Information on Frozen shoulder – Adhesive capsulitis and Platelet Rich Plasma Therapy

Marc Darrow, MD., JD.

Clinically we have seen many patients with various and diverse shoulder problems. One such problem is the problem of frozen shoulder. People with frozen shoulder are typically someone who had a shoulder injury or surgery that required immobilization or someone who suffers from diabetes. As we are dealing with treatments surrounding musculoskeletal repair, we will focus on post-traumatic injury or surgical cause of “frozen shoulder.” Below is also new research on the use of PRP shoulder injections in the frozen shoulder shoulders of diabetes patients.

Many people contact us after they have had tradition treatments for their frozen shoulder. This included manipulation, stretching, corticosteroids, injectable painkillers or numbing agents and various other remedies. Sometimes these treatments work well. Sometimes they work well enough. Sometimes they do not help at all and another surgery may be called for. In these cases people may reach out to us to see if Platelet Rich Plasma injections may help. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration.

Is an MRI necessary to diagnose frozen shoulder?

A June 2022 paper (1) wrote: “Shoulder magnetic resonance imaging (MRI) is commonly performed in patients with frozen shoulder. However, the necessity of MRI and its diagnostic value is questionable.” The goal of the study was to see if MRI found anything else in the shoulder not previously suspected in the clinical examination and if any change in the treatment plan based on these additional MRI findings in frozen shoulder patients was observed.

In 403  patients a shoulder MRI was performed. An additional structural shoulder pathology was identified in 89 of 403 (22%) patients following the shoulder MRI, mostly rotator cuff tears (partial 11.4%, full-thickness: 7.4%, re-rupture following reconstruction: 2.5% and labrum tears 0.7%. At minimum 2-year follow-up, 11 of 403 (2.7%) patients were treated surgically for the additional pathology identified on the MRI scan consisting of an arthroscopic rotator cuff reconstruction in 10 patients and a labrum refixation in one patient. Five of the 609 (0.8%) patients were treated for refractory frozen shoulder by arthroscopic capsulotomy.

Conclusions: “Although additional pathologies were identified in 22% of the patients, a change in treatment plan due to the MRI findings was only observed in 2.7% (that is 37 MRIs needed to identify 1 patient with frozen shoulder requiring surgery for the additional MRI findings). Therefore, routine use of shoulder MRI scans in patients with frozen shoulder but without suspicion of an additional pathology may not be indicated.”

Shoulder instability and shoulder immobilization as a cause of frozen shoulder

Until recently, it was common in cases of dislocation to immobilize the shoulder for long periods of time. But studies showed that while immobilization helped alleviate the pain of such injuries, it also contributed to a general weakening of the ligaments and predominance of “adhesive capsulitis,” where the arm is frozen (frozen shoulder) and can no longer be lifted. In cases of painful shoulder and instability, the shoulder ligaments and tendons within the shoulder joint capsule, when damaged, can cause a “swelling” or thickening of the tissue within the shoulder, preventing normal range of motion. It is during this time that scar tissue can form.

Frozen shoulder and cervical radiculopathy, links and misdiagnosis risks

A May 2024 study (2) investigated the connection between adhesive capsulitis (frozen shoulder) and cervical radiculopathy. The researchers wrote of their study: “Patients with cervical spondylosis often exhibit shoulder symptoms. Cervical radiculopathies, particularly C5, can cause severe shoulder pain and reduced shoulder mobility, mimicking glenohumeral adhesive capsulitis (frozen shoulder), a common shoulder condition.”

The data:

  • 438 patients who underwent glenohumeral hydrodistension (filling and stretching the shoulder joint with water and steroids).
  • Included were individuals with unilateral frozen shoulder investigated using ultrasound and cervical spine MRI to investigate cervical spondylosis.
  • Among the 438 patients, 107 reported frozen shoulder and neck pain (24.5%)
  • A significant association between ipsilateral frozen shoulder and C4/5 foraminal stenosis was observed.
    • Ipsilateral (same side of body) foraminal stenosis was observed in 57.3% of these cases, with bilateral stenosis in 29.1%.
    • Additionally, 78% had neck pain on the same side as their frozen shoulder, and 44% had pain radiating to the shoulder.
    • 48% patients underwent nerve-targeted interventions, with 44% addressing the C5 nerve (25% C5 steroid injection and 19% C4/5 anterior cervical discectomy and fusion).

Conclusion from the researchers: A substantial association between C5 foraminal stenosis and ipsilateral frozen shoulder was found. C5 radiculopathy could be a risk factor for “neurogenic frozen shoulder.” Those diagnosing frozen shoulder and cervicobrachialgia (neck and shoulder pain) should recognize that frozen shoulder and C5 radiculopathy may coexist.”

Frozen shoulder treatments filled with controversy

A paper published in November 2021 (3) offers us an understanding of the controversies surround frozen shoulder treatment:

“Despite being relatively common, one might say a frozen shoulder remains full of controversy. One of the debatable issues concerns the best treatment method. Through various nonsurgical procedures remaining a gold standard of treatment, many studies investigated nonsteroidal anti-inflammatory drugs, corticosteroids including oral steroids and local injectable steroids, and physiotherapy. There have also been some studies concerning the usage of acupuncture, hydrodilatation, calcitonin, extracorporeal shock wave therapy, and nerve block. The surgical treatment that consists of manipulation under anesthesia and arthroscopic capsular release is recommended only when an extended nonsurgical therapy for 6–9 months is unsuccessful.

The justification for waiting to decide on surgical treatment in patients with an idiopathic frozen shoulder is that it has always been considered a disease starting with a decreasing function in the first month in every case, with symptoms resolving spontaneously sooner or later. Some studies report even up to 90% of patients in whom nonsurgical methods or even no therapy is used will resolve the symptoms of the disease.”

From aggressive treatment to no treatment at all. How does a person know what path to take?

Exercise, physiotherapy, and conservative care treatments.

A November 2021 paper (4) compared the clinical and functional outcomes of patients diagnosed with an idiopathic frozen shoulder with symptom onset of a maximum of six months, treated by arthroscopic capsular release followed by corticosteroid injection and physiotherapy to patients who received only corticosteroid injection followed by physiotherapy.

  • The patients of the study were divided into two groups:
    • Those who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy, or
    • Those who received only corticosteroids injection and physiotherapy.
  • Both groups were examined in terms of shoulder range of motion (ROM), pain intensity, and function before a given treatment and three, six, and twelve months later.
  • The groups were comparable pre-treatment in terms of ROM, pain, and functional outcome.
    • Group I, those who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy had statistically and clinically significantly better ROM and function at three and six months post-treatment than Group II. Those who received only corticosteroids injection and physiotherapy.
    • Despite being statistically significant, the between-group differences at twelve-month follow-up in ROM and function were too small to be considered clinically notable. The between-group comparison of pain revealed no significant differences at any post-treatment point of time. The early arthroscopic capsular release preceding corticosteroid injection and physiotherapy seemed more effective at three- and six-month follow-up; however, it brought a comparable result to corticosteroid injection and subsequent physiotherapy at twelve months follow-up.

Intra-articular corticosteroid and suprascapular nerve block combination

A December 2021 study (5) evaluated the short and long-term effects of the combination of suprascapular nerve block  (an injection of painkiller near the suprascapular nerve. Typically this nerve block provides pain relief within a month and up to six months in the shoulder) and intra-articular corticosteroid injection on pain, shoulder range of motion  , disability, and quality of life in the management of patients with adhesive capsulitis.
In this study Forty patients (ages 30-70 years) who were diagnosed with adhesive capsulitis stages 1 and 2 were randomly assigned to one of two groups:
  • Group-1 received intra-articular corticosteroid and suprascapular nerve block combination, while group-2 only-intra-articular corticosteroid. The difference the research found between the two groups was the suprascapular nerve block as an adjunct to intra-articular corticosteroid in adhesive capsulitis positively affected the immediate pain relief and functional improvement after the intervention; however, it did not yield any additional benefit in the short and long-terms.

Extracorporeal shock wave therapy for frozen shoulder

Two papers in the Journal of physical therapy science suggest that some patients may benefit from extracorporeal shock wave therapy. The concept behind extracorporeal shock wave therapy or shock wave therapy is that a focused shock or pressure waves created by an electric charge may impact the frozen shoulder tissue with enough force to cause an inflammation and circulation to come to the area of injury to start a repair.

The first of the two studies mentioned above (6) compared outcomes in 15 patients receiving extracorporeal shock wave therapy for frozen shoulder against a group of 15 patients who had conservative physical therapy. Both groups showed improvement in pain reduction and better range of motion. The extracorporeal shock wave therapy group showed better improvement than the conservative physical therapy group.

The second study (7) compared the effectiveness of extracorporeal shock wave therapy versus ultrasound therapy. The patients in this group suffered from diabetic frozen shoulder. The doctors in this study found improvement in both patient groups pain and function scores. The extracorporeal shock wave therapy showed significantly better results in reduced pain.

An April 2024 study (8) examined the evidence related to the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular lidocaine / steroid injection in individuals with frozen shoulder.

In this study 60 eligible participants with frozen shoulder were included and the active group of thirty receiving a lidocaine injection (1% lidocaine (Xylocaine) and 2cc (80 mg) methylprednisolone acetate) with active ESWT  three sessions a week for 4 weeks. The placebo group of thirty people received lidocaine injection with placebo treatment (a special head that blocked the shock waves) three sessions a week for 4 weeks.

Both groups received progressive resistance exercises (PRE) to the shoulder muscles. At four weeks the treatment group showed an improvement in pain and function compared to the placebo group. Similar effects were noted after 8 weeks and at the 6-month follow-up. Similar improvements were also found in the thickness of the coracohumeral ligament, abduction and lateral rotation, functional disability, kinesiophobia, depression status and quality of life at the 6-month follow-up period. “The study concluded that the addition of extracorporeal shockwave therapy after intra-articular lidocaine injection improves pain, functional disability, range of motion, kinesiophobia, depression status, and quality of life in people with frozen shoulder.”

Research on Platelet Rich Plasma injections – PRP may help frozen shoulders

There are many treatments that can work for to get the shoulder “unstuck” or “unfrozen” as described in the above research. Platelet Rich Plasma is seen as a treatment that can help frozen shoulder by addressing the problems of shoulder instability which can cause a thickening of the shoulder capsule.

A July 2024 study (16) reviewed the effectiveness of PRP treatments for frozen shoulder. In this review, patient data from six previous studies and 578 patients with 263 patients receiving PRP (45.5%).

  • All six studies used PRP as part of non-operative treatment. PRP was compared to another intervention in all six studies. Four of these studies found PRP to be more effective.

The authors concluded: “PRP is a safe treatment option that can be added to the investigative treatment arsenal of adhesive shoulder capsulitis”

A January 2021 (9) study suggested PRP injections could help frozen shoulder.

This was triple blind study, the doctors did not know what they were injecting, the patients didn’t know what they were being inject with and the researcher analysis did not know what treatment offered the results they were examining.

  • Methods: 32 adult patients with adhesive capsulitis (21 female, 11 male with an average age of 57, ranging from 23 to 70) were included in this study.
  • Patients had to have shoulder pain and restrictions in movements (at least 25% when compared to the other side, and at least in two directions) for three months minimum and nine months maximum.
  • Patients were randomized to two groups, and one group took PRP injections for three times every two weeks, while the other group took saline injections in same frequency and volume.
  • A standardized exercise program was also applied to all patients.
  • Patients were evaluated with Shoulder Pain and Disability Index (SPADI), Visual Analogue Scales for pain and disability, ranges of movements, and use of analgesics in before, after, and third month after the initiation of the therapy.

Results: Baseline comparisons between groups showed no differences.

  • Shoulder Pain and Disability Index  and ranges of motion in all directions showed significant improvements with therapy, and the group which took PRP injections showed better improvements when compared to the control group. Visual Analogue Scale was found to be better for the PRP group after therapy and third month, and not for the control group. Use of analgesics was not found to be significant for both groups.

Conclusion: PRP injections were found to be effective in both pain and disability, and showed improvements in a restricted shoulder due to adhesive capsulitis. These findings might point out PRP as a therapeutic option in the management of adhesive capsulitis.

A November 2023 study (10) reviewed patient outcomes with  adhesive capsulitis after PRP injection, determine effectiveness compared to corticosteroid, and compare adverse events. In all, the data from seven studies were reviewed investigating 385 patients undergoing PRP or corticosteroid injections.

  • Both intra-articular PRP and steroid injections resulted in improved outcomes for treatment of adhesive capsulitis at 3 months.
  • PRP injections had significantly better range of motion in passive forward flexion and had improved Shoulder Pain and Disability Index (SPADI) scores compared to steroid, however these may not reach minimum clinical thresholds.
  • PRP had significantly better active and passive internal rotation compared to steroid which did reach minimum clinical thresholds.

Prior to this research there was very limited studies. In fact a search of the medical literature shows two case histories. Both are discussed below.

A December 2021 paper (11) aimed to investigate the effectiveness of intra-articular platelet-rich plasma (PRP) injection in adhesive capsulitis. A total of 40 patients (21 males, 19 females; average age: 57) with idiopathic adhesive capsulitis were included. The patients were randomly assigned into two equal groups as the PRP and the control group.

  • The PRP group received two doses of PRP via intra-articular route biweekly under ultrasound guidance.
  • No injection was performed to the control group.

Results: There were significant differences in pain and function scores at all time points after treatment compared to baseline in both groups. At the end of the study, there were significant differences in the active flexion, passive flexion, active abduction, passive abduction, and active external rotation scores at 12 weeks between the groups. No significant difference was observed between the groups in terms of pain and disability scores and the other parameters (active and passive extension, active and passive internal rotation, passive external rotation) at 2, 6, and 12 weeks. Conclusion: “The addition of PRP to exercise treatment can improve patients’ joint mobility, but not pain and disability in patients with adhesive capsulitis.”

Doctors report case histories using PRP for frozen shoulder

One case history was published in the publication The archives of bone and joint surgery (12). It describes the situation and treatment of frozen shoulder in a 45-year-old-man.

“Platelet-rich plasma can produce collagen and growth factors, which increases stem cells and consequently enhances the healing. To date, there is no evidence regarding the effectiveness of platelet-rich plasma in frozen shoulder. A 45-year-old man with shoulder adhesive capsulitis volunteered for this treatment. He underwent two consecutive platelet-rich plasma injections at the seventh and eighth month after initiation of symptoms. We measured pain, function, range of motion by the visual analogue scale (VAS), scores from the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and goniometer (to measure improvement in arm angles); respectively.

After first injection, the patient reported 60% improvement regarding diurnal (during the day) shoulder pain, and no night pain. Also, two-fold improvement for ROM and more than 70% improvement for function were reported. This study suggests the use of platelet-rich plasma in frozen shoulder to be tested in randomized trials.”

PRP compared to physical therapy in treating frozen shoulder

A December 2020 study (13) evaluated the effect of ultrasound guided injection of PRP into the shoulder joint in patients with adhesive capsulitis  and compared its effect with that of conventional physiotherapy

  • Methods: Sixty-four subjects with adhesive capsulitis were included and randomly allocated into two groups, as follows:
    • PRP (32 patients) : Conservative physical therapy (CPT); short wave diathermy and exercise therapy were performed at three sessions/week for 6 weeks).
    • Treatment outcomes evaluated therapeutic effectiveness before and at 1, 3, and 6 weeks after PRP injection and CPT initiation.

Results: Subjects in both groups showed a significant decrease in the visual analogue scale score for pain and shoulder and hand scores, and they a significant increase in shoulder passive range of motion at all evaluation time points. There was no significant difference in the measured outcomes between the two groups. However, there was less acetaminophen consumption after PRP injection compared with that after conservative physical therapy.

Frozen shoulder treated with PRP in a patient with chronic kidney disease

A published case history from 2020 (14) describes how PRP helped a patient with her adhesive capsulitis brought on by chronic kidney disease. (A point here, we do not treat kidney disease, this case history is about the patient’s frozen shoulder treatment with PRP). Here is the case:

“Adhesive capsulitis is a common problem in patients with chronic kidney disease. Patients suffer from joint stiffness and painful joint movement. Conservative treatments consist non-steroid anti-inflamatory drugs, intraarticular injections and physical therapy. Newer approaches such as platelet-rich plasma injections (PRP) also can be applied but there is little evidence for the effectiveness of PRP in patients with adhesive capsulitis.

A 70 year-old woman, receives dialysis treatment admitted to our out-patient clinic with stiffness and pain in her right shoulder. Her diagnosis was confirmed with MRI as adhesive capsulitis. PRP injection began to be applied as planned; 3 times, 15 days between each injection.

At the last assessment average ROM increased on flexor, abductor and internal rotator sides.” The patient did not however note pain improvement.

In this case the patient noted improvement in range of motion. The study was on three single injections spaced 15 days apart. It may be possible that the patient would have had pain improvement and increased range of motion with further treatment.

Frozen shoulder treated with PRP in a patient with diabetes. A comparison with physical therapy

A November 2021 study (15) compared the efficacy of platelet-rich plasma (PRP) injection with an institution-based physical therapy program for adhesive capsulitis  of the shoulder in patients with diabetes mellitus.

  • A total of seventy diabetic patients with adhesive capsulitis of the shoulder for less than 6 months were assigned to two groups:
    • PRP group and physical therapy group.
    • In the PRP group, 35 patients were administered a single shot of PRP (4 mL) into the glenohumeral joint.
    • In the physical therapy group, 35 patients were given institution-based physical therapy that included 10 30-minute sessions of planned physical therapy over a 2-week period.
    • After the interventions, all patients were prospectively followed for 12 weeks. Intensity of shoulder pain, function, and range of motion were assessed at baseline and then at 3, 6, and 12 weeks.

Results: Thirty-three patients in the PRP group and 32 in the physical therapy group completed the 12-week study. At 12 weeks, patients who received PRP injections showed greater improvement in shoulder pain than those recruited to the physical therapy group.




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2 Russo S, Sharma A, Vardanyan R, Thavarajasingam SG, Riew KD. The Association Between Cervical Foraminal Stenosis and Adhesive Capsulitis: An Imaging-based Case-Control Study. Spine. 2024 May 8:10-97.
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4 Li K, Bichoupan K, Gilchriest JA, Moosazadeh K. Real-world experience of treating frozen shoulder using active manipulation under local anesthetic: A retrospective study. Medicine. 2021 Nov 24;100(47).
5 Atalay KG, Kurt S, Kaplan E, Yağcı İ. Clinical effects of suprascapular nerve block in addition to intra-articular corticosteroid injection in the early stages of adhesive capsulitis: A singleblind, randomized controlled trial.
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7 Muthukrishnan R, Rashid AA, Al-Alkharji F. The effectiveness of extracorporeal shockwave therapy for frozen shoulder in patients with diabetes: randomized control trial. Journal of physical therapy science. 2019;31(7):493-7.
8 Nambi G, Alghadier M, Eltayeb MM, Aldhafian OR, Saleh AK, Alsanousi N, Ibrahim MN, Attallah AA, Ismail MA, Elfeshawy M, Wahd YE. Additional Effect of Extracorporeal Shockwave Therapy with Lidocaine Injection on Clinical and MRI Findings in Frozen Shoulder: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial. Pain and Therapy. 2024 Feb 5:1-8.
9 Ünlü B, Çalış FA, Karapolat H, Üzdü A, Tanıgör G, Kirazlı Y. Efficacy of platelet-rich plasma injections in patients with adhesive capsulitis of the shoulder. International Orthopaedics. 2020 Nov 18:1-0.
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11 Karabaş Ç, Topaloğlu US, Karakükçü Ç. Effects of platelet-rich plasma injection on pain, range of motion, and disability in adhesive capsulitis: A prospective, randomized-controlled study. Turkish Journal of Physical Medicine and Rehabilitation. 2021 Dec 1;67(4):462-72.
12 Aslani H, Nourbakhsh ST, Zafarani Z, Ahmadi-Bani M, Ananloo ME, Beigy M, Salehi S. Platelet-rich plasma for frozen shoulder: a case report. Archives of Bone and Joint Surgery. 2016 Jan;4(1):90.
13 Thu AC, Kwak SG, Shein WN, Htun LM, Htwe TT, Chang MC. Comparison of ultrasound-guided platelet-rich plasma injection and conventional physical therapy for management of adhesive capsulitis: a randomized trial. Journal of International Medical Research. 2020 Dec;48(12):0300060520976032.
14 Şenlikci HB, Afşar Sİ, Özen S. Platelet-rich plasma injection in a patient with adhesive capsulitis due to chronic kidney disease. Agri: Agri (Algoloji) Dernegi’nin Yayin organidir= The journal of the Turkish Society of Algology. 2020 Apr;32(2):113-4..
15 Barman A, Mukherjee S, Sinha MK, Sahoo J, Viswanath A. The benefit of platelet-rich plasma injection over institution-based physical therapy program in adhesive capsulitis patients with diabetes mellitus: prospective observational cohort study. Journal of the Korean Shoulder and Elbow Society. 2021 Nov 11.
16 El-Swaify ST, Refaat MA, AbdelWahab AA, Seddik ME, Mostafa Abdelrazek AE, Doas Y, Beshay PW. Is platelet-rich plasma a new solution for shoulder adhesive capsulitis? A systematic scoping review of the literature. Shoulder & Elbow. 2023 May 17:17585732231174184.



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