Part of Frozen shoulder
Frozen shoulder injections and other treatments: what the evidence says
Warning signs, and when to get help
Does a steroid injection work for frozen shoulder?
For pain, in the short term, yes, and it is the best-supported single treatment there is for this condition. Challoumas and colleagues reviewed 65 randomized studies covering 4,097 people. Of those, 34 studies with 2,402 participants went into head-to-head comparisons and 39 studies with 2,736 participants into network comparisons. Only one option came out both statistically and clinically better than the rest in the short term for pain and function: a corticosteroid injection into the joint. Their conclusion was that early use, in shoulders that had been going on for less than a year, went with better outcomes, and that the injection should come with a home exercise program.
The JOSPT clinical practice guideline arrives in the same place from the physical therapy side. It gives its strongest grade to an injection into the joint combined with mobility and stretching exercises, which produced better pain relief and function over the first 4 to 6 weeks than the exercises on their own (Kelley and colleagues, 2013).
Two things that advantage is not. It is not a cure, and it is not a reason to delay: the benefit shows up in weeks and fades, which is the argument for having it while the shoulder is in its painful phase rather than months later when stiffness is the problem. If night pain is what has driven you to look this up, sleeping with a frozen shoulder is worth trying first and alongside.
What is hydrodilatation, and does it help?
Hydrodilatation, also called arthrographic distension, means injecting fluid into the joint to stretch the capsule from the inside. Arthrographic means it is done with imaging, so the needle and the fluid can be seen going into the joint rather than being placed by feel. In the trials behind the evidence below the fluid was saline mixed with a steroid (Buchbinder and colleagues, 2008). What goes in varies between services, so ask yours what the mix will be. The idea is that the volume does some of the work a stretch cannot reach.
A Cochrane review looked at the trials. In the study with the lowest risk of bias, distension with saline and steroid beat placebo for pain, function and range of movement at three weeks, with a number needed to treat of 2 for pain and 3 for function, meaning two or three people had to be treated for one to get a benefit they would not otherwise have had. That came from a single trial of 46 people, and by six and 12 weeks the advantage was still showing on only one of the two scores used to measure function. The reviewers described this as silver level evidence of short-term benefits in pain, range of movement and function (Buchbinder and colleagues, 2008).
Worth holding in mind: the distension in those trials contained steroid, so it is hard to separate the effect of the fluid from the effect of the drug. The review is also from 2008, which puts it before the larger trials on this page. Where hydrodilatation is offered it is usually as an alternative to a plain injection rather than an extra step.
What about manipulation under anesthesia and surgery?
These are options for a shoulder that is still badly stiff after months of proper care, and the best evidence on them is the UK FROST trial. It randomized 503 adults referred to hospital with primary frozen shoulder into three arms: early structured physiotherapy with a steroid injection, manipulation under anesthesia with a steroid injection, and arthroscopic capsular release followed by manipulation.
What each one does to the shoulder is worth knowing before you choose. In the manipulation, you are asleep under a general anesthetic and the surgeon moves the arm to stretch and tear the tight capsule, then gives a steroid injection. In the capsular release, also under a general anesthetic, the surgeon divides the tightened capsule at the front of the joint, in the gap between two of the cuff tendons (the rotator interval), through keyhole incisions, and then manipulates the shoulder, with a steroid injection in some cases. Both were followed by physiotherapy, 12 sessions over up to 12 weeks, which is the same amount the physiotherapy arm had (Rangan and colleagues, 2020). Neither procedure is a stand-alone fix: the movement the surgeon gains in theater is kept, or lost, in the weeks that follow.
At 12 months none of the three was clinically better than the other two. There were 8 serious adverse events following capsular release against 2 following manipulation, and the trial also reported one in a participant who had physiotherapy outside the trial. Within the UK health service manipulation came out as the most cost effective of the three (Rangan and colleagues, 2020).
