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Frozen Shoulder

Causes, Symptoms, Treatment, & Other resources

Shoulder injuries can be debilitating, and a very painful and limiting one is called a frozen shoulder. What is a frozen shoulder?  What is frozen shoulder manipulation?  What is the frozen shoulder manipulation success rate?  What should I expect after shoulder manipulation?  What is the best treatment for frozen shoulder?  Let’s dig in.

What Is a Frozen Shoulder?

Frozen shoulder, also known as adhesive capsulitis, is a painful loss of shoulder movement and range in motion.  The incidence of frozen shoulder is 3-5% in the general population and up to 20% in those with diabetes (1).  The peak incidence is between 40-60 years of age (2).  The exact mechanism is poorly understood.  In general, the capsule becomes inflamed, thickened, and contracted with pain and significant restriction in range of motion. 

Causes of Frozen Shoulder

Causes are poorly understood but risk factors include trauma, prolonged immobility, systematic diseases such as diabetes, stroke, connective tissue disease, and heart disease.  Other causes include post-surgery, chronic inflammation causing stimulation of myofibroblasts (3).


True to its name, the shoulder starts to lose range of motion, making it hard to do everyday tasks, as if frozen. Frozen shoulder typically develops gradually, and in three phases. Each stage may last months.

  • Freezing stage. Pain occurs when you move your shoulder, and the range of motion of your shoulder begins to be restricted.
  • Frozen stage. The pain begins to lessen at this point. While your shoulder gets stiffer, using it becomes more difficult.
  • Thawing stage. Your shoulder’s range of motion begins to improve.

Arm Pain at Night

Arm pain at night can be miserable.  The pain can interrupt your sleep and erode your quality of life. Irritability becomes increasingly more common.  What are the causes?  When should I worry about it?  What are the treatment options for arm pain at night? The neck is composed of 7 boney building blocks numbered 1- 7. Sandwiched between the bones is a disc that functions as an important shock absorber. The cervical discs are susceptible to injury due to trauma, degeneration, repetitive motion, and surgery. Common disc injuries include disc bulges, and herniations. The injured disc can compress or irritate one or more nerves resulting in arm pain at night. It can…

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Left Shoulder Blade Pain

Learn to know the symptoms and causes of shoulder blade pain as well as the diagnostic tests to run for it and its treatment options. Shoulder blade pain can be a common, annoying, hard to diagnose problem. There are many different causes of shoulder blade pain and the exact cause of the shoulder blade pain will determine what type of treatments would be recommended.

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Shoulder Cracking

The Scapula is your shoulder blade. It is a large triangular bone that compromises part of the shoulder joint. The Scapula is positioned over the back chest wall and ribs where it moves in different directions with shoulder movements (1). The Scapula meets with the arm bone (humerus) to form the shoulder joint. It also meets with the clavicle to form the AC joint. Multiple structures attach onto the Scapula which provides important support and movement for the scapulae and shoulder joint (2). These include:- Muscles/Tendons: Multiple muscles attach to the Scapula which include the deltoid, supraspinatus, infraspinatus, triceps, and teres minor.

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Shoulder Pain at Night

There are several reasons why shoulder pain at night occurs or is aggravated; The common explanations include: Sleep typically involves a static position lasting hours at a time with little or no movement. Sleeping on your side places additional pressure on the tendons and bursa of the shoulder. Sleep can cause muscles and tendons to settle in a slightly different position resulting in additional pressure and reduced blood flow. Identifying the underlying problem is important!  This allows therapy to focus exclusively on the exact problem or problems.  When appropriate conservative care is always the first line of treatment.  Focus is typically on strengthening and improving range of motion. 

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Shoulder Pain When Reaching Across Body

Shoulder pain can make simple chores almost impossible.  Have you ever reached for an object high on a shelf only to have pain that takes your breath away?  What causes shoulder pain when reaching across the body?  What is shoulder impingement?  What does shoulder impingement feel like?  Can a shoulder X-ray show shoulder impingement?  What are the treatment options for shoulder pain when reaching across the body? ulder impingement and rotator cuff injuries are among the most common causes of shoulder pain (1).  Both can cause shoulder pain when reaching across the body. Shoulder impingement is a painful condition in which the bursa and muscles of the shoulder are pinched or compressed. 

