Guideline Recommendations for the Management of Frozen Shoulder (Adhesive Capsulitis)

Initial Conservative Management

Intra‑articular corticosteroid injection is the most effective first‑line intervention, delivering superior short‑term pain relief and functional improvement compared with physical therapy alone. 1
Short‑term oral NSAIDs (e.g., ibuprofen) or acetaminophen are recommended for acute‑phase pain control. 2
A brief course of oral corticosteroids (≈30–50 mg prednisone daily for 3–5 days, then taper) reduces swelling and pain, particularly when complex regional pain syndrome is present. 2
Topical NSAIDs provide comparable analgesia without the gastrointestinal bleeding risk of systemic NSAIDs. 3
Cryotherapy (ice applied with a wet towel for ~10 minutes) offers immediate pain relief and is widely accepted. 4

Stretching and mobilization should specifically target external rotation and abduction, as limited external rotation is strongly linked to shoulder pain. 1
Gentle, progressive range‑of‑motion exercises prevent progression to full‑thickness stiffness and shoulder‑hand pain syndrome. 1
Overhead pulley exercises should be avoided because they may exacerbate symptoms by encouraging uncontrolled abduction. 1
Active and active‑assisted exercises are preferred over complete immobilization to avert muscle atrophy and deconditioning. 1
Heat, soft‑tissue massage, and gentle mobilization can be used as adjunctive modalities. 1

Patients with diabetes should receive counseling about the transient hyperglycemia risk after corticosteroid injection, with glucose monitoring recommended during the first 1–3 days post‑injection. 5

Strict aseptic technique is mandatory when performing intra‑articular injections. 5
Ultrasound guidance may enhance injection accuracy, although it is not strictly required. 5
Offering a local anesthetic together with the steroid injection, and explaining its benefits and risks, is advised. 5
Joint overuse should be avoided for 24 hours after injection, but immobilization is discouraged. 5

Surgical options (e.g., manipulation under anesthesia or arthroscopic capsular release) are reserved for patients who show minimal improvement after 6–12 weeks of comprehensive conservative therapy. 4

Decisions regarding repeat corticosteroid injections should weigh the benefits achieved from prior injections, alternative treatment options, and individual patient factors. 5
Repeated corticosteroid injections without adequate response may impair healing and diminish tissue tensile strength. 3
Injecting corticosteroids directly into tendon tissue should be avoided because it increases the risk of tendon rupture. 3