The trial gives those as counts rather than describing each one, so for what can actually go wrong the surgical literature is the better guide. A review in the Journal of the American Academy of Orthopaedic Surgeons lists a break in the bone, injuries to the socket rim and its cartilage, nerve bruising (neurapraxia) and rotator cuff damage among the complications of these procedures, and says post-operative care should always include early physical therapy (Redler and Dennis, 2019). The arm bone breaking during a manipulation is rare, but it is the reason the procedure is done by a surgeon under anesthetic rather than as a stretch in a clinic.
That is still a useful result, because the most invasive option did not buy a better shoulder. It is a specialist decision either way. Rehabilitation after a manipulation or a release follows the protocol your surgeon and physio set, and the staged program on this site is not written for those first weeks. If you have had either procedure, the warning signs at the end of this page include the ones that matter most in the weeks afterward.
Where does physiotherapy fit around all this?
It is what you do for most of the time, and it is also where the evidence is least flattering. A Cochrane review of manual therapy and exercise concluded that the combination may not be as effective as a steroid injection in the short term, and that better trials were needed to work out what these treatments add (Page and colleagues, 2014).
That finding is often read as physiotherapy not working. What it actually says is that an injection beats hands-on treatment and exercise over a few weeks for pain. Over the year that this condition takes, the exercises are how the arm stays usable and how range comes back, and the trials that favored injection gave exercise alongside it rather than instead.
How hard you push still matters more than most people expect. Diercks and Stevens followed 77 people in the Netherlands: one group got hands-on mobilization and hard passive stretching, the other was taught to keep every movement inside what the shoulder would accept, and two years on it was the second group that had done better. Nobody was randomized into those groups, so take it as support for the gentler route rather than the last word on it. The JOSPT guideline separately warns that stretching beyond painful limits may lead to worse results. Frozen shoulder exercises by stage sets the dose, and the three stages explains how to tell which one you are in.
What the evidence does not single out
Plenty of other treatments have been tried, and across those 65 randomized studies the corticosteroid injection was the only one that stood out from the pack in the short term (Challoumas and colleagues, 2020). That is not the same as saying nothing else does anything. It does mean that if you are being offered something and told it is the answer, the research does not back that confidence.
One thing is worth checking for yourself before any of this: that the diagnosis is right. A painful tendon, shoulder arthritis and referred neck pain all get treated differently, and the rotator cuff tendinopathy program and shoulder pain when lifting your arm cover the commonest mix-ups.
When to see a physio or doctor
Ask about an injection if pain is the dominant problem, if it is wrecking your sleep, or if the shoulder is early in its course, since that is where the evidence is strongest. Ask about the hospital options if months of consistent work have left you with a shoulder that is stiff rather than sore.
Tell your doctor about diabetes before any injection, because an injection into a joint can push blood sugar up for several days (Choudhry and colleagues, 2016), and frozen shoulder and diabetes covers why that matters. How long frozen shoulder lasts gives the timeframe these treatments sit inside, and the frozen shoulder program is the exercise side. Act on anything in the list below at the timing its own line gives.
Related exercise programs
Warning signs
Get emergency help now
- Chest pain or tightness, which may spread to your arm, neck or jaw, or shoulder or arm pain that comes with shortness of breath, sweating or feeling sick. This can be a heart attack. Call emergency services straight away.
- The shoulder feels as if it has slipped out of place, looks a different shape or suddenly locks so you cannot move the arm, or the pain is severe after a fall or an injury. Go to an emergency department straight away, without driving yourself, and do not try to put the shoulder back in yourself.
- Your arm, hand or fingers turn cold, pale, blue or gray compared with the other side. Call emergency services or go to an emergency department straight away, and do not drive yourself. The blood supply to the arm may be blocked.
- You have a fever or feel unwell, or the shoulder is hot, red and swollen. This can be a joint infection. Go to an emergency department straight away.
