What is the recommended exercise program for adhesive capsulitis (frozen shoulder), including specific stretches, frequency, progression to active motion, and adjunctive treatments?

Exercise Program for Frozen Shoulder (Adhesive Capsulitis)

Immediate First-Line Exercise Protocol

Begin stretching and mobilization exercises immediately upon diagnosis, with absolute priority given to external rotation and abduction movements—external rotation is the single most critical factor in preventing and treating shoulder pain. 1

Specific Exercise Prescription

Core stretching exercises:

• External rotation stretches should be performed as the primary movement, as this is the most severely restricted motion and correlates directly with pain onset 1, 2
• Abduction exercises as the secondary priority 1
• Perform stretches when pain and stiffness are minimal (typically before bedtime) 3
• Hold each terminal stretch position for 10-30 seconds before slowly returning to resting position 3
• Breathe continuously during each stretch 3

Frequency and duration:

• Perform stretching exercises daily for flexibility training 3
• Each session should include 5-10 minutes of warm-up with low-intensity range-of-motion exercises 3
• Progress to 30-60 minutes of exercise per session as tolerated 3
• Continue with 5 minutes of cool-down stretching 3

Progression to Active Motion

Gradual advancement protocol:

• Begin with passive stretching focusing on external rotation and abduction 1
• Progress to active-assisted range of motion exercises once pain decreases 1
• Advance to active range of motion while simultaneously restoring proper shoulder girdle alignment 1
• Incorporate strengthening of weakened shoulder girdle muscles as motion improves 1
• Land-based exercises are preferred over aquatic therapy due to better accessibility, though aquatic therapy may supplement the program 3

Critical Exercise Contraindications

Absolutely avoid overhead pulley exercises—this single intervention carries the highest risk of worsening shoulder pain and complications. 1, 2, 4

Additional contraindications:

• Avoid shoulder immobilization, arm slings, or wraps as these directly promote frozen shoulder development 1, 4
• Do not perform explosive movements or high-impact activities 3
• Modify exercises to avoid pain when the joint is inflamed 3

Adjunctive Treatment Modalities

Pain control measures to enable exercise participation:

• NSAIDs (ibuprofen, naproxen) or acetaminophen as first-line analgesics to facilitate physical therapy 1
• Ice, heat, and soft-tissue massage as adjunctive pain relief 1
• Functional electrical stimulation for short-term pain management 1

Second-line interventions when exercise and oral analgesics are insufficient:

• Intra-articular triamcinolone injections provide significant pain relief, particularly effective in stage 1 (freezing phase) frozen shoulder 1
• Subacromial corticosteroid injections when pain relates to subacromial inflammation 1
• Suprascapular nerve block for refractory pain in stage 2 adhesive capsulitis 1

Supervised vs. Self-Directed Exercise

Active, supervised exercise interventions are conditionally preferred over passive interventions (massage, ultrasound, heat) because the goal is patient education in self-management 3

• Passive interventions may supplement but should not substitute for active physical therapy 3
• Formal physical therapy must be instituted by 6-8 weeks if full shoulder function is not achieved—delays beyond this timeframe may result in permanent shoulder dysfunction 1, 4

Common Pitfalls to Avoid

Critical timing error: Delaying treatment initiation leads to further motion loss and potentially permanent dysfunction 1, 4

Technique errors:

• Using aggressive overhead pulleys (highest risk intervention) 1, 2
• Immobilizing the shoulder in any way 1, 4
• Performing exercises that cause sharp pain rather than mild stretching discomfort 3
• Exercising joints during acute flare-ups 3

Evidence Quality Considerations

The recommendation for external rotation priority comes from the American College of Physicians and American Heart Association guidelines 1, representing the highest quality evidence available. The prohibition against overhead pulleys is consistently emphasized across multiple guideline sources including the American Academy of Orthopaedic Surgeons 1, 2. While newer mobilization techniques like angular joint mobilization show promise in case reports 5, the guideline-based approach focusing on external rotation and abduction remains the evidence-based standard.