For most people, frozen shoulder treatment should start with a steroid injection and physio, not surgery.
The biggest trial ever run on this, in 503 patients, compared physio with an injection, manipulation under anesthetic, and keyhole surgery. At one year, all three ended up about the SAME. The difference between them was too small for patients to notice.
Surgery was worse for the first three months, carried most of the serious complications, and cost the most.
The main options
- Steroid injection: a cortisone injection into the shoulder joint. Best for the early, painful stage. It calms the pain so you can move
- Physio: exercises and hands-on treatment, with the intensity matched to how irritable the shoulder is. See frozen shoulder exercises
- Manipulation under anesthetic: you’re put to sleep and the surgeon moves the shoulder through its range to stretch the tight capsule. Takes minutes. No cuts
- Keyhole surgery (capsular release): the surgeon cuts the tight capsule through small incisions, usually followed by a manipulation
- Hydrodilatation: fluid is injected into the joint to stretch it from the inside. Widely offered, but with less evidence behind it than the other options
What the big trial found
- At one year: surgery scored slightly higher on paper, but below the level patients can actually feel
- At three months: the surgery group was clearly WORSE than the physio group. You pay for the operation with a harder first few months
- Serious complications: 8 of the 10 serious problems in the whole trial happened in the surgery group
- Needing more treatment: about 1 in 7 people who started with physio needed something more, compared with about 1 in 25 after surgery. So 6 in 7 people who start with physio never need anything further
- Value for money: manipulation under anesthetic came out best. Keyhole surgery came out worst
At one year you can’t tell the three treatments apart. At three months, you can.
The injection: when and why
- Early is better. The injection works best in the painful, freezing stage. The benefit fades over months, which is an argument for having it sooner, not skipping it
- It doesn’t replace exercise. It buys you a window of less pain to get moving
- If you have diabetes, your blood sugar will rise for a few days. Plan for it. See frozen shoulder and diabetes
A sensible order
- Steroid injection while pain is the main problem
- Physio, with the stretching matched to how irritable the shoulder is, and rechecked as it changes
- Manipulation under anesthetic if progress stalls for several months
- Keyhole surgery if the first three haven’t worked
If you’re offered surgery first, that isn’t automatically wrong. But it’s fair to ask your surgeon what it is about YOUR shoulder that makes the usual order a poor fit.
Questions to ask
- Which stage do you think my shoulder is in?
- Would an injection help me now?
- How hard should I be stretching, and when should that change?
- What would make you recommend a procedure, and which one?
For how the condition behaves over time, see frozen shoulder: symptoms, stages and how long it lasts.
Get reviewed rather than pushing on if
- Pain keeps rising after several weeks of treatment
- Night pain comes back after it had settled
- The shoulder is hot, red or swollen, or you have a fever
- You have numbness, tingling or weakness down the arm
- The stiffness started after an operation or injury. See shoulder stiffness after surgery
Injection first, the right exercises second, the operating room last.