Figure 1. Diagnosis of shoulder problems in primary care. Guidelines on treatment and referral.
302 M Shoulder & Elbow 7(4)
shoulder with arm by the side, over other disease (e.g. night pain). The onset of stiness may
movements. be rapid, and cause signicant functional decit, typ-
History of diabetes, cardiovascular disease or ically in individuals of working age.
other associations. Treatment should be tailored to individual patient
Normal X-rays in two planes to rule out needs depending on response and severity of
mechanical glenohumeral incongruity such as symptoms.
arthritis, avascular necrosis or dislocation of . Beware of red ags such as tumour, infection, unre-
the shoulder, which produce a similar clinical duced dislocation or inammatory polyarthritis.
picture. . Overall, a step-up approach may be adopted in
terms of degree of treatment invasiveness. Some
patients may have particular treatment preferences
based on their needs and referral to secondary care
may need to be considered early in such circum-
Red flags for the shoulder
stances. Shared decision-making is particularly
Acute severe shoulder pain needs proper and competent important for this condition.
diagnosis. Any shoulder red ags identied during pri- . A proportion of patients with frozen shoulder will
mary care assessment needs urgent secondary care respond to conservative treatment, and the response
referral. needs to be monitored. The most frequent indica-
tions for invasive treatments are persistent and
. A suspected infected joint needs same day urgent severe functional restrictions that are resistant to
referral. conservative measures.
. An unreduced dislocation needs same day urgent . Symptoms usually of up to 3 months with failure of
referral. conservative treatment measures may trigger referral
. Suspected malignancy or tumour needs urgent refer- to secondary care for consideration of more invasive
ral following the local 2-week cancer referral treatment. Severity of symptoms may necessitate
pathway. earlier referral; it would not be appropriate to persist
. An acute cu tear as a result of a traumatic event with ineective treatment measures and delay refer-
needs urgent referral and ideally should be seen in ral of patients who experience severe pain and
the next available outpatient clinic. restriction.
. Suspected inammatory oligo or poly-arthritis . Shared decision-making is important, and individual
or systemic inammatory disease should be patients needs are dierent. Failure of initial treat-
considered as a rheumatological red ag and ment to control pain, if degree of stiness causes
local rheumatology referral pathways should be considerable functional compromise, or if there is
followed. any doubt about diagnosis, prompt referral to sec-
ondary care is indicated.
. Physiotherapy rehabilitation is usually for 6 weeks
Treatment in primary care/community triage services unless patients are unable to tolerate the exercises, or
physiotherapists identify a reason for earlier referral
. Treatment depends on the phase of the disease, to secondary care. If there is patient improvement in
severity of symptoms and degree of restriction of the rst 6 weeks of physiotherapy, then a further
work, domestic and leisure activities. The aims of 6 weeks of therapy is justied.
treatment are: . Treatment timelines should include primary care and
Pain relief intermediate care time. Intermediate care should not
Improving range of motion delay appropriate referral to secondary care.
Reducing duration of symptoms
Return to normal activities
. Following interventions are suitable for primary Secondary care
care:
Analgesics/nonsteroidal anti-inammatory drugs . In a UK study of patterns of referral of shoulder
(NSAIDs) conditions, 22% of patients were referred to second-
Corticosteroid injection ary care up to 3 years following initial presentation,
Domestic exercise programme although most referrals occurred within 3 months.16
Supervised physiotherapy/manual therapy There is little evidence available on referral patterns
. This is a painful and debilitating condition, for frozen shoulder specically.
where the pain is often severe, mimicking malignant . Conrm diagnosis with history and examination.
M Rangan et al. 303
. Obtain imaging with plain radiographs to rule out Both procedures are typically performed as
mechanical glenohumeral incongruence such as arth- day care or 23-hour admission (depending on the
ritis, avascular necrosis or dislocation. time of the day the procedure takes place), unless
. Counsel patient fully regarding operative and non- clinical or social circumstances dictate otherwise.
operative options. Standard postoperative care should involve
. Ensure multidisciplinary approach to care with prompt start of physiotherapy and pain relief as
availability of specialist shoulder physiotherapists required.
and shoulder surgeons. Physiotherapy services vary across the country,
although up to 12 weeks of physiotherapy are
The most commonly used secondary care interven- typically required to maintain range of motion
tions are: in the treated shoulder.