Get help now, day or night
- Since your manipulation under anesthesia or capsular release, you have severe pain in the upper arm, the arm looks a different shape, it is heavily bruised or swollen, or you cannot move it at all. A manipulation works by stretching and tearing the tight capsule, and the arm bone can break or the joint can be damaged during it. Contact your surgical team straight away, day or night, and if you cannot reach them, go to an emergency department the same day.
- Same day: since your manipulation under anesthesia or capsular release, the shoulder is hot, red and swollen, you have shoulder pain with a fever, or the redness, warmth, swelling or pain in your shoulder is not getting better or is getting worse, for example the shoulder pain keeps building both when you move and when you rest. This can be an infection in the shoulder joint. Contact your surgical team or the ward you went home from straight away, and if you cannot reach them, go to an emergency department the same day.
Get help today
- Sudden, very bad shoulder pain, or you suddenly cannot lift or move your arm at all. Get medical help the same day.
- The pain started after a fall, a pull or another injury, especially if the arm has been weak since, for example you cannot lift it out to the side or hold it up. This can be a broken bone or a torn tendon. Get medical advice the same day, and say how it happened and that the arm has been weak since, because UK shoulder surgeons advise urgent referral for a rotator cuff tear caused by an injury.
- Same day: numbness, tingling, pins and needles or weakness in your arm or hand that is still there more than 48 hours after a manipulation or a capsular release, or that starts once the numbness from a nerve block has worn off. A nerve block usually wears off within 12 to 48 hours, and a nerve can be bruised during these procedures. Contact your surgical team or the ward you went home from the same day.
- Severe pain in both shoulders that has come on recently. Get medical advice the same day.
- You are over 50 and have aching and stiffness in both shoulders, often in the neck or hips too, that is worst in the morning and lasts more than 45 minutes after you get up. This can be an inflammatory condition (polymyalgia rheumatica) rather than frozen shoulder. If you also get a new headache, pain or tenderness at your temples or on your scalp, or jaw pain when you eat or talk, get medical advice the same day, and if your vision changes, call emergency services. Even without those extra signs, see your doctor within a few days about the aching and stiffness.
- Pins and needles or numbness in the arm that does not go away, no feeling in part of the arm, or weakness that is getting worse. Get medical advice the same day. For pain spreading down the arm from your neck, ask for an urgent appointment with your doctor. If one side of your face or body suddenly goes numb or weak, or your speech becomes slurred or muddled, call emergency services, even if it goes away.
- Pain at night or at rest that is constant, that no rest or change of position eases at all, and that keeps getting worse. If you are being treated for cancer now, contact your cancer team the same day.
Book an appointment
- Within a few days: since your manipulation under anesthesia or capsular release, the shoulder is stiffening up again and has lost movement it had gained, or pain is stopping you doing the exercises you were given. Contact your physio or surgical team within the next few days rather than waiting for your next appointment. The movement the surgeon gains is held on to by moving the arm in the weeks straight afterward, so a shoulder that is closing up again is worth telling them about early.
- Pain at night or at rest that is constant, that no rest or change of position eases at all, and that keeps getting worse. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse.
- Night pain is common with this condition, but get checked within a few days if the pain is constant, no rest or change of position eases it at all, and it keeps getting worse.
- New shoulder pain and you have had cancer, now or in the past, or you are losing weight without trying. See your doctor within a day or two and mention it.
Common questions
How long does a frozen shoulder injection take to work?
The studies measure the benefit over the first few weeks rather than the first few days. The JOSPT guideline reports better pain relief and function over the first 4 to 6 weeks for an injection into the joint combined with mobility and stretching exercises, compared with the exercises alone (Kelley and colleagues, 2013). Challoumas and colleagues found the advantage of a corticosteroid injection was a short-term one, which is part of why it is recommended early rather than saved for later (Challoumas and colleagues, 2020). Ask the person giving it what to expect and when, since that varies with what was injected and where.
Is hydrodilatation better than a steroid injection?
