Frozen shoulder is a widespread problem that causes shoulder pain and stiffness. Generally, it is more common in women between 40 and 60. This blog outlines the most commonly asked questions, including the best frozen shoulder treatments.
What is frozen shoulder?
Frozen shoulder, also known as adhesive capsulitis, is a condition affecting the ball-and-socket joint of the shoulder. Typically, it presents with a gradual onset of shoulder pain and stiffness, leading to functional loss. The primary area of the shoulder affected is the capsule, which surrounds the joint but is under the tendons and muscles that move the joint.
What causes Frozen Shoulder?
Overall, we still don’t know the answer. However, certain conditions increase the risk of frozen shoulder. For example, those with diabetes and hypothyroidism are more likely to develop frozen shoulder. Additionally, this condition is common between the ages of 40 and 60 and is more prevalent in women. The peak age is the mid-50s. In up to 17% of people with frozen shoulder, the contralateral shoulder is affected within 5 years. Finally, trauma to the shoulder – either after a fall or an injury while playing sports – can lead to this condition.
How do you know you have Frozen Shoulder?
Overall, the most common complaint is shoulder pain. In general, pain is not localised to a single site and affects both the front and back of the shoulder. Usually, night pain is a common finding as the disease progresses. However, it is often challenging to distinguish frozen shoulder from other causes of shoulder pain, such as arthritis or rotator cuff tendon disease. Often, it is not until stiffness occurs that the diagnosis is obvious.
You should see your doctor if you have a frozen shoulder. In a frozen shoulder, shoulder joint movements are restricted. Sometimes, it is difficult to know whether the restriction is due to capsule restriction or pain inhibition. Your doctor should be able to exclude other causes.
Can you get a frozen shoulder twice?
No, but you are more likely to get frozen shoulder on the other side. About 17% of people who develop frozen shoulder also get it in the other shoulder within 5 years.
Frozen shoulder imaging
Often, your doctor will perform a simple X-ray and ultrasound to confirm the diagnosis. An MRI scan may be required to exclude serious pathology, such as a tumour or significant arthritis.
Other conditions of the shoulder that should be ruled out include:
- Rotator cuff tendon injuries
- AC joint arthritis
- Shoulder joint arthritis
- Long head of biceps tendonitis
What are the Different Stages of Frozen Shoulder?
Generally, adhesive capsulitis has three distinct phases. Each stage can vary in duration and sometimes last for months or years. Stage 1, also known as the painful stage, is characterised by pain. Stage 2, also known as the stiff phase, is characterised by pain and increased stiffness. Finally, the pain and stiffness gradually improve in stage 3, the thawing phase. However, this last stage may take many months and, in some cases, may never fully resolve.
Best Frozen shoulder treatments
Overall, most cases of frozen shoulder will improve without surgery. However, some people find their condition challenging to improve with simple treatments. The earlier you start treatment for frozen shoulder, the better the outcome. Some of the most effective frozen shoulder treatments include:
Exercise therapy
Usually, we try simple treatments for frozen shoulder first. Physiotherapy, including stretching, manual techniques to mobilise the shoulder joint, and acupuncture, may be beneficial. Some simple tips at home include gentle stretching with a towel after a hot shower and sleeping on your other shoulder. The Shoulder towel stretch, also known as the hand-behind-the-back stretch, can help release a tightly contracted capsule. Once movement improves, active exercise can help thaw the capsule. Finally, strengthening with a rotator cuff band in all planes, including flexion, abduction, and external rotation, can improve shoulder function. Additionally, simple painkillers such as ibuprofen or paracetamol can reduce pain and facilitate exercise.
Shockwave therapy: Is it effective?
We think shockwave can be effective for some people with frozen shoulder. A recent randomised controlled trial found that shockwave therapy improved movement and pain compared with placebo shockwave therapy. Also, a recent review of all shockwave studies found improvements in pain after shockwave therapy.
Injections
Sometimes, pain levels may be so high that it’s difficult to perform exercises. In these cases, doctors suggest a cortisone injection for a frozen shoulder to get the pain under control.
In general, injections for a frozen shoulder are effective. However, there is debate over which type of injection is preferable.
One option is to inject a low-volume dose of corticosteroid and local anaesthetic into the joint. Evidence suggests this injection reduces pain and allows you to continue with exercise therapy. This simple cortisone injection for a frozen shoulder is also well-tolerated and minimally painful. Studies suggest that physiotherapy following a cortisone injection improves pain relief.
Shoulder hydrodistension
Another option is to inject higher volume cortisone and fluid into the shoulder. We refer to this procedure as a frozen shoulder hydrodilatation injection. Generally, the injection is performed using a higher volume of 30 mL of local anaesthetic and water added to the cortisone. The higher volume stretches the capsule, thereby improving thawing.
Overall, we are uncertain which injection option is preferable. However, recent studies suggest that hydrodistension injection for frozen shoulder may have an advantage. We recommend using ultrasound-guided injection to improve accuracy and effectiveness, regardless of the chosen injection method.
We think shoulder hydrodistension with a volume that stretches the capsule is better than very high volumes that rupture it. One study found that stretching the capsule is much better for pain and function than rupturing it.
Also, studies suggest that an injeciton performed in the early stages of frozen shoulder is more effective than one conducted in the later stages. For example, in this study on injections for frozen shoulder, subjects who received an injection at stage 1 recovered within 2-6 weeks, whereas those at stage 2 resolved within 7-12 weeks. Early assessment and injeciton ensure better efficacy.
Is a hydrodistension the same as a cortisone injection?
Yes. Both injections contain corticosteroids, but hydrodistension uses a larger volume to stretch the capsule while reducing inflammation.
How many injections are required for a frozen shoulder?
