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Shoulder Ozone Injection Protocol
Posterior landmarks, fluid volume and schedule for ozone shoulder injections, including a reported septic arthritis case, with Prolozone and ozone-oxygen approaches side by side.
Quick answer: Ozone shoulder injection uses a posterior approach with 2–4 mL of fluid (Wright) and 5–20 µg/mL (Madrid), repeated every 10–14 days (Wright). The sheet also covers a reported septic arthritis case.
Warning
Requires hands-on training from an experienced physician
Shoulder ozone injection should only be performed by a practitioner trained in it by an experienced physician.
Practitioner-only procedure. Injecting ozone, with or without a nutrient mixture, is done by trained, licensed clinicians. This sheet is a reference for them. It is not a self-treatment guide and not medical advice. Strict sterile technique is required every time.
What are the basics of ozone shoulder injection?
- The shoulder is one of the joints in Madrid's general intra-articular table (shoulder, knee, hip, elbow, ankle). Madrid has no separate shoulder section.
- A serious adverse event has been reported after shoulder injections: Cutibacterium acnes septic arthritis needing arthroscopic debridement after four intra-articular ozone/Prolozone injections of 8 mL at 33 µg/mL given without ultrasound. The first injection also contained triamcinolone and lidocaine, and injections 2 to 4 used a proliferant mixture of unknown make-up (Richards 2026). Our study coding found the link to ozone unclear and the cause to be the procedure. It is a reason to keep strict sterile technique.
- Prolozone, as Dr. Jeff Wright teaches it, adds nutrients and ozone to damaged tissue. His explanation: swollen tissue receives less blood, which leaves the area short of oxygen, and ozone supplies bioavailable oxygen.
- Wright's expected course from his own practice: a second injection 10 to 14 days after the first, with results after as few as 3 injections or as many as 6 to 8. Chronically ill patients can need more. He describes his success as 90 to 95 percent. That is his clinical impression, not a trial result.
- Wright's tutorials do not state ingredient amounts. The solution he used is a compounded pre-mix of methylcobalamin (vitamin B12), pyridoxine (vitamin B6), dextrose and procaine. The amounts are in the table below, taken from the compounded formula sheet. He also describes drawing up individual nutrients in a hood.
- The Madrid Declaration describes ozone-oxygen infiltration only: no nutrient mixture. Both are shown side by side below and labeled.
Sources: Dr. Jeff Wright's tutorial videos for MediSkill; Madrid Declaration on Ozone Therapy, 4th edition (ISCO3, 2025), sections 1.12 and 4. Paraphrased.
What dose and technique are used for ozone shoulder injection?
Two approaches are shown side by side. They are different procedures: the Prolozone mixture is Wright's, and ozone-oxygen alone is what Madrid describes.
| Prolozone mixture (per Wright) | Ozone-oxygen only (per Madrid) | |
|---|---|---|
| What goes in | Dr. Wright's pre-mixed solution (formula below), given as 2 to 4 mL in the shoulder, then ozone gas pushed in where the solution went. | Ozone-oxygen mixture only. |
| Fluid volume | 2 to 4 mL, less if the patient has a lot of discomfort. | Not applicable. |
| Gas volume | Not stated. Wright pushes gas in gently until the patient says the pressure is enough. | General joint table: 5 to 20 mL. |
| Concentration | Not stated in the tutorial. | General joint table: low 5, medium 10, high 15 to 20 µg/mL. |
| Approach | Posterior. Inject just below the spine of the scapula, aiming toward the acromion. | Not specified for the shoulder. |
| Schedule | Second injection 10 to 14 days after the first. Results in as few as 3 and as many as 6 to 8 injections. | Not specified for the shoulder. |
Dr. Wright's pre-mixed solution: how it is made (per 8 mL of mixture)
This is the compounded mixture Dr. Wright used in his protocols. The amounts below are the recipe for making the mixture, taken from the compounded formula sheet, not from the tutorial videos. They are not the amount injected at one site.
| Ingredient | Strength | Amount per 8 mL of mixture |
|---|---|---|
| Methylcobalamin (methyl-B12) | 1 mg/mL | 2 mL |
| Pyridoxine (vitamin B6) | 100 mg/mL | 1 mL |
| Dextrose | 50% | 1 mL |
| Procaine | 2% | 4 mL |
| Total | 8 mL |
- Draw up the solution into a sterile syringe using antiseptic technique (the formula sheet uses a 10 mL syringe).
- Inject the solution at the selected site, using this sheet's own technique and volume.
- Leave the needle in place, remove the syringe, and inject the ozone through the same needle.
The volume injected is as Dr. Wright's shoulder demonstration states it: 2 to 4 mL of fluid.
This is a compounded pre-mix with a beyond-use date of 90 days refrigerated. The solution is compounded by a pharmacy and requires a prescriber.
Madrid advises placing any local anesthetic so that the ozone does not break it down. Dr. Wright gives his solution first and then the ozone through the same needle. These are two different practices.
Needle gauge for the shoulder is not stated in the tutorial, so none is given here.
What are the best tips when using ozone shoulder injection?
- Let the alcohol dry before the needle goes through the skin.
- Hold the syringe exactly perpendicular to the needle when you attach the ozone syringe, so the needle does not bend or move deeper or shallower (Wright).
