What is the recommended physiotherapy protocol for adhesive capsulitis (frozen shoulder), including timing, modalities, exercises, frequency, and adjunctive treatments?

Physiotherapy Protocol for Frozen Shoulder (Adhesive Capsulitis)

Immediate First-Line Treatment

Begin stretching and mobilization exercises immediately upon diagnosis, with external rotation as the single most critical movement to prioritize, followed by abduction exercises. 1

Core Exercise Protocol

• External rotation exercises are the highest priority because external rotation limitation correlates most strongly with shoulder pain onset and is the most severely restricted movement in frozen shoulder. 1, 2
• Progress exercises in this sequence: external rotation → abduction → internal rotation (internal rotation is least affected). 2
• Perform gentle stretching and mobilization techniques focusing on these two primary movements, avoiding aggressive passive range-of-motion techniques. 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened muscles. 1, 2

Exercise Frequency and Progression

• Initiate supervised physical therapy within 6-8 weeks of symptom onset or post-surgery to prevent permanent shoulder dysfunction. 1
• Continue exercises as a home program between supervised sessions. 2
• The condition typically progresses through three stages (freezing, frozen, thawing), and exercises should be maintained throughout all stages. 3

Critical Interventions to AVOID

Never use overhead pulleys—this single intervention carries the highest risk of worsening shoulder pain and complications. 4, 5, 1, 2

• 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

Adjunctive Modalities

Pain Control Modalities

• Use ice, heat, and soft tissue massage as adjunctive pain relief measures. 4
• Low-level laser therapy is strongly recommended for pain relief but not for improving range of motion. 6
• Deep heat can be used for pain relief and improving range of motion. 6
• Electrotherapy provides short-term pain relief only. 6

Pharmacologic Support

• Prescribe NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy. 1, 2
• For stage 1 (freezing phase) frozen shoulder with inadequate response to exercises and oral analgesics, add intra-articular triamcinolone injections for significant pain relief. 4, 1
• Subacromial corticosteroid injections target rotator cuff or bursal inflammation when present. 1, 2
• Short-course oral corticosteroids (30-50 mg daily for 3-5 days with 1-2 week taper) are indicated only if shoulder-hand syndrome with edema and trophic skin changes develops. 2

Alternative Modalities

• Acupuncture combined with therapeutic exercises produces statistically significant reduction in pain and functional limitation. 2, 6
• Functional electrical stimulation can be considered for pain management. 4
• Botulinum toxin injections into subscapularis and pectoralis muscles are reserved for cases where pain relates to spasticity. 1, 2

Treatment Algorithm by Response

If Adequate Progress at 6-12 Weeks

• Continue exercise-based physiotherapy with gradual progression. 1
• Combine physiotherapy with corticosteroid injections for greater improvement than physiotherapy alone. 7

If Minimal Improvement at 6-12 Weeks

• Consider manipulation under anesthesia or arthroscopic capsular release, though manipulation carries risk of joint damage. 7, 8
• Arthroscopic capsule release is supported by expert opinion but lacks high-quality research. 8

Special Population Considerations

Post-Stroke Patients

• Up to 72% of stroke patients experience shoulder pain in the first year, with 67% developing shoulder-hand-pain syndrome if they have combined motor, sensory, and visuoperceptual deficits. 4, 2
• Staff education to prevent trauma to the hemiplegic shoulder is essential. 4
• Shoulder strapping may be beneficial in this population. 4
• Electrical stimulation improves shoulder lateral rotation in post-stroke patients. 4

Breast Cancer Patients

• Women on aromatase inhibitor therapy have approximately 50% prevalence of frozen shoulder development. 2
• Avoid aggressive overhead pulley exercises in this population. 5

Diabetic Patients

• Intra-articular corticosteroids have equivalent efficacy to NSAIDs at 24 weeks in diabetic patients. 1
• Diabetes mellitus is a key systemic risk factor for developing adhesive capsulitis. 5

Common Pitfalls

• 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 show preserved passive motion with focal weakness. 5, 2
• Peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength, potentially causing spontaneous rupture. 1
• Continuous passive motion provides only short-term pain relief and does not improve range of motion or function. 6
• Ultrasound is not recommended for pain relief, improving range of motion, or function. 6