Randomized Clinical Trial
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Sep 18, 2018; 9(9): 165-172
Published online Sep 18, 2018. doi: 10.5312/wjo.v9.i9.165
Corticosteroid injection alone vs additional physiotherapy treatment in early stage frozen shoulders
Tim Kraal, Inger Sierevelt, Derek van Deurzen, Michel PJ van den Bekerom, Lijkele Beimers
Tim Kraal, Inger Sierevelt, Lijkele Beimers, Department of Orthopedic Surgery, Slotervaart Center of Orthopedic Research and Education, Amsterdam 1066 EC, The Netherlands
Derek van Deurzen, Michel PJ van den Bekerom, Department of Orthopedic Surgery, Shoulder and Elbow Unit, OLVG Hospital, Amsterdam 1091 AC, The Netherlands
Author contributions: Kraal T is the initiator of this study and wrote the study protocol and a large part of this manuscript; Sierevelt I is involved as a clinical epidemiologist and research coordinator; Sierevelt I is responsible for the statistical analysis and correct presentation of the results; van Deurzen D and van den Bekerom MPJ both included patients at their center, and were both responsible for follow up at this location; Beimers L is responsible for inclusions at the other center and responsible as supervisor for the protocol and progress of the study; all authors were involved in the writing and revising of this manuscript.
Institutional review board statement: Approval for a prospective randomized clinical trial (D-FROST; Dutch frozen shoulder study) was obtained by the MC Slotervaart Hospital Medical Ethics Committee (NL47325.048.13).
Clinical trial registration statement: The trial was registered in the Dutch Trial Register (NTR4587).
Conflict-of-interest statement: All authors declare that they have no conflict of interest to declare.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Lijkele Beimers, MD, PhD, Staff Physician, Orthopedic Surgeon, Department of Orthopedic Surgery, Slotervaart Center of Orthopedic Research and Education, MC Slotervaart, Louwesweg 6, Amsterdam 1066 EC, The Netherlands. lijkele.beimers@slz.nl
Telephone: +31-20-5125116
Received: April 7, 2018
Peer-review started: April 7, 2018
First decision: June 14, 2018
Revised: July 1, 2018
Accepted: August 2, 2018
Article in press: August 3, 2018
Published online: September 18, 2018

To investigate the additional value of physiotherapy after a corticosteroid injection in stage one or two idiopathic frozen shoulders (FSs).


A two center, randomized controlled trial was done. Patients with a painful early stage idiopathic FS were eligible for inclusion. After written consent, patients were randomly allocated into two groups. All patients received an ultrasound-guided intra-articular corticosteroid injection. One group underwent additional physiotherapy treatment (PT) and the other group did not (non-PT). The primary outcome measure was the Shoulder Pain and Disability Index (SPADI). Secondary outcomes were pain (numeric pain rating scale), range of motion (ROM), quality of life (RAND-36 score), and patient satisfaction. Follow-up was scheduled after 6, 12 and 26 wk.


Twenty-one patients were included, 11 patients in the non-PT and ten in the PT group, with a mean age of 52 years. Both treatment groups showed a significant improvement at 26 wk for SPADI score (non-PT: P = 0.05, PT: P = 0.03). At the 6 wk follow-up, median SPADI score was significant decreased in the PT group (14 IQR: 6-38) vs the non-PT group (63 IQR: 45-76) (P = 0.01). Pain decreased significantly in both groups but no differences were observed between both treatment groups at any time point, except for night pain at 6 wk in favor of the PT group (P = 0.02). Significant differences in all three ROM directions were observed after 6 wk in favor of the PT group (P ≤ 0.02 for all directions). A significantly greater improvement in abduction (P = 0.03) and external rotation (P = 0.04) was also present in favor of the PT group after 12 wk. RAND-36 scores showed no significant differences in health-related quality of life at all follow-up moments. At 26 wk, both groups did not differ significantly with respect to any of the outcome parameters. No complications were reported in both groups.


Additional physiotherapy after corticosteroid injection improves ROM and functional limitations in early-stage FSs up to the first three months.

Keywords: Corticosteroid, Frozen shoulder, Adhesive capsulitis, Physiotherapy

Core tip: Corticosteroids and physiotherapy are the most widely used treatment modalities in frozen shoulders (FSs). However, the role of physiotherapy, especially in early FSs, is controversial. Corticosteroid injection with additional physiotherapy leads to better Shoulder Pain and Disability Index scores and range of motion up to three months compared to corticosteroid injection alone. Although a trend was recognized in favor of the physiotherapy group, both groups did not differ significantly with respect to any of the outcome parameters at the final follow-up after 26 wk.