Frozen shoulder: What can help?

The treatment for frozen shoulder depends on the symptoms and the phase of the condition:

At first, the aim is to relieve the pain. This usually involves treatment with steroid tablets or steroid injections. After that, you can start to carefully stretch the arm and do gentle exercises to loosen up the joint. But stretching and mobility exercises shouldn't be forced or very painful. When you are able to move the shoulder more easily and it hurts less, you can increase the intensity of the exercises in order to improve the function of the shoulder again.

If you have a frozen shoulder, you can generally use your arm as you normally would and don't have to worry about harming it. But to stop the pain from getting worse, it's best to be careful and avoid sudden movements.

Many people use cold or heat packs to relieve shoulder pain. If you use these kinds of packs, it's important to protect your skin from extreme temperatures – for instance, with a towel. Cold can damage the skin too, like heat can.

Over-the-counter painkillers are also a popular option, especially non-steroidal anti-inflammatory drugs (NSAIDs). Examples of NSAIDs include diclofenac, ibuprofen and naproxen. NSAIDs relieve pain and reduce inflammation. They can be taken as tablets or applied to the shoulder in the form of a gel or cream. But they are less effective than steroids.

Steroid tablets (oral steroids) can relieve pain and improve mobility in the shoulder. One study that looked into the effectiveness of taking steroids for three weeks showed the following:

• Without steroids, the symptoms improved in 48 out of 100 people.
• With steroids, the symptoms improved in 96 out of 100 people.

Steroid tablets only work for as long as they are taken, though. And they aren't suitable for long-term use: When taken for a long period of time, they can increase the likelihood of weight gain and infections. They also increase the risk of various diseases, such as diabetes and osteoporosis.

Alternatively, steroids can be injected into the stiff joint. This can relieve the pain and improve mobility. The effect of injections lasts longer than that of steroid tablets.

But the pain may temporarily get worse just after an injection. A sudden sensation of heat with skin reddening (flushing) may be one unpleasant side effect of the injections. Some women also report menstruation (period) problems after treatment. Injections are associated with a risk of infection in the joint too. A joint infection is a very rare but serious side effect. So it's important to carefully consider the potential pros and cons of the treatment together with your doctor beforehand.

Whether tablets or injections are more suitable will depend on things like which treatment you prefer and whether you have any other medical conditions. For example, steroid tablets might not be an option for someone with diabetes.

In a procedure known as hydrodilatation (also called arthrographic distension), a solution is injected into the shoulder after the joint has been numbed with a local anesthetic. The solution usually contains water, salt and a steroid. The aim is for the solution to dilate (stretch) the joint capsule and loosen the joint. You may be able to hear the solution in the joint afterwards.

Hydrodilatation can relieve the symptoms of frozen shoulder. But it's not more effective than steroid injections. Because this treatment can be very painful at first, most doctors do not recommend it nowadays.

There is also another injection-based treatment known as a nerve block. It involves injecting a local anesthetic near to the nerve that leads to the shoulder blade. There is a lack of good research on the use of this treatment for frozen shoulder, though.

During the first phase of frozen shoulder, when pain is the main problem, people are advised to only move the shoulder carefully. If you would like to try a gentle mobility exercise, you can do the following:

• While standing, lean forward and hold on to a chair or table with your healthy arm.
• Let the affected arm hang down and then carefully start to swing it in circular motions, like a pendulum. This shouldn't feel too unpleasant.
• You can also create this swinging motion by slightly moving your upper body without using the muscles in the arm.

Physical therapy (physiotherapy) and more intensive exercises are only recommended once the pain starts to get better – in the later phases. You can then try to improve mobility by doing various exercises that stretch the shoulder in different directions. These include the following:

1. Armpit stretch: With the support of your healthy arm, lift the arm with the frozen shoulder up and rest it on a surface at about chest level. In this position, slowly bend your knees so that your armpit opens up and you can feel it stretching. Then stand up straight again.

2. External rotation stretch: Stand in a doorframe with the affected arm out to the side of your body, and the elbow bent at a 90-degree angle so that your forearm is parallel to the floor. Keep the upper arm at your side. Then place the palm of your hand on the doorframe to stop the arm from moving. Now turn your upper body away from the arm to stretch the shoulder.

3. Internal rotation stretch: Stand with your back to the doorframe. Place the back of your hand on the affected side against your bottom so that your arm is at a slight angle. Now lean the back of that elbow against the doorframe – gently "trapping" your elbow to keep it in place – and turn your upper body slightly inward towards the arm.

These exercises are typically repeated 10 to 20 times once or twice a day. It is important to start stretching slowly until you feel it, but without it hurting a lot.

These and other stretching and mobility exercises can also be demonstrated by a doctor or physical therapist, and then you can do them at home on a regular basis. Later on, you can do more intensive exercises, for example using a rubber exercise band.

Previous research has shown that shoulder stiffness is most effectively relieved with a combination of steroids and exercises or physical therapy.

Frozen shoulder usually gets better on its own over time, so surgery generally isn't needed. It is only considered as a treatment option if the symptoms still haven't improved after a few months. There are two possibilities.

• Arthroscopy (capsular release): A tiny camera and instruments are inserted into the joint through cuts in the skin. The surgeon cuts individual ligaments and removes inflamed tissue.
• Manipulation: The surgeon carefully moves the shoulder in various directions with the aim of stretching and releasing the "stuck" shoulder capsule so you can move the shoulder more normally again. This is done under anesthesia.

The best-quality studies on these procedures didn't find that they were any better than conservative treatment with steroids and physical therapy. Because both approaches are associated with surgical and anesthesia-related risks, it's important to carefully consider the pros and cons before making a decision.

If a doctor recommends that you have one of these procedures, they are obliged to inform you that you have a right to get a second medical opinion. In other words, you can seek advice from a different doctor in a different practice or hospital. Our decision aid may help you to decide. It briefly summarizes the main advantages and disadvantages of the various treatment options.

Physical therapists sometimes treat frozen shoulder with ultrasound waves. This has not been proven to work, though. Acupuncture, laser therapy, magnetic field therapy and short-wave diathermy are also sometimes offered. But there is no good-quality research on the effectiveness of these approaches.