Back Pain Doctor
Frozen Shoulder
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Frozen shoulder, or adhesive capsulitis, causes pain and progressive restriction of shoulder movement. It can occur without a clear trigger or after injury, surgery or prolonged guarding. It is more common in people with diabetes or thyroid disease.
Assessment is important because frozen shoulder can be confused with rotator cuff pain, arthritis or referred pain from the neck. The key finding is restriction of both active and passive shoulder movement.
Management depends on the phase. During the painful phase, aggressive stretching can flare symptoms. Treatment often focuses on pain control, sleep, gentle mobility and maintaining function. As pain settles, progressive mobility and strengthening become more useful.
Common symptoms
- Shoulder pain with progressive stiffness
- Difficulty reaching overhead, behind the back or out to the side
- Pain at night or when lying on the affected side
- Reduced passive and active range of motion
Commonly seen in
Evidence for twelve treatment options in frozen shoulder
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation — diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan — with weight management where that is clinically relevant.
What the evidence shows
Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is honest about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).
Pairing reviewed 2026-09-02.
Where it fits for you
Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot — strength, capacity and weight.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Only if relevant
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with 0.02-0.08% lignocaine is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling — the same technique with nothing injected — is not offered here.
What the evidence shows
No controlled trial has tested trigger point injection in frozen shoulder. The injection evidence is five case reports of subscapularis trigger point infiltration combined with a subscapular nerve block in people who had not responded to usual treatment (Jankovic, Acta Anaesthesiol Belg 2006). The needling evidence is stronger but still limited: 70 people given dry needling of shoulder girdle trigger points alongside physiotherapy improved in pain, range and disability over twelve days, in a study with no control group (Kalia, J Bodyw Mov Ther 2020), and a randomised trial of 88 people compared intramuscular electrical stimulation with dry needling, both with exercise, where both arms improved and the difference between them fell below what patients notice (Shanmugam, Int J Surg Protoc 2021). Neither trial included a group that had no needling.
Pairing reviewed 2026-09-11.
Where it fits for you
Aimed at the tight shoulder girdle muscles that often accompany a frozen shoulder, not at the capsule itself. Considered where those muscles are reproducing part of your pain and are limiting the movement work.
Ultrasound-guided injections Guidance means we can see the needle reach the target. What goes into the needle depends on the diagnosis. Worth discussing
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis — and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
A double-blind randomised trial found ultrasound guidance made glenohumeral injection 100% accurate against 71% blind, yet produced no difference in pain, function or range of movement out to 12 weeks (Cho, Bone Joint J 2021).
Pairing reviewed 2026-08-30.
Where it fits for you
Injection has a real place in the painful phase. Guidance is used where the joint is difficult to enter rather than as a routine.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible — no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits for you
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Only if relevant
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue — including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Shockwave reviews in myofascial pain report a possible benefit but mix protocols and often mix radial pressure wave with focused shockwave; that evidence cannot be transferred to the underlying diagnosis. Condition reviewed: frozen shoulder.
Evidence source: Wu et al., shockwave for myofascial pain review (2022)
Pairing reviewed 2026-08-30.
Where it fits for you
For frozen shoulder, radial pressure wave may be considered for a distinct superficial muscle or fascial component. It is not used as evidence of benefit for the primary diagnosis.
Focused shockwave (ESWT) A true shock wave converging at depth — for tendon, joint, ligament and bone. Worth discussing
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form we use for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
A Level I systematic review and meta-analysis of 20 randomised trials found shockwave used as an adjunct improved pain and function immediately and at short term, though heterogeneity was high for longer-term analgesia and range of movement (Zhang, Orthop J Sports Med 2022).
Pairing reviewed 2026-08-30.
Where it fits for you
An adjunct to the mobility and loading work, discussed where pain is limiting progress through the stiff phase.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Painless, no contact. Plausible — no studies
What it involves
You sit with the applicator positioned over the area for a short session. Painless, no gel or contact required, and usually delivered as a course — commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that we can point to. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative — a randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits for you
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why we describe it this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Outlasted cortisone in pooled trials
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
Tested in more than a dozen randomised trials in frozen shoulder, nearly all against a cortisone injection rather than a dummy injection. Pooled, the two were level for the first month and PRP was ahead later: across 7 trials and 692 people pain was lower by about 1 point out of 10 and shoulder disability (SPADI) by 17 points out of 100 at six months, on evidence its authors grade low to moderate (Peng, J Back Musculoskelet Rehabil 2026), and across 13 trials and 1,056 people pain was lower by 1.8 points at six months with no difference at one or three months (Xu, Front Med 2026). Most of those trials were small, single-centre and unblinded. Against a saline dummy injection there is one small triple-blind trial: 32 people had three injections a fortnight apart with an exercise program, and pain, disability and movement were better with PRP at three months (Ünlü, Int Orthop 2020). The contrary findings matter. In the one three-arm trial with both a cortisone and a saline group (90 people, ultrasound-guided, all with physiotherapy), cortisone was clearly better than PRP from one month through six, and all three groups improved (Hsieh, Arch Phys Med Rehabil 2026). Added to a home exercise program, two ultrasound-guided PRP injections improved movement but not pain or disability at twelve weeks in 40 people (Karabaş, Turk J Phys Med Rehabil 2021), and a single injection did no better than six weeks of physiotherapy in 64 (Thu, J Int Med Res 2020).
