What initial management strategies should I consider for a patient diagnosed with adhesive capsulitis?

Initial management strategies for adhesive capsulitis (frozen shoulder) should focus on pain relief, maintaining shoulder mobility, and patient education.

Start with analgesia to control pain, particularly in the early painful phase. Paracetamol is recommended first line with regular dosing preferred over as-needed use. If paracetamol is insufficient, consider oral NSAIDs such as ibuprofen, taking into account contraindications and risk factors. Codeine may be considered if NSAIDs are unsuitable, but stronger opioids are not recommended due to dependence risks. Adequate analgesia is important to enable participation in physiotherapy and exercises ¹.

Physiotherapy should be initiated as early as possible. It typically involves supervised exercise programs focusing on gentle stretching, mobilization, and maintaining range of motion within the patient’s pain tolerance. Education and advice from physiotherapists are crucial, as patients value understanding their condition and management. A supervised program tends to improve range of movement faster than unsupervised home exercises. The course usually lasts around 6 weeks, extendable if improvement continues ¹.

Intra-articular corticosteroid injections can be considered early if there is inadequate progress with conservative measures. These injections, preferably with triamcinolone or methylprednisolone combined with local anesthetic, may reduce pain and inflammation, facilitating physiotherapy. They should be administered by trained practitioners with informed consent regarding rare risks such as infection, tendon rupture, and transient hyperglycaemia in diabetics. Post-injection rest for 24 hours is advised ¹.

Activity modification is important: patients should continue to use the arm to maintain movement and avoid positions or activities that exacerbate pain, such as overhead reaching. Supportive measures like hot packs and arm positioning during sleep (e.g., pillows to prevent rolling onto the affected shoulder) may help symptom control ¹.

A stepwise approach is recommended, starting with non-invasive treatments (analgesia, physiotherapy, education), progressing to corticosteroid injections if needed, and reserving referral to secondary care for refractory or severe cases ¹.

Recent literature supports these strategies, emphasizing early physiotherapy and pain control to improve outcomes and reduce disease severity (Cho et al., 2019; Pandey and Madi, 2021). The importance of shared decision-making and tailoring treatment to symptom severity and functional impact is also highlighted (Cho et al., 2019).