- He knows he is in the right spot from the insertion point and the patient's reaction.
- Tell the patient what to expect. Pressure and fullness while the gas goes in are normal, and the patient should say when it is too much. Wright says an electrical zing is not normal: stop and reposition.
What are the precautions for ozone shoulder injection, and who should avoid it?
- Sterile technique every time. Madrid says most serious side effects trace back to malpractice, including technique, asepsis and antisepsis. Its reported serious events include septic arthritis of the knee after intra-articular infiltration, abscess after paravertebral injection, and one death from sepsis after a paravertebral infiltration done without proper asepsis (Madrid Declaration on Ozone Therapy, 4th edition (ISCO3, 2025), section 2.5).
- Clean the injection site with alcohol and let it dry before the needle goes through (as Dr. Wright does). Use sterile, single-use syringes and needles, and do not touch the vial adapter once it is out of its package (Wright).
- Draw up nutrient solutions in a hood with needleless vial adapters, as Dr. Wright demonstrates in his overview video. Check that every solution you inject is allowed by your licensing board, as he advises.
- Never inject ozone gas into a vein or an artery. Madrid strongly discourages both because of the risk of air embolism, and lists embolic events after paravertebral and intradiscal injections among its serious adverse events.
- The reported C. acnes septic arthritis (Richards 2026, above) is the reason to use ultrasound guidance and full asepsis for shoulder injections. Ultrasound was used in the two randomized shoulder trials below.
- Madrid's list of serious events is not shoulder-specific; the infection and embolism cautions above apply here too.
Contraindications
The Madrid Declaration lists these contraindications for systemic ozone (IV and blood). It gives no separate list for intra-articular injection, but many practitioners use the same screening before treating:
- Direct inhalation of ozone gas. The fluid lining the lungs has no antioxidants to buffer it, so inhaled ozone is toxic.
- Glucose-6-phosphate dehydrogenase (G6PD) deficiency (favism, acute hemolytic anemia). Madrid lists it as a contraindication for systemic ozone, but whether it is absolute is debated. MediSkill protocols start low and go slow; see the contraindications article.
- Toxic hyperthyroidism (severe Graves' disease)
- Thrombocytopenia (platelets under 50,000) and severe coagulation disorders
- Severe cardiovascular instability
- Acute alcohol intoxication
- Recent acute myocardial infarction
- Acute massive hemorrhage
- Convulsive states
- Hemochromatosis
- Patients receiving intravenous copper or iron therapy
Pregnancy. Madrid advises avoiding ozone therapy in the first trimester (weeks 0 to 13) and reserves its use in pregnancy for specialists in gynecology and obstetrics.
More detail
Landmarks and steps, as demonstrated by Dr. Wright
- Find the spine of the scapula. The site is just below it.
- Clean the site with alcohol and let it dry.
- Aim toward the acromion process and insert the needle. Stabilize the needle and syringe.
- Inject 2 to 4 mL of fluid, fewer if the patient is uncomfortable.
- Attach the ozone syringe, holding it exactly perpendicular, and push the gas in gently where the anesthetic went.
- Ask about the pressure, then remove the needle.
Equipment
- Sterile syringes and needles (gauge not stated for the shoulder)
- Dr. Wright's compounded pre-mixed solution (requires a prescriber), or individual nutrients drawn up in a hood with needleless vial adapters
- Ozone-oxygen gas in a syringe
- Alcohol prep; ultrasound as in the studies
What the studies used
Study doses are listed as printed in each paper and are not Madrid or Wright dosing.
- In 45 people with adhesive capsulitis, ultrasound-guided posterior intra-articular ozone (15 µg/mL, 10 mL, one injection after 5 mL of bupivacaine 0.125%) was no different from a corticosteroid at 8 weeks. Pulsed radiofrequency did best (Foula 2023).
- In 45 people with shoulder tendinopathy, ultrasound-guided subacromial ozone (5 mL, one injection) gave VAS 4.20 at 6 months vs 3.73 with steroid (no difference) and 2.73 with dextrose prolotherapy, which was better than ozone (p=0.042) (Babaei-Ghazani 2026).
- In 10 people with adhesive capsulitis (case series, no control), 8 to 10 weekly sessions of intra-articular ozone (7 mL, posterior) plus subcutaneous ozone and ozone cream took pain from 8 to 1.9 and the Constant score from 32.5 to 92.4. Pain lasted a few minutes after the first three injections (Peretti 2017).
Shoulder trials are small, and in two of them ozone did no better than steroid. No human study of the classic Prolozone mixture (procaine, vitamins and ozone) is in the study summary we drew on. Trials that add something to ozone used dextrose, somatropin or hypertonic saline, and the evidence for Wright's mixture itself rests on his clinical experience.
Video
Overview of the technique and the reasoning behind it: Prolozone Overview - Ozone Joint Injections | Dr. Jeff Wright.
Learn more
Background, benefits and research on injections: Ozone injections, full article.
Related protocols: Elbow Ozone Injection Protocol, Ankle Ozone Injection Protocol, Neck Ozone Injection Protocol.
Other injection protocols
For licensed practitioners. Educational reference only, not medical advice. Follow your scope of practice and local regulations.