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Why Does My Shoulder Hurt When I Lift My Arm?

Shoulder pain can be very non-specific, meaning that multiple structures and issues can cause identical pain in the shoulder. Most shoulder examination maneuvers are very limited in their ability to assess exactly what the problem is.  With pain when lifting your shoulder, it is critical to take a detailed history, good examination, coupled with imaging to fully understand what is causing the shoulder pain.  Many conditions can present with these symptoms

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What Is Frozen Shoulder Manipulation?

Manipulation under anesthesia (MUA) is a procedure that is performed in a hospital or ambulatory surgery setting. It is performed when conservative therapies have failed.  After the patient is anesthetized the surgeon forcefully moves the shoulder in various directions in an effort to stretch or tear the scar tissue.  Risks include fracture of the arm bone, dislocation of the shoulder, tears in the rotator cuff and labrum, blood clots, and nerve damage (4). Manipulation under anesthesia is typically combined with an intra-articular steroid injection.  Steroids are toxic to cartilage and other orthopedic tissue (5).

Frozen Shoulder Manipulation Success Rate

Success rates vary depending upon the parameters being evaluated and time points.  Patient satisfaction varied.  Dodenhoff reported that 41% of patients with frozen shoulder were satisfied at six weeks and 87% at three months (6)   A 2000 study of 37 patients with frozen shoulder who underwent MUA, at 3 months 59% had no or mild pain and limitation vs 28% had moderate pain and restriction (7)  At 15-year followup, Ferrel et al described a mean 8/10 satisfaction level (8).  A high-level review of the literature pointed out an important flaw in the studies to date examining the frozen shoulder manipulation success rate.  All but one study lacked a control group that did not undergo manipulation (9). This is essential to determine the true effectiveness of a procedure.  This is the gold standard in medicine and was incorporated compromising the validity of the reported results.

What Should I Expect After Shoulder Manipulation?

Recovery time varies can vary based upon several factors including the severity of shoulder scarring, general health, and range of motion.  Expect pain due to the stretching and tearing of scarred down tissue.  Oral narcotics and muscle relaxants are commonly used during the first one to two weeks.  Physical therapy is critical and should be instituted early.

What Is the Best Treatment for Frozen Shoulder?

Conservative therapy is the initial treatment of choice.  Surgery is often recommended when conservative options have failed.  The aim of surgery is to release the scarred shoulder tissue and supporting ligaments. Both surgery and manipulation under anesthesia have similar outcomes at 2 and 3 years (10).  Surgery has the risks of bleeding, infection, failure, nerve injury, and rotator cuff injuries.  Is there a regenerative option?

Yes!  At the Centeno-Schultz Clinic, capsular distention is performed for patients with frozen shoulder and advanced shoulder arthritis.  The shoulder joint is first injected with a large volume of local anesthetic which numbs the joint and stretches the capsule.  Once the shoulder joint is numb, PRP is injected to further stretch the shoulder capsule.  The injected PRP distends the shoulder capsule and provides growth factors to facilitate healing.  The shoulder is then put through both active and passive range of motion in an effort the stretch the tight capsule.  Regular physical therapy thereafter is important to maintain shoulder range of motion.  Is this different than MUA?  Absolutely as the former is aggressive torquing of the shoulder joint during a general anesthetic followed by injection of steroid injection which can compromise both the cartilage and rotator cuff tendons.  At the Centeno-Schultz Clinic, high dose steroids are not used.  Rather PRP which is rich in growth factors is injected using ultrasound guidance.

Graston Technique

The Graston Technique® (GT) is a manual therapy used to diagnose and treat soft tissue injuries and pain. It involves using handheld instruments that allow clinicians to detect and treat scar tissue and adhesions in muscles, tendons, and ligaments.  It is usually performed to increase the range of motion of the soft tissues, especially after a soft tissue injury. It can be used to treat a variety of conditions, including tendinitis, plantar fasciitis, carpal tunnel syndrome, and rotator cuff injuries.  Short-term studies have shown that it successfully improves the range of motion with around six treatments for the ankle and elbow (1)…

