Treatment

Management of frozen shoulder may be non surgical or surgical.

Non surgical

• oral analgesics
  • non-steroidal anti-inflammatory drugs (NSAIDs) are used to relieve pain and improve range of motion
• physiotherapy
  • used as the first line treatment for frozen shoulder
  • especially useful in the stiffness phase
  • typically includes combinations of advice and education, manual therapy and exercises, thermotherapy, and electrotherapy
  • graded physiotherapy programmes (movements within the comfort zone) have been shown to have a better long term outcome than high intensity (movements at the limits of pain tolerance) programmes
• oral corticosteroid
  • is not considered routinely for the management due to
    • short period of positive effects (do not last beyond 6 weeks)
    • their potential for serious adverse effects
• intra articular steroids
  • can induce short-term pain relief and improvement in range of motion
  • effect usually only lasts for a maximum of 6 weeks
  • a single corticosteroid injection for up to a year in duration may accelerate improvements in pain and function by some weeks
  • more effective when given earlier in the course of the disease
  • a single steroid injection in combination with physiotherapy is effective in reducing both pain and disability associated with frozen shoulder (2)
• hydrodilatation
  • injection of up to 40 ml of sterile saline solution usually together with corticosteorids to distend the joint capsule

Surgical

• considered in patients with refractory symptoms after adequate conservative treatment
• surgical options include
  • manipulation under anaesthesia (MUA) - generally results in notable improvement in shoulder function and range of motion within three months
  • capsular release - this has proved useful in refractory cases

In general, treatment of frozen shoulder should be tailored according to the stage of the condition

• painful freezing phase
  • main aim is pain relief – NSAIDs
  • physiotherapy
  • steroid injection
• adhesive phase
  • steroid injections are not indicated
  • aggressive stretching exercises should be the focus to regain the range of motion
• the UK FROST trial compared manipulation under anaesthetic, arthroscopic capsular release, and early structured physiotherapy with intra-articular corticosteroid injections, and found that none of the interventions were clinically superior (4)

Reference:

• (1) Dias R et al. Frozen shoulder. BMJ 2005; 331:1453-1456.
• (2) van de Laar SM, van der Zwaal P. Management of frozen shoulder Orthopedic Research and Reviews 2014;6:81-90
• (3) Rangan A, Hanchard N, McDaid C. What is the most effective treatment for frozen shoulder? BMJ. 2016;354:i4162
• (4) Karbowiak M, Holme T, Mirza M, Siddiqui N. Frozen shoulder BMJ 2022; 377 :e068547 doi:10.1136/bmj-2021-068547.