What is the first‑line management of frozen shoulder (adhesive capsulitis) in a middle‑aged adult (40‑65 years) who may have diabetes or thyroid disease?

Management of Frozen Shoulder (Adhesive Capsulitis)

Begin immediately with stretching and mobilization exercises emphasizing external rotation and abduction, combined with oral NSAIDs or acetaminophen for pain control. 1

First-Line Treatment Protocol

Exercise Therapy (Start Immediately)

• External rotation exercises are the single most critical intervention and should be prioritized above all other movements, as external rotation limitation correlates most strongly with shoulder pain onset and functional disability. 1, 2
• Progress to abduction exercises as the second priority, since frozen shoulder follows a capsular pattern where external rotation > abduction > internal rotation in terms of restriction severity. 2
• Gradually increase active range of motion while simultaneously restoring proper shoulder girdle alignment and strengthening weakened periscapular muscles. 1
• Avoid overhead pulley exercises entirely—this single intervention carries the highest risk of worsening shoulder pain and complications. 3, 1, 4

Pharmacologic Pain Control

• Initiate oral NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to enable participation in physical therapy. 1
• These medications provide adequate pain control for most patients in the early freezing phase when combined with appropriate exercises. 1

Critical Timing Consideration

• Formal physical therapy must be initiated within 6-8 weeks of symptom onset—delaying beyond this window may result in permanent shoulder dysfunction. 4
• Avoid shoulder immobilization, arm slings, or wraps, as these promote frozen shoulder progression. 1

Second-Line Interventions (For Inadequate Response at 6-12 Weeks)

Intra-Articular Corticosteroid Injection

• Intra-articular triamcinolone injection provides significant pain relief, particularly effective in stage 1 (freezing phase) frozen shoulder when oral analgesics and exercises prove insufficient. 1, 5
• Target the glenohumeral joint when capsular involvement is predominant. 2
• Target the subacromial space when pain relates to rotator cuff or bursal inflammation. 2
• Combining corticosteroid injection with physical therapy provides greater improvement than physiotherapy alone. 6, 7

Alternative Injectable Options

• Suprascapular nerve block can be employed for refractory pain despite standard conservative measures. 1, 5
• Botulinum toxin injection into subscapularis and pectoralis muscles should be considered when pain relates to spasticity (particularly relevant in post-stroke patients). 1, 2

Adjunctive Modalities

• Ice, heat, and soft tissue massage provide supplementary pain relief. 3, 1
• Functional electrical stimulation may be used for short-term pain management and improves lateral rotation in post-stroke patients. 3, 1, 2

Special Population Considerations

Diabetic and Thyroid Disease Patients

• These patients have significantly increased prevalence of adhesive capsulitis and should be monitored closely for early symptoms. 6, 8
• Diabetes and hypothyroidism are the two most common systemic risk factors for developing frozen shoulder. 4, 6
• Treatment algorithms remain identical, though response may be slower and more resistant to conservative management. 8

Post-Stroke Patients

• Up to 72% of stroke patients experience shoulder pain within the first year, with 67% developing shoulder-hand-pain syndrome when motor, sensory, and visuoperceptual deficits coexist. 1, 2
• Staff education to prevent trauma to the hemiplegic shoulder is essential. 3, 2
• Shoulder strapping may be beneficial in this population. 3, 2
• Electrical stimulation specifically improves lateral rotation and should be prioritized. 3, 2

Surgical Intervention (Reserved for Refractory Cases)

• Consider manipulation under anesthesia or arthroscopic capsular release only after 6-12 months of failed conservative treatment. 6, 7, 8
• Both surgical options show similar clinical outcomes, though manipulation carries risk of humeral fracture or rotator cuff tear. 8

Critical Diagnostic Differentiation

Distinguishing from Rotator Cuff Pathology

• Frozen shoulder demonstrates equal restriction of both active AND passive range of motion in all planes, whereas rotator cuff syndrome shows preserved passive motion with weakness primarily during active movement. 2, 4
• Frozen shoulder shows no focal weakness on resistance testing, unlike rotator cuff tears. 2
• External rotation is most severely affected in frozen shoulder, followed by abduction, then internal rotation (capsular pattern). 2, 4

When to Order Imaging

• MRI without contrast is the preferred imaging modality when diagnosis is uncertain or to exclude rotator cuff pathology, showing coracohumeral ligament thickening with high specificity. 4, 6
• Imaging is not necessary when clinical presentation is classic (global passive restriction, no focal weakness, gradual onset). 6, 7

Common Pitfalls to Avoid

• Never prescribe overhead pulley exercises—this is the most harmful intervention and consistently worsens outcomes. 3, 1, 4
• Do not delay physical therapy beyond 6-8 weeks, as this leads to permanent dysfunction. 4
• Avoid shoulder immobilization devices, which accelerate capsular contracture. 1
• Do not confuse with rotator cuff tears—check for preserved passive motion and absence of focal weakness. 2, 4
• In postmenopausal women, never initiate estrogen therapy for frozen shoulder, as cardiovascular risks outweigh any potential musculoskeletal benefit. 2