Up to three outpatient follow-up appointments
Manipulation under anaesthesia (MUA) may be needed, depending on progress.
Arthroscopic capsular release (ACR)
Distension arthrogram (DA) or hydrodilatation
Physiotherapy and corticosteroid injection, usually
to supplement any of the above interventions
Linked metrics
Current interventions
. If symptoms fail to resolve with conservative treat-
ment, then MUA, DA or ACR may be considered. . BESS has led a survey of health professionals to
This choice depends mainly on expertise and clin- determine treatment pathways in current use in the
ician preference. UK, aiming to inform design of future studies of
. MUA is performed under general anaesthesia where eectiveness of interventions for frozen shoulder.
the arm is manipulated to tear the contracted
shoulder capsule in a controlled fashion, thus restor- MUA for frozen shoulder
ing external rotation and other movements. This is
supplemented with corticosteroid injection for pain . Diagnosis codes M750.
relief and with physiotherapy to maintain range of . Procedure codes (OPCS 4.5) W919, Z814.
motion post MUA.
. ACR involves arthroscopic surgery under general ACR
anaesthesia. The contracted capsule is released in a
controlled fashion using arthroscopic instruments, . Diagnosis codes M750.
frequently with radiofrequency ablation. The most . Procedure codes (OPCS 4.5) W784, Y767, Z814.
prominent contracture occurs anteriorly and release
of this improves external rotation. The inferior cap-
sule may be released with arthroscopic instruments, Outcome metrics
or with a controlled MUA.
. DA is a procedure where the shoulder capsule is . Length of stay day case (23 hours) and overnight.
injected with saline and local anaesthetic under pres- . Re-admission rate within 90 days.
sure to distend and disrupt the capsule. This proced- . Patient-reported outcome measure (PROM) pre-
ure is usually performed by an interventional procedure, and 12 months post-procedure.
radiologist, and does not require general anaesthe- . Infection/other adverse events.
sia. It is performed under uoroscopy or ultrasound
guidance and a radio-opaque dye may be used to
conrm accuracy of placement of the injected uid. Research and audit
Both DA and ACR are supplemented with post-
procedural physiotherapy to maintain range of . In partnership with Centre for Reviews and
motion in the aected shoulder. Dissemination in York, BESS members were com-
. It would be expected that surgical units performing missioned to conduct an evidence synthesis on
ACR or MUA: frozen shoulder by the National Institute for
Ensure patients undergo appropriate pre- Health Research Health Technology Assessment
operative assessment to ensure tness for surgery (NIHR-HTA) Program. This report titled
and to conrm discharge planning. Management of frozen shoulder: a systematic
Perform surgery or MUA in appropriately review and cost-eectiveness analysis has now been
resourced and staed units. published, and forms a key reference document that
304 M Shoulder & Elbow 7(4)
summarises current evidence, and areas for future interventions from available primary research is also
research on this topic.17 included in this report.
. A recent survey of health professionals in the UK has
found that the professional groups (general practi-
Summary
tioners, general practitioner with a special interest,
physiotherapists, orthopaedic surgeons) had dierent It is important to note that evidence to support the
views on the most appropriate treatment pathway for eectiveness of conservative treatment, surgical treat-
the frozen shoulder.18. There was, however, consensus ment or the potential benet of one over the other
that treatment should depend on phase of the disease remains limited. Until such evidence becomes available,
and a step-up approach would be appropriate. clinical and shared decision-making on accessing avail-
. In addition, a scoping review identied that most able interventions based on level of symptoms and
previous reviews have concentrated on one particu- functional restriction is recommended.
lar intervention and there is general paucity of good
primary research on frozen shoulder.19 . Corticosteroid injection. Based on best available evi-
. Members of BESS involved in the above evidence dence, corticosteroid injection has mainly short-term
syntheses are currently designing an interventional benet with a single injection. There appears to be
trial for frozen shoulder investigating commonly added benet with providing physiotherapy
used interventions for management in secondary promptly following steroid injection compared to
care. home exercise alone and physiotherapy alone.2023
. A validated clinical score, preferably a PROM, There is insucient evidence to conclude with rea-
should be used pre-operatively and following sonable certainty in what clinical situations steroid
treatment. injection, with or without physiotherapy, is most
. Acceptable scores include the Shoulder Pain and likely to be eective for treatment of frozen shoulder.