Most people will get better after one frozen shoulder injection. Occasionally, you may need more than one injection if your symptoms worsen. However, we limit the number of injections to two or three, depending on your symptoms and response.
Frozen shoulder surgery
In general, surgery involves cutting the capsule using keyhole instruments. Although this surgery seems straightforward and is a day case, it has risks. For example, a recent study comparing surgery with physiotherapy for frozen shoulder found comparable outcomes at 12 months. Still, the surgical group had a 4-5% risk of severe side effects. Therefore, we suggest you avoid surgery unless you’ve tried other, more straightforward options, including injections.
Can you get a Frozen Shoulder Twice?
In general, the answer is no, which is a relief. However, you may get a frozen shoulder on the other side. In up to 17% of people with frozen shoulder, the contralateral shoulder is affected within 5 years.
What Diseases increase the Risk of developing a Frozen Shoulder?
A range of diseases predispose to the development of frozen shoulder. Examples include diabetes, heart disease, Parkinson’s, stroke, thyroid disorders, inflammatory arthritis, and Dupuytren’s contracture of the fingers.
Some doctors advocate that all patients with frozen shoulder undergo blood tests, including oestrogen, progesterone, testosterone, thyroid function tests, lipid profile, and blood glucose/HbA1c.
Final Word from Sportdoctorlondon on the Best Frozen Shoulder Treatments
Overall, most cases of frozen shoulder will get better with simple treatments. However, it is essential to get a speedy diagnosis to improve outcomes. Moreover, you should avoid surgery unless you’ve tried simple treatments and at least two frozen shoulder injections. Remember, surgery is not without risks and is not always effective.
Is it possible to get frozen shoulder in your 20’s and can it heal without injections?
Can you get frozen shoulder in your 20’s and can it heal without injections?
Hi Charlie, Thank you for your question. Overall, it is rare for persons in theirs 20s to get a frozen shoulder. As a general rule, I always look for other causes of shoulder pain and stiffness such as a cartilage or tendon tear.
Which is best post injection, ice or heat? I say heat. The wife says ice!
ice always
I have frozen shoulder with a supraspinatous and subscapularis along with a Labrum tear. Both tendons only 50% tears. My Dr states surgery is not indicated due to my diabetes. States that injection and PT should work. Any other ideas or suggestions? Thank you so much.
Ken Jones RN
agree injections and rehab are the way forward for frozen shoulder. i’d suggest a hydrodistension followed by rehab. (see blog onnhydrodistension).
I had a frozen shoulder 10 years ago and now have it again in the same shoulder.
This time I am doing more therapy before the pain goes down my arm.
The first time I had a cortisone injection that helped and I was able to pop the shoulder.
I mention this because you said it is unlikely to get it again in the same shoulder.
Thanks for your comment. Yes, It’s unlikely but not impossible. LM
If you have passed the most painful stage but are still very restricted in movement but with manageable pain is there any point having the US guided injection at this stage ? Will it help to improve flexibility or no difference ? Thank you
Good question; thanks for asking. So, the answer is probably not if the pain is much better. Generally, once the pain settles, then the shoulder restriction eventually ‘thaw out’ – although there is always an exception to this rule.
I have been diagnosed with Frozen shoulder ( 12 months ago) and also some age related osteoarthritis. I am 58 but generally fit ( I have hypothyroidism since 30yrs and take thyroxine). I lift weights x3 per week and not overweight. I have been given basic mobility exercises for my frozen shoulder, which I do twice daily. Is there anything I shouldn’t do? I’m trying to reduce my weight load and I don’t lift anything above my head, however it is quite frustrating for the other arm, which could lift heavier if I let it.
I am able to dead lift, but some of my lifting causes pain in my frozen shoulder.
You are the only person I have heard not telling mid life women not to lift heavy weights.
My goal is to prevent osteoporosis and retain muscle mass to keep me fit into old age. My strategy has been for many years to have a variety of exercises, now I feel this is limited because of my frozen shoulder. I am currently unable to weight bear on my poorly shoulder therefore have stopped yoga.
To recap, should I lift through pain?( To improve/ increase muscle strength around shoulder joint??) Thank you
Thank you for getting in touch, and for such a clearly explained question.
The short answer is yes — you should keep lifting. Your goals of maintaining bone density and muscle mass are exactly the right ones, and resistance training remains one of the most effective ways to achieve both. A frozen shoulder is not a reason to stop.
The key is to use pain as your guide. Mild discomfort during or after exercise, which settles down afterwards, is acceptable — you can safely continue training through that. If you are getting more severe pain, or pain that lingers and builds over the following day, that is your signal to back down: reduce the load, the range, or the number of sets until it settles, then build up again gradually.
What you are already doing is sensible. Avoiding overhead lifting and not weight-bearing through the affected shoulder while it remains irritable is the right approach. I would encourage you to keep training everything else at full load — your deadlifts, your lower body, and your unaffected arm. There is no harm in one arm lifting heavier than the other for a period, and training the good side actually helps maintain strength on the affected side too. The asymmetry is temporary and will even out as the shoulder recovers.
It is also worth saying that your hypothyroidism is relevant here, as thyroid conditions are a recognised association with frozen shoulder. At twelve months in, you are likely moving into the stiffer, less painful phase, and continuing your mobility exercises twice daily is exactly right.
If pain becomes a significant limitation — to the point where it is genuinely restricting your training rather than just niggling — then I would consider an injection, specifically hydrodistension. This involves injecting fluid and cortisone into the joint under ultrasound guidance to stretch the tight capsule, and it can be very effective at reducing pain and improving movement, which then allows you to train properly again. I have outlined this in detail here:
https://sportdoctorlondon.com/frozen-shoulder-injection/