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Frozen Shoulder

Shoulder pain

Frozen shoulder is a painful condition in which the shoulder joint becomes rigid and painful. It mainly affects people between the ages of 40 and 60 (women more than men) and oftenly begins for no apparent reason. Occasionally, it may happen after shoulder surgery or a fall. Your clinician will be able to diagnose frozen shoulder at your first appointment using clinical tests and a diagnostic ultrasound scan. Frozen shoulder does not always respond well to physiotherapy or conservative treatments such as rest and/or pain relievers. The most effective treatment for frozen shoulder is an ultrasound-guided steroid injection.


The symptoms of a frozen shoulder are:

  • The shoulder is in a lot of pain, and it’s stiff.
  • The pain is getting worse and it is radiating down the arm.
  • You’re awakened in the middle of the night by pain.

If this sounds like a problem you’re having, keep reading…

What are some other symptoms of frozen shoulder?

If this does not sound like your pain there are other conditions that can cause the pain of frozen shoulder such as:

  • sub-acromial bursitis
  • calcific tendinopathy
  • shoulder impingement
  • rotator cuff pain
  • osteoarthritis


The ball-shaped protuberance at the end of the humerus (long bone of the upper arm) and the shallow dish (called the glenoid fossa) on the shoulder blade(scapula) form the glenohumeral (shoulder) joint. The glenohumeral joint is a ball and socket joint made up of these bones. This joint is capable of performing all of the motions seen in the shoulder. This blog will concentrate on the joint that is affected by adhesive capsulitis (frozen shoulder).

Shoulder Anatomy - Shoulder Girdle and Shoulder joint Explained

Frozen shoulder is distinguished by severe pain and gradual stiffness of the shoulder joint. More specifically, the capsule around the joint becomes swollen and tight.

It is a very common cause of shoulder pain that affects between 2% and 5% of the population (Wu et al., 2017). It is unknown what causes frozen shoulder, but it is clear that it is a painful and incapacitating condition. Frozen shoulder frequently wakes people up at night, and even simple daily activities can be severely constrained and painful.

There are three different stages of frozen shoulder. The duration of each of these stages varies from person to person and can last for years before resolving. These stages are:

  • Stage one is referred to as the ‘painful’ stage. This stage can last for several months, during which time the shoulder becomes tighter and more painful.
  • The second stage is referred to as the “stiff” stage. The shoulder remains very tight during this phase, leading to poor function.
  • The third stage is known as the ‘unfreezing’ or ‘thawing’ stage. During the thawing phase, the shoulder begins to relax and movement becomes easier. This can take months or even years to fully resolve. According to recent research, only 59% of patients regain full function within 4 years (Wang et al., 2016).

The Risk Factors involved in the treatment of Frozen Shoulder

Although the mechanism underlying the onset of frozen shoulder is still unclear, the following factors are known to increase the risk of onset:

  • Frozen shoulder is more common in women than it is in men.
  • The majority of frozen shoulder cases occur between the ages of 40 and 60.
  • Trauma – injuries to the shoulder, such as fractures, dislocations, rotator cuff tears, or surgery – may all cause secondary frozen shoulder.
  • Diabetes mellitus (type 1 and type 2)
  • Over or underactive thyroid
  • Cardiovascular disease.

How do you know if you have frozen shoulder or not?

Frozen shoulder usually develops gradually, but it may also occur as a result of trauma or injury. However, the most common onset is a gradual one.

Its symptoms include:

  • Significant pain that is hard to control with over-the-counter pain relievers, ice, and physiotherapy.
  • Pain that interferes with your ability to sleep or regularly wakes you up at night.
  • Increasing shoulder stiffness that limits your ability to raise your arm or perform daily activities such as dressing and undressing

Frozen Shoulder Diagnostics

If you suspect you have frozen shoulder, it is best to seek professional help as soon as possible. Your clinician will use clinical assessment to make a diagnosis of frozen shoulder. A combination of strength and range of motion testing results in a formal diagnosis.

Crop unrecognizable orthopedist stretching shoulder of female patient

Other pathologies that may manifest as a frozen shoulder must be held out. This includes:

  • Glenohumeral joint osteoarthritis
  • Acromioclavicular joint osteoarthritis
  • Calcific tendinopathy
  • Rotator cuff tendinitis/tendinopathy
  • Subacromial bursitis
  • Long head of bicep tendinitis/tendinopathy

If your clinician is still unsure about your diagnosis after completing a clinical assessment, you may be referred for an x-ray. This is done to rule out other shoulder pathologies that can mimic frozen shoulder, such as shoulder osteoarthritis.