Pairing reviewed 2026-10-09.
Where it fits for you
An option that can be discussed for a frozen shoulder that is still painful and stiff after time and a stretching program, particularly where a cortisone injection has worn off or is best avoided. Cortisone usually works faster in the first month, and that is said plainly. If used, PRP is injected into the shoulder joint under ultrasound guidance alongside the exercise program, and the response is reviewed at about three months.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Evidence mixed
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
Two randomised trials, pointing different ways. Ultrasound-guided capsule-preserving hydrodilatation with 20 mL of 5% dextrose matched 40 mg triamcinolone on pain, disability and range of motion at twelve weeks in 84 people, though the dextrose group used more anti-inflammatories at eight weeks (Liu, J Shoulder Elbow Surg 2025). Against saline, however, prolotherapy improved pain and function no more than the saline injection did, separating only on some range-of-motion measures (Sam, Medicine 2023). Read together, much of the benefit may come from the volume of fluid distending the capsule rather than from the dextrose.
Pairing reviewed 2026-09-05.
Where it fits for you
Of interest mainly where a corticosteroid injection is unsuitable — poorly controlled diabetes, or repeated steroid exposure already. It buys a window for the stretching and loading work; it does not shorten the condition on its own.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Evidence mixed
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Hyaluronic acid has been tested here and has not stood out. A network meta-analysis of 31 studies found intra-articular hyaluronate (2 randomised trials, 42 people) gave no benefit over physiotherapy at twelve weeks, while cortisone (8 trials, 340 people) and PRP (3 trials, 177 people) did (Berner, Rheumatology 2024). A later randomised trial of 56 people found the high-molecular-weight form outperformed the low-molecular-weight form, but it had no untreated comparison group (Mir, Future Sci OA 2025).
Pairing reviewed 2026-09-07.
Where it fits for you
Not a first choice here. Raised only where cortisone is unsuitable, and with the weakness of the evidence stated at the time.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve—not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Dextrose tested as a different procedure
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
No study has tested a series of subcutaneous dextrose injections in frozen shoulder. The dextrose evidence at this shoulder belongs to two other procedures. A noninferiority randomised trial gave 84 people three capsule-preserving hydrodilatations with either 20 mL of 5% dextrose or triamcinolone and found the two equivalent on pain, disability and range of motion through twelve weeks (Liu, J Shoulder Elbow Surg 2025), which distends the joint capsule rather than treating a nerve. A narrative review sets out ultrasound-guided hydrodissection of the suprascapular, axillary and subscapular nerves as the nerve-targeted option, and calls its own framework preliminary and in need of prospective testing (Chang, Life 2026).
Pairing reviewed 2026-09-16.
Where it fits for you
Considered where tender, hypersensitive skin is found over the shoulder rather than the deep, stiff, end-of-range pain that defines this condition.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Only if relevant
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
The frozen shoulder evidence is for hydrodilatation, not nerve hydrodissection. A scoping review that screened 138 studies and included 21 reports adhesive capsulitis among the conditions where the technique may relieve pain and improve function, but pools hydrodissection with hydrodilatation — distending the joint capsule with fluid, which is a different procedure aimed at the capsule rather than at a nerve (Leahy, Front Pain Res 2026). We found no trial of nerve hydrodissection in frozen shoulder.
Pairing reviewed 2026-09-08.
Where it fits for you
Only where assessment finds a nerve contributing alongside the stiff capsule; suprascapular nerve pain is the pattern that occasionally fits. Capsular hydrodilatation is a different procedure and a separate conversation.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments we do not offer, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So we do not build treatment plans around it. Where an injection is the right call, we review the specific diagnosis and target, discuss what is being injected and why, keep the number low, and pair it with the loading work that changes the longer-term course.
When we would still consider it
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal — a trip, a procedure, a return to work
- Diagnostic use, where the response tells us where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other shoulder conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Related articles
Shorter articles that answer the questions patients ask most often about this.
- Frozen Shoulder: What the Evidence Says About TreatmentFrozen shoulder is painful, slow and often misunderstood. A plain-English look at what the evidence supports for pain, stiffness and regaining movement.
- Shoulder Pain: Causes, Symptoms, and Effective Treatment StrategiesRotator cuff injury, frozen shoulder and shoulder arthritis are common causes of shoulder pain. How they present and what treatment involves.
Frequently asked questions
Is frozen shoulder the same as rotator cuff pain?
How long does frozen shoulder last?
Can injections help?
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