain control compared to oral NSAIDs in the acute phase. 1, 5

• One high-quality trial demonstrated that glucocorticoid injection was superior to manual therapy and exercise at 7 weeks: Mean pain reduction was 58 points (0-100 scale) with injection versus 32 points with manual therapy/exercise (absolute difference 26%, 95% CI 15-37%). Function improved by 39 points with injection versus 14 points with manual therapy/exercise (absolute difference 25%, 95% CI 15-35%). 6

• The benefits of corticosteroid injection over manual therapy/exercise are not maintained beyond 6 months, with no clinically important differences detected at longer follow-up. 6

Oral Corticosteroids (Alternative Option)

• A 3-week course of oral prednisolone 30 mg daily provides significant short-term benefit but effects are not maintained beyond 6 weeks. At 3 weeks, prednisolone improved overall pain by 4.1 points versus 1.4 points with placebo (adjusted difference 2.4 points, 95% CI 1.1-3.8), with marked or moderate improvement in 22/23 patients versus 11/23 with placebo (RR=2,95% CI 1.3-3.1). However, by 12 weeks, outcomes tended to favor the placebo group. 7

Hydrodilatation (Arthrographic Distension)

• Arthrographic distension with saline and steroid provides short-term benefits in pain, range of movement, and function. One low-risk-of-bias trial demonstrated superiority over placebo at 3 weeks for pain (NNTB=2), function (NNTB=3), and range of movement, with some functional benefits maintained at 6 and 12 weeks. 8

• Following arthrographic joint distension with glucocorticoid and saline, adding manual therapy and supervised exercise for 6 weeks provides similar effects to sham ultrasound for pain, function, and quality of life, but may provide greater patient-reported treatment success and active shoulder abduction at 6 weeks. 6

• A modified sonographically-guided technique (S-FSR) has been described involving anterior injection of lidocaine mixed with triamcinolone (80 mg total) at the rotator interval, fenestration of the superior glenohumeral ligament, followed by posterior hydrodilatation with approximately 50 mL normal saline under ultrasound visualization. 9

Critical Pitfalls to Avoid

• Never immobilize the shoulder with slings or wraps. Immobilization promotes frozen shoulder development and worsens outcomes. 1

• Do not delay formal physical therapy beyond 6-8 weeks post-injury or post-surgery, as this may result in permanent shoulder dysfunction. 1, 4

• Avoid aggressive overhead pulley exercises, which carry the highest risk of worsening pain and causing harm. 1, 2

• Be cautious with peritendinous or intratendinous corticosteroid injections, as these may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture. 1

Special Population Considerations

• Monitor diabetic patients closely, as adhesive capsulitis has increased prevalence in diabetes mellitus and hypothyroidism. 5, 2

• In post-stroke patients, up to two-thirds with combined motor, sensory, and visuoperceptual deficits may develop shoulder-hand-pain syndrome contributing to adhesive capsulitis, requiring early monitoring and intervention. 2

• Breast cancer patients should be monitored for early signs, as early identification and treatment may prevent unnecessary pauses during exercise programming. 4

Surgical Options (For Refractory Cases After 6-12 Weeks)

• Consider manipulation under anesthesia or arthroscopic capsule release for patients with minimal improvement after 6-12 weeks of nonsurgical treatment. 5

Key Diagnostic Differentiation

• Adhesive capsulitis demonstrates equal restriction of both active and passive range of motion in all planes, particularly external rotation, while rotator cuff syndrome shows preserved passive motion with weakness primarily during active movement. 2

• MRI without contrast is the most appropriate imaging modality when radiographs are noncontributory, with coracohumeral ligament thickening yielding high specificity for adhesive capsulitis. 2, 5