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The other day I was evaluating a patient and reviewing the treatment options for their spine condition.  After discussing prior treatments, we got to the topic of medications taken for pain relief. She explained that she mainly utilized anti-inflammatory (NSAID) medications and then she told me to hold much she takes and has been for many years…..she takes close to 2 grams (2000 milligrams) on a daily basis which equated to about 9-10 capsules of medication per day.  I was shocked, considering she was pre-diabetic and with high blood pressure plus the kicker of it is that her PCP (primary care physician) is ok with this…

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Platelet-Rich Plasma (PRP) Injections

PRP is short for platelet-rich plasma, and it is autologous blood with concentrations of platelets above baseline values. The potential benefit of platelet-rich plasma has received considerable interest due to the appeal of a simple, safe, and minimally invasive method of applying growth factors. PRP treatments are a form of regenerative medicine that utilizes the blood’s healing factors to help the body repair itself by means of injecting PRP into the damaged tissue. In regenerative orthopedics, it is typically used for the treatment of muscle strains, tears, ligament and tendon tears, minor arthritis, and joint instability. There have been more than 30 randomized controlled trials of PRP…

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Prolotherapy Injections

It has been successful in the treatment of many disorders including neck, shoulder, knee, and ankle pain. Dr. Centeno recently published an article in The Journal of Prolotherapy in which he discusses the use of x-ray guidance with prolotherapy. This ensures that the injection is in the correct place to maximize clinical results. Dr. Centeno discusses the use of prolotherapy for the treatment of neck, knee, sacroiliac joint, ankle, ischial tuberosity, and shoulder pain. At the Centeno-Schultz Clinic x-ray guided prolotherapy is just one of the therapies utilized in the successful treatment of pain. Regenerative injection therapy (RIT) or prolotherapy…

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In Conclusion

Frozen shoulder is also known as adhesive capsulitis and is a painful loss of shoulder movement and range in motion.  Its exact cause is poorly understood. Risk factors include trauma, surgery, prolonged immobility, and systematic diseases such as diabetes and cardiovascular disease. Manipulation under anesthesia (MUA) is a procedure where the shoulder is aggressively put through maneuvers in an attempt to break up or stretch the scar tissue.  Patients undergo general anesthetic and receive a shoulder steroid injection at the completion of the MUA.   Frozen shoulder manipulation success rate varies over time and most study designs are flawed as they did not evaluate placebo. Surgery is recommended to those who fail conservative treatment.  Surgery and MUA have similar outcomes at 2-3 years.   MUA involves the injection of steroids which are toxic to orthopedic tissue and should be avoided.  PRP is a safe alternative to steroids and is used at the Centeno-Schultz Clinic in the treatment of frozen shoulders.

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Our Doctors Who Treat Frozen Shoulder

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

My passion and specialization are in the evaluation and treatment of cervical disc, facet, ligament and nerve pain, including the non-surgical treatment of Craniocervical instability (CCI). I quit a successful career in anesthesia and traditional pain management to pursue and advance the use of PRP and bone marrow concentrate for common orthopedic conditions. I have been a patient with severe pain and know firsthand the limitations of traditional orthopedic surgery. I am a co-founder of the Centeno-Schultz Clinic which was established in 2005. Being active is a central part of my life as I enjoy time skiing, biking, hiking, sailing with my family and 9 grandchildren.

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Matthew William Hyzy, D.O.

Doctor Hyzy is Board Certified in Physical Medicine and Rehabilitation (Physiatry) and fellowship-trained in Interventional Orthopedics and Spine. Dr. Hyzy is also clinical faculty at the University of Colorado School of Medicine in the Department of Physical Medicine and Rehabilitation; In addition, Dr. Hyzy is an Adjunct Clinical Assistant Professor at The Rocky Vista University College of Osteopathic Medicine. Dr. Hyzy also maintains an active hospital-based practice at Swedish Medical Center and Sky Ridge Medical Center. He is also recognized and qualified as an expert physician witness for medical-legal cases and Life Care Planning. He is published in the use of autologous solutions including…

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Other Resources

  • How To Release A Pinched Nerve In The Shoulder

    A pinched nerve in the shoulder occurs when a nerve is compressed or irritated anywhere along its path, from the nerve root where it emerges from the cervical spine to the area in the shoulder it supplies. This can lead to shoulder pain, numbness, and pins and needles, and can even affect the movement of … Continued