The research behind this page does not settle it. The trials that compared the two directly were small and at high risk of bias with conflicting results, and the Cochrane reviewers concluded that it is uncertain whether distension is better than the alternatives. A Cochrane review of arthrographic distension, which is the same procedure, found that the trial with the lowest risk of bias showed distension with saline and steroid was better than a placebo for pain, function and range of movement at three weeks, with a number needed to treat of 2 for pain and 3 for function. That trial had 46 participants, and at six and 12 weeks the advantage held on only one of the two function scores. The reviewers graded it silver level evidence of short-term benefit (Buchbinder and colleagues, 2008). Note that the distension used in those trials included steroid, so some of the benefit may be the steroid rather than the volume of fluid. Which of the two you are offered usually depends on your local service.
Can I exercise after a frozen shoulder injection?
Exercise is part of the package rather than something to stop. Both the JOSPT guideline and the Challoumas meta-analysis tested or recommended the injection alongside exercise, not instead of it (Kelley and colleagues, 2013; Challoumas and colleagues, 2020). The practical point is that less pain lets you move further, so an injection is a chance to make progress with the stretching rather than a reason to rest. Ask the clinician who gave the injection when to restart, since local advice on the first day or two varies.
Do I need surgery for a frozen shoulder?
Most people do not. The UK FROST trial randomized 503 adults referred to hospital with primary frozen shoulder to early structured physiotherapy with a steroid injection, manipulation under anesthesia with a steroid injection, or arthroscopic capsular release followed by manipulation. Both operations were followed by physiotherapy, 12 sessions over up to 12 weeks. At 12 months none of the three was clinically better than the others, there were 8 serious adverse events after capsular release against 2 after manipulation, with one more in a participant who had physiotherapy outside the trial, and in the UK health service manipulation came out as the most cost effective (Rangan and colleagues, 2020). Surgery is a conversation for a shoulder specialist, and this page does not cover rehabilitation after either procedure: follow the plan your surgeon and physio give you.
Will an injection raise my blood sugar if I have diabetes?
It can, for several days. A systematic review of blood glucose levels after steroid injections into a joint in people with diabetes found levels can rise for several days afterward and advised monitoring for up to a week (Choudhry and colleagues, 2016). Tell the doctor you have diabetes before the injection, ask how often to test and who to contact if your readings climb, and discuss it with your diabetes team.
References
- Kelley MJ, Shaffer MA, Kuhn JE, et al. Shoulder pain and mobility deficits: adhesive capsulitis. Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy. 2013;43(5):A1-A31. https://doi.org/10.2519/jospt.2013.0302
- Challoumas D, Biddle M, McLean M, Millar NL. Comparison of treatments for frozen shoulder: a systematic review and meta-analysis. JAMA Network Open. 2020;3(12):e2029581. https://doi.org/10.1001/jamanetworkopen.2020.29581
- Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database of Systematic Reviews. 2008;(1):CD007005. https://doi.org/10.1002/14651858.CD007005
- Page MJ, Green S, Kramer S, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database of Systematic Reviews. 2014;(8):CD011275. https://doi.org/10.1002/14651858.CD011275
- Rangan A, Brealey SD, Keding A, et al. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. The Lancet. 2020;396(10256):977-989. https://doi.org/10.1016/S0140-6736(20)31965-6
- Choudhry MN, Malik RA, Charalambous CP. Blood glucose levels following intra-articular steroid injections in patients with diabetes: a systematic review. JBJS Reviews. 2016;4(3):e5. https://doi.org/10.2106/JBJS.RVW.O.00029
- Redler LH, Dennis ER. Treatment of adhesive capsulitis of the shoulder. Journal of the American Academy of Orthopaedic Surgeons. 2019;27(12):e544-e554. https://doi.org/10.5435/JAAOS-D-17-00606
- Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. Journal of Shoulder and Elbow Surgery. 2004;13(5):499-502. https://doi.org/10.1016/j.jse.2004.03.002
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-18.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.