Shoulder - Frozen shoulder

Frozen shoulder guidelines

Cumulative incidence of frozen shoulder (adhesive capsulitis) is estimated at 2.4 per 1000 population per year (BESS/BOA guidelines).

This is a condition which in many cases appears to be idiopathic; it is known to be associated with diabetes in 30% of cases. It is divided into two broad phases which overlap: pain predominant and stiffness predominant. Appropriate intervention will vary depending on the stage at which presentation occurs. That being the case it is important that a clear understanding, not only of the diagnosis, but also of the stage, can be reached by the clinician.

Key Messages

Community based treatments including analgesia, landmark guided injection and physiotherapy are the mainstay of treatment for most shoulder conditions

Scope

Adults in primary care with frozen shoulder

Out of scope

Patients without frozen shoulder

Assessment

  • The salient features of frozen shoulder are global restriction of movement but especially external rotation

Differential Diagnoses

Red Flags

  • Combination of Trauma, Pain and Weakness should raise suspicion of Acute Cuff Tear
  • Mass or swelling should raise suspicion of tumour
  • Erythema, Fever should raise suspicion of infection
  • Unexplained wasting, significant sensory or motor deficit
  • