Episode 30 | Ask the Expert | Guest: Dr Lewis Raiman MBBS, MRCGP, FFSEM – Consultant in Sports and Exercise Medicine, LBSM
Shoulder pain is one of the most common musculoskeletal complaints seen in clinic, and frozen shoulder is one of its most disruptive causes. Unlike many sports injuries, it often has no clear trigger. It can develop gradually in someone who has never had a shoulder problem before, and without appropriate treatment it can run its course over 18 months or more.
In this episode of the London Bridge Sports Medicine podcast, Lucie is joined by Dr Lewis Raiman, Consultant in Sports and Exercise Medicine at LBSM, to walk through everything a patient needs to understand about frozen shoulder – from the first vague ache to full recovery.
What is frozen shoulder?
Frozen shoulder – clinically known as adhesive capsulitis – is a condition in which the capsule surrounding the shoulder joint becomes thickened, inflamed, and progressively tighter, causing pain and significant restriction of movement. What makes it distinctive is that it typically develops without any identifiable injury or incident. One day the shoulder simply begins to ache, and things gradually worsen from there.
The condition passes through three recognisable stages:
- Painful stage – a vague, often worsening pain across the shoulder, sometimes radiating into the upper arm. Night pain is very typical. Movement and activity aggravate it. This stage is often misattributed to rotator cuff problems or shoulder impingement.
- Freezing stage – range of motion progressively reduces. Patients notice difficulty reaching behind their back, lifting the arm above their head, putting on a top, doing up a bra, or reaching for a seat belt. The restriction can become marked when compared side to side.
- Thawing stage – pain and stiffness gradually ease and range of motion returns. The process is slow. Average duration across all three stages is around 18 months, though this varies considerably.
Who gets it – and why?
Frozen shoulder most commonly affects people between the ages of 40 and 60, and there is evidence suggesting women are affected more frequently than men. Certain medical conditions significantly increase the risk – diabetes in particular is strongly associated, and Dr Raiman routinely checks for undiagnosed metabolic conditions through blood screening when a patient presents with a frozen shoulder diagnosis. Thyroid disruption is also thought to be a contributing factor in some cases.
Around 15 to 20% of cases appear to have a traumatic trigger – a previous fracture, a significant muscle strain, or a tendinopathy that was never fully resolved. In these cases, the period of reduced shoulder use following injury seems to prompt the capsular response. For patients with diabetes or a history of frozen shoulder in one shoulder, the risk of the other shoulder being affected at some future point is a genuine consideration.
How is it diagnosed?
Frozen shoulder is primarily a clinical diagnosis – meaning a thorough history and examination, in the hands of an experienced clinician, is usually sufficient to make the diagnosis with confidence. The pattern of pain and restricted movement, the absence of a clear injury trigger, and the characteristic difficulties with specific movements (reaching behind the back, lifting above the head) are strong indicators.
Investigations are used mainly to rule out other causes rather than confirm the diagnosis. Dr Raiman uses in-clinic ultrasound to assess the rotator cuff tendons and the posterior aspect of the shoulder joint, which helps exclude conditions such as rotator cuff tears or shoulder arthritis that can present similarly. MRI is available when there is suspicion of referred pain from the neck – a bulging disc or trapped nerve can produce a very similar symptom pattern. Blood tests are routine to check for underlying metabolic conditions.
Treatment: physiotherapy is the foundation
The cornerstone of frozen shoulder management is physiotherapy, ideally delivered with a progressive protocol focused first on restoring range of motion and then building strength. The challenge is that physiotherapy works best when pain is not overwhelming engagement with it – and in the painful and freezing stages, it often is.
This is where the sports medicine contribution becomes particularly valuable. By managing pain and stiffness medically, Dr Raiman’s role enables patients to engage fully with physiotherapy rather than being limited by it. The two approaches work best in combination.
Injection therapy: two different tools for two different stages
The type of injection that is most appropriate depends on which stage of frozen shoulder the patient is in.
Corticosteroid injection – for the painful stage
When pain is the dominant symptom – disrupting sleep, limiting daily activities, preventing engagement with physio – a targeted steroid injection into the shoulder joint can provide significant and relatively rapid relief. The effect on pain and inflammation can be dramatic, improving not just comfort but sleep quality and day-to-day function. Evidence supports the use of steroid injection combined with physiotherapy as producing better outcomes than either approach alone.
Hydrodistension – for the freezing stage
When stiffness rather than pain becomes the primary issue – the shoulder is restricted and range of motion is not returning – a different procedure is indicated: hydrodistension (also called hydrodilatation). This involves injecting a higher volume of fluid (local anaesthetic, steroid, and saline) into the shoulder joint under imaging guidance, with the aim of physically expanding the thickened, contracted capsule.
Patients often notice an improvement in range of motion relatively quickly after the procedure. The evidence for hydrodistension in accelerating recovery from frozen shoulder is strong. Crucially, patients are encouraged to begin gentle range of motion exercises within 24 hours and to attend physiotherapy within a week – the procedure is the starting pistol for rehabilitation, not a substitute for it.
In clinical practice, the line between stages is rarely as clean as the textbook suggests – many patients present with both pain and stiffness simultaneously. The decision about which intervention is most appropriate is always based on the individual assessment.
What recovery looks like
Both injection procedures are quick – setup takes longer than the procedure itself – and patients go home the same day. Typical advice is a short period of relative rest followed by prompt re-engagement with activity. “We’ve moved away from bed rest,” says Dr Raiman. “We know that if we’re not using the shoulder, it will stiffen up. We’re very proactive from that aspect.”
For patients returning to sport, the same principle applies: a graduated, progressive return rather than jumping straight back in. For racket sports players in particular – an area Dr Raiman knows well from his time working with the Lawn Tennis Association – the temptation to return to full play too quickly is a real risk. Spikes in load after a period of restricted movement are a reliable trigger for setback.
The last degrees of range of motion are typically the hardest to recover. Getting broadly functional range back is usually achievable relatively quickly; regaining full, pain-free end-range movement in all directions takes longer and requires consistent, ongoing work.
The bottom line
Frozen shoulder is a self-limiting condition – it will eventually resolve – but left entirely to its own devices that can take a very long time, with significant impact on quality of life throughout. With the right combination of physiotherapy and targeted injection therapy, recovery can be meaningfully accelerated, pain can be controlled, and the disruption to sleep and daily life substantially reduced.
If you are experiencing shoulder pain that is worsening gradually, affecting your sleep, or making it difficult to dress or reach behind your back, it is worth getting it assessed sooner rather than later. Getting the diagnosis right is the first step – and there is a lot that can be done from there.
Dr Lewis Raiman (MBBS, MRCGP, FFSEM) is a Consultant in Sports and Exercise Medicine at London Bridge Sports Medicine. He holds clinics at Highgate Private Hospital and at the London Bridge Clinic at the Shard.
To book an appointment with Dr Raiman or another member of the LBSM team, visit lbsm.co.uk/booking
Listen to the full episode below ↓