Disability Index (SPADI), Disability of Arm, . Sodium hyaluronate injection. A small number of
Shoulder and Hand (DASH) and the Oxford diverse studies, all of which may have a high risk
Shoulder Score (OSS). The disability subscale of of bias, provide insucient evidence to make conclu-
the SPADI has been used by several published sions about eectiveness of sodium hyaluronate in
reports for this condition. Other measures such as the treatment of frozen shoulder.2426
EQ 5D may be used for economic analysis. . Physiotherapy/physical therapy. Primary studies
. Scores should be captured pre-operatively and 1 year comparing dierent types of physiotherapy/physical
following intervention, which allows longitudinal therapies support the use of various techniques to
analysis to determine sustenance of treatment eect provide short- to medium-term benet. Some inter-
and consequences of any treatment-related adverse ventions in current use that were investigated include
events. therapeutic ultrasound,27 end range mobilization,28
short-wave diathermy plus stretching29 and high-
grade mobilization therapy.30 These interventions
Patient/public/clinician information should be stage of disease and response-dependent.
Based on best available evidence, there may be bene-
. Patient and public information ensure all available t from short-wave diathermy plus stretching and
information is provided regarding the benets and high-grade mobilization techniques in patients who
risks of all treatment options have already had physiotherapy or a steroid injec-
. Clinician information ensure access to available tion. There is insucient evidence to make conclu-
evidence. sions on best mode of physiotherapy for frozen
shoulder
. Acupuncture. The role of acupuncture in treatment
Evidence for effectiveness and cost of frozen shoulder is not clear. Available evidence
does not demonstrate clear benet.
effectiveness of treatment
NIHR-HTA commissioned evidence synthesis has led
to publication of report titled Management of frozen
shoulder: a systematic review and cost-eectiveness ana-
Oral drug treatment
lysis.17 This report provides full details of method- Likely to be benecial
ology, search strategy, economic analysis, decision
model, and suggestions for future research. An analysis . NSAIDS (oral) reduce pain in people with acute
of the eectiveness and cost eectiveness of capsulitis.
M Rangan et al. 305
Gojyukata: comparison of hyaluronate and steroid. Jpn J 33. Gam AN, Schydlowsky P, Rossel I, et al. Treatment of
Med Pharm Sci 1996; 35: 37781. frozen shoulder with distension and glucocorticoid com-
27. Dogru H, Basaran S and Sarpel T. Effectiveness of thera- pared with glucocorticoid alone: a randomised controlled
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2008; 75: 44550. 34. Kivimaki J, Pohjolainen T, Malmivaara A, et al.
28. Yang J-I, Chang C-W, Chen S-Y, et al. Mobilisation Manipulation under anaesthesia with home exercises
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randomised multiple treatment trial. Phys Ther 2007; shoulder: a randomised controlled trial. J Shoulder
87: 130715. Elbow Surg 2007; 16: 7226.
29. Leung MSF and Cheing GLY. Effects of deep and super- 35. Jacobs LG, Smith MG, Khan SA, Smith K and Joshi M.
ficial heating in the management of frozen shoulder. Manipulation or intraarticular steroids in the manage-
J Rehabil Med 2008; 40: 14550. ment of adhesive capsulitis of the shoulder? J Shoulder
30. Vermeulen HM, Rozing MP, Obermann WR, et al. Elbow Surg 2009; 18: 34853.
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31. Tveita EK, Tariq R, Sesseng S, et al. Hydrodilatation, 2007; 89: 1197200.
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