Best Next Step After Intra-Articular Steroid for Frozen Shoulder
After intra-articular corticosteroid injection for adhesive capsulitis, initiate structured physical therapy immediately rather than prescribing oral ibuprofen alone, as this combination provides faster recovery of shoulder range of motion and function.
Evidence for Physical Therapy After Injection
The highest quality evidence demonstrates that combining corticosteroid injection with supervised physiotherapy produces superior outcomes compared to injection alone or other approaches:
A fluoroscopically-guided corticosteroid injection (triamcinolone hexacetonide 40 mg) combined with supervised physiotherapy resulted in significantly greater improvement in shoulder range of motion at 6 weeks and 3 months compared to injection alone, physiotherapy alone, or placebo 1
Patients receiving the combination treatment showed the greatest increase in total range of active and passive motion among all treatment groups 1
The injection provides rapid pain relief (effective within the first 8 weeks), while adding supervised physiotherapy accelerates functional recovery and range of motion gains 2, 1
Why Not Oral Ibuprofen Alone?
Oral NSAIDs (including ibuprofen) are significantly inferior to the combination approach:
Corticosteroid injection achieves faster pain relief and earlier improvement in shoulder function compared to oral NSAIDs during the critical first 8 weeks 2
When comparing local steroid injection versus physical therapy plus NSAIDs, both approaches showed similar long-term outcomes, but neither oral NSAIDs nor physiotherapy alone matched the efficacy of combining injection with structured exercise 3
Supervised physiotherapy alone (with NSAIDs) showed limited efficacy and was not significantly better than placebo except for modest improvement in shoulder flexion at 3 months 1
Optimal Treatment Protocol
Immediate post-injection management:
- Begin active range of motion exercises immediately after the injection 4
- Patients should perform exercises four times daily as part of a home program 4, 1
- Avoid joint overuse for 24 hours following injection, but immobilization is discouraged 5
Structured physiotherapy program:
- Initiate 12 sessions of supervised physiotherapy following the injection 1
- This supervised program should be combined with a simple home exercise program 1
- The combination provides significantly greater improvement in range of motion at 6 weeks compared to injection alone 1
Timeline of Expected Benefits
Short-term (0-8 weeks):
- Corticosteroid injection provides rapid pain relief, with maximal benefit during the first 8 weeks 2, 6
- The combination of injection plus physiotherapy shows significantly greater functional improvement during this period 1
Long-term (beyond 8 weeks):
- Pain relief from the injection alone does not sustain beyond 8-12 weeks 2, 6
- However, improvement in passive range of motion persists in both short and long term when injection is used 6
- By 12 months, all treatment groups converge to similar outcomes, but the combination approach achieves faster recovery 1
Important Clinical Considerations
Patient selection factors:
- Normal-weight patients (BMI <25 kg/m²) respond significantly better to this treatment approach, with Constant scores improving from 35.4 to 74.6 at 8 weeks 4
- Overweight patients (BMI ≥25 kg/m²) show less improvement (Constant score 32.0 to 47.2), and manipulation under anesthesia may need to be considered earlier in this population 4
Common pitfall to avoid:
- Do not rely on injection alone without structured exercise, as this misses the opportunity for accelerated functional recovery that physiotherapy provides 1
- Do not prescribe oral NSAIDs as the primary next step, as they are inferior to the injection you have already administered and do not address the need for active range of motion restoration 2, 3