  • Rotator Cuff Tear Relief Without Surgery: A How-To Guide

    INTRODUCTION: Welcome to the How-to Guide for Rotator Cuff Tear Relief Without Surgery. If you want to avoid Rotator Cuff surgery, you’re in the right place! Let’s start with the basics. Basics The basics of Rotator Cuff tears include 4 different muscles, 1 in the front, 1 on the top and 2 in the back. … Continued

  • When Not to have Rotator Cuff Surgery? Know Your Options

    It happened as you were playing racketball. There was loud pop followed by immediate pain. Moving your shoulder is almost impossible. What is the rotator cuff? What causes rotator cuff tears? What is rotator cuff surgery? When not to have rotator cuff surgery? Let’s dig in.What Is the Rotator Cuff? (4 Tendons) The rotator cuff is a group of four muscles and tendons that stabilize the ball and socket shoulder joint (1). The four muscles that compromise the rotator cuff are the: Supraspinatus, Infraspinatus, Subscapularis, and Teres minor. The rotator cuff is also important in shoulder functions such as reaching outward, reaching overhead, and putting your hand into your back pocket. Tendons attach muscles to bones. Tendons are susceptible to acute inflammation, degeneration, and tears. Rotator cuff tears are common…

  • KT Tape Shoulder: Facts You Need to Know!

    KT Tape is used extensively for shoulder injuries. Dr. Schultz discusses what KT tape is, what it is used for, how it helps shoulder pain, whether it really works and a better solution.

  • Rotater Cuff Tear Surgery

    Shoulder Pain Shoulder pain can come in many different forms and be caused by many different issues. Many structures exist in a small area making it more difficult to accurately diagnose what is causing pain without spending appropriate time to diagnose the issue. Common causes of shoulder pain include shoulder arthritis, acromioclavicular (AC) joint sprain … Continued

  • MRI Images Showing Torn Rotator Cuff

    What Is the Rotator Cuff? The Rotator Cuff is a group of 4 principal muscles that stabilize and support the shoulder joint. The four muscles, and their attached tendons that comprise the Rotator Cuff are the supraspinatus, infraspinatus, subscapularis, and teres minor, and any of these could be where we could find Rotator Cuff tears. … Continued

1.Manske RC, Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med. 2008;1(3-4):180-9.DOI: 10.1007/s12178-008-9031-6.

2.Robinson CM, Seah KT, Chee YH, Hindle P, Murray IR. Frozen shoulder. J Bone Joint Surg Br. 2012;94:1–9.

3. Ko JY, Wang FS, Huang HY, Wang CJ, Tseng SL, Hsu C. Increased IL-1beta expression and myofibroblast recruitment in subacromial bursa is associated with rotator cuff lesions with shoulder stiffness. J Orthop Res. 2008;26(8):1090-7. DOI: 10.1002/jor.20631.

4.Uppal HS, Evans JP, Smith C. Frozen shoulder: A systematic review of therapeutic options. World J Orthop. 2015;6(2):263-8. doi: 10.5312/wjo.v6.i2.263.

5.Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015;3(5):2325967115581163. doi: 10.1177/2325967115581163.

6. Dodenhoff RM , Levy O , Wilson A , Copeland SA . Manipulation under anesthesia for primary frozen shoulder: effect on early recovery and return to activity. J Shoulder Elbow Surg 2000;9:23-26.

7.Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA. Current review of adhesive capsulitis. J Shoulder Elbow Surg. 2011;20:502–514.DOI: DOI: 10.1016/j.jse.2010.08.023.

8.Farrell CM, Sperling JW, Cofield RH. Manipulation for frozen shoulder: long-term results. J Shoulder Elbow Surg. 2005;14(5):480-4. DOI: 10.1016/j.jse.2005.02.012.

9.Kraal T, Beimers L, The B, Sierevelt I, van den Bekerom M, Eygendaal D. Manipulation under anaesthesia for frozen shoulders: outdated technique or well-established quick fix. EFORT Open Rev. 2019;4(3):98-109. doi: 10.1302/2058-5241.4.180044.

10.Sharma S. Management of frozen shoulder – conservative vs surgical. Ann R Coll Surg Engl. 2011;93(5):343-4; discussion 345-6.doi: 10.1308/147870811X582080.

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