Background: Stiff shoulder, also termed adhesive capsulitis or frozen shoulder, is a common clinical problem, particularly in diabetic individuals. Among the available interventions, hydrodilatation combined with manipulation is emerging as a minimally invasive option. Moreover our approach utilizes awake hydrodilatation and manipulation without general anesthesia or imaging, making it a safe, low-cost, and widely applicable method. Aim: To evaluate the functional and clinical outcomes following a combined technique of hydrodilatation and awake manipulation in patients with stage 2 stiff shoulder. Methods: This retrospective study included patients treated at SRI LAKSHMI NARAYANA INSTITUTE OF MEDICAL SCIENCES -- PONDICHERRY between June 2018 and August 2023. Inclusion criteria were clinical signs of shoulder stiffness, radiologically normal joint, partial-thickness cuff tear on MRI suggestive of adhesive capsulitis, and failure of conservative management. Patients underwent hydrodilatation with 0.2% ropivacaine followed by manipulation under no general anesthesia and an aggressive physiotherapy protocol. Outcomes were measured using range of motion (ROM), Oxford Shoulder Score (OSS), and Visual Analog Scale (VAS) at 4 weeks and 1 year. Results: A total of 53 patients were treated (mean age: 54 years; female predominance; high diabetic prevalence). Statistically significant improvements were seen in ROM and functional scores: OSS improved from 48 to 76, VAS decreased from 7 to 2, and abduction improved from 70° to 110°. No complications such as fractures or neurovascular injury were noted. Forty patients had excellent outcomes at 1-year follow-up. Conclusion: Hydrodilatation with manipulation, performed on awake patients without general anesthesia or imaging guidance using long-acting regional anesthetic (0.2% ropivacaine), is a novel, cost-effective alternative and safe treatment for stiff shoulder. By eliminating anesthesia and imaging requirements, this approach can serve as a first-line interventional procedure in resource-limited settings, achieving excellent outcomes in both diabetic and non-diabetic patients. Further prospective studies with larger sample sizes and RCTs are warranted