Shoulder X-Ray

The gold standard imaging technique for assessing joint pathology, such as osteoarthritis or fracture, is X-ray. A series of blood tests may be recommended by your clinician. Blood tests are used to rule out other pathologies, such as rheumatoid arthritis-related systemic inflammation. Normally, these are not required.

Although x-ray is an excellent method for evaluating joint pathology, it cannot assess the soft tissue swelling that is frequently associated with this condition. This is easily visible with diagnostic ultrasound imaging.

All of our clinicians at are fully qualified musculoskeletal physiotherapists and sonographers. All of our evaluations include a mixture of clinical testing and a diagnostic ultrasound scan. Our thorough evaluations result in a highly specific diagnosis and the development of an effective, personalized treatment plan.

Frozen Shoulder Treatment

According to studies, conservative management alone has little value in the painful (first) stage of frozen shoulder. A progressive stretching exercise program, manual techniques to mobilize your shoulder joint, and possibly acupuncture and taping will be included in physiotherapy for the treatment of frozen shoulder.

Crop masseur preparing client for spine treatment

It is not uncommon for the pain to be too severe for you to take part in physiotherapy. This is when an injection is recommended to alleviate the pain. An ultrasound-guided injection is a well-supported treatment option for frozen shoulder that is recommended by NICE guidelines.

Here are some helpful points:

  • Change your everyday activities and try to avoid tasks that aggravate your discomfort. Taking daily breaks or breaking down an assignment into smaller, more achievable steps are examples of this.
  • If you sleep on your side, place a pillow under your sore arm and lie on the unaffected side. If you lie down on your back, put the pillow under the back of your shoulder and under the sore arm.
  • Start a gentle stretching routine for your arm. Stretching the shoulder joint by walking your fingers up a wall is a good place to start. Stretching the shoulder after a hot shower/bath or using a hot water bottle can be easier.
  • Pain can be relieved with over-the-counter medications like paracetamol or nonsteroidal anti-inflammatory gels like Voltarol. Before beginning treatment, talk to your pharmacist about the prescription you’ll be taking.

Injection Therapy

If the pain persists and is interfering with your everyday activities, injection therapy may be necessary. Injection therapy is particularly useful in the following situations:

  • If you’re in a lot of pain, particularly if it’s waking you up multiple times a night, an ultrasound-guided steroid injection is the way to go. The medical literature backs up this argument.
  • Pain that prevents you from performing daily tasks such as washing and dressing, cooking, or engaging in recreational activities.
  • Your desire to participate in physiotherapy recovery is being hampered by pain.

Steroid injections were found to be the most effective treatment for frozen shoulder in stage one, the “painful stage,” according to a recent systematic review (Wang et al., 2016). Patients find it hard to locate some pain relief at this point, and even minor movements worsen the pain. When pain becomes intense, it can take several hours or even days for it to subside. Frozen shoulder is treated with injections to relieve the pain and swelling. This gives you a ‘golden opportunity’ to stretch your shoulder properly. According to research, physiotherapy should be begun within two weeks after getting a shoulder joint injection for the best results.

Injections performed under ultrasound image guidance are more successful at transmitting medication to the shoulder joint and more effective at minimising pain and increasing function than injections performed using landmarks (Daniels et al., 2018; Aly et al., 2015). Ultrasound-guided injections have also been shown to significantly reduce pain that comes with frozen shoulder, particularly in the brief period, according to research. When injection therapy is combined with physiotherapy, this can be extremely beneficial.

Hydro-distension for Frozen Shoulder (Adhesive Capsulitis)

Hydrodilatation, also known as hydro-distension, is an injection used to extend the tight joint capsule under ultrasound (or x-ray) guidance. Under strain, local anaesthetic, steroid, and saline are injected into the shoulder capsule in an effort to stretch it and facilitate movement.Andren and Lundberg (1965) were the first to describe hydrodistention, describing an injection into the glenohumeral joint under x-ray guidance.

Stretching and exercise, which are often used to treat other shoulder conditions, can be very painful and, in many situations, are of little use when dealing with a frozen shoulder.Pain-relieving injections such as steroid and an unique injection used to stretch the shoulder joint to assist with movement known as “Hydro distension” or “High Volume” injections are increasingly being shown to be the most successful in treating this disease, allowing the movement and stretches to take effect.

If you have any further questions then please don’t hesitate to contact us for an individual assessment.

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