If you have been diagnosed with a frozen shoulder, you will probably be offered a choice at some point.
Physiotherapy with a steroid injection. Manipulation under anaesthetic. Or keyhole surgery to release the capsule.
They sound like three rungs on a ladder, with the implication that if the first does not work you climb to the next, and that the ones higher up work better.
A major UK trial tested exactly that assumption, and the result is worth knowing before you decide.
The UK FROST Trial
A multicentre randomised controlled trial conducted in UK secondary care compared the three main treatment options for primary frozen shoulder.
The three arms:
Early structured physiotherapy plus a steroid injection.
Manipulation under anaesthesia with a steroid injection, where the shoulder is moved through its range while you are under a short general anaesthetic.
Arthroscopic capsular release, keyhole surgery to cut the tightened capsule.
The Result
None of the three was clinically superior to the others.
A systematic review placing the trial in context concluded that UK FROST provided the strongest evidence that, when compared with each other, neither physiotherapy with steroid injection, manipulation under anaesthesia, nor arthroscopic capsular release are clinically superior.
None of the differences between treatments met the threshold of clinical significance, and most confidence intervals included zero.
Evidence from smaller randomised trials did not change that conclusion.
Which means the ladder model is wrong. These are three different routes to a broadly similar destination, not three levels of effectiveness.
So How Do You Choose?
If outcomes are comparable, the decision shifts to the practical differences, and the trial examined those too.
Physiotherapy with a steroid injection was accessed more quickly than the other options and was lower in cost. However, more patients in this group required further treatment for their frozen shoulder.
Manipulation under anaesthesia was found to be the most cost effective of the three, but had the longest waiting times.
Arthroscopic capsular release is the most invasive of the three.
Which gives you a genuinely different basis for the conversation. Not which works best, but which set of trade offs suits your circumstances. How quickly you need to be seen. How you feel about a general anaesthetic. Whether you can tolerate a possibility of needing something further.
What About Hydrodilatation?
This is the treatment many people ask about, and the honest answer is an evidence gap.
Hydrodilatation involves injecting a volume of sterile saline, usually with a corticosteroid, into the joint to distend the capsule. Volumes of up to around 40ml are described.
The systematic review found that evidence of its effectiveness, based on four randomised trials, was inconclusive, and the authors identified it specifically as an evidence gap requiring a rigorously designed and adequately powered trial.
It was not included in UK FROST, and the trial authors noted in subsequent correspondence that it was not common during the study period and that evidence to support its use remains scarce.
That is not a reason to avoid it. It is a reason to understand that if it is offered, it sits on weaker evidence than the three options above, rather than on stronger evidence.
What the Broader Reviews Say
Stepping back from the comparison between intensive treatments.
A review published in the BMJ concluded that there is insufficient evidence to reliably recommend a particular treatment approach for frozen shoulder.
It identified moderate evidence supporting corticosteroid injection or hydrodilatation, and physiotherapy in the reduction of pain and stiffness.
And it noted that a single corticosteroid injection, in people whose frozen shoulder has been present for up to a year, may hasten recovery.
That last point matters for timing. Injections appear to be most useful earlier in the course, when pain dominates, rather than later when stiffness is the main problem.
The Context Worth Holding Onto
Frozen shoulder is described as benign and self limiting.
Which is accurate, and which people frequently hear as more reassuring than it deserves, because self limiting here means resolving over a period typically measured in many months to a couple of years.
And it is not universal. Reviews note that despite the self limiting description, long term symptoms persist in some people.
So the realistic framing: most people get better eventually, the treatments above appear to influence how quickly and how comfortably rather than whether, and none of them is clearly better than the others.
Where Physiotherapy Fits
It is one of the three options tested, and it performed comparably to the two more invasive ones.
What the physiotherapy in UK FROST actually involved was a structured, multi component programme delivered in secondary care, combined with a steroid injection. That is a considerably more substantial intervention than a sheet of exercises.
Which is the distinction worth making if physiotherapy is your chosen route. The trial tested properly delivered, structured treatment. A handful of sessions and a handout is not the same thing.
And regardless of which route you take, rehabilitation matters afterwards. A manipulation or a release restores range under anaesthetic. Keeping that range and rebuilding strength is the work that follows.
Practical Points Through the Course
Early on, when pain dominates, the priority is pain management and maintaining the range you have without forcing it. Aggressive stretching at this stage frequently backfires.
As stiffness dominates, progressive range work and loading become the focus.
Throughout, keep the rest of the arm and shoulder girdle strong, because disuse costs capacity that then has to be rebuilt.
And sleep setup matters, since night pain is one of the more disabling features. A pillow supporting the arm in front of you frequently helps.
One More Thing Worth Raising
If you have been diagnosed with frozen shoulder, it is reasonable to ask your GP about a blood test.
The association between frozen shoulder and diabetes is strong, and in research examining people presenting with frozen shoulder and no known diabetes, a substantial proportion were found to have diabetes or prediabetes when tested.
Published analyses have concluded that screening should be considered in patients presenting with this condition.
Symptoms That Need Prompt Assessment
See your GP promptly for:
Shoulder stiffness following a specific injury, which may indicate something structural.
True weakness rather than pain limited movement.
Numbness, tingling or weakness down the arm.
Severe unrelenting night pain.
Shoulder pain with fever, unexplained weight loss, or any history of cancer.
And seek emergency care for shoulder or arm pain accompanied by chest discomfort or pressure, breathlessness, sweating, nausea, or pain spreading into the jaw.
Make an Informed Choice
When three treatments produce comparable outcomes, the decision belongs to you, based on the trade offs rather than on a hierarchy.
Body Zest offers a free discovery visit at no cost and no obligation. You will get a thorough assessment confirming what you are dealing with, a clear explanation of the stage you are in, and an honest account of your options including the ones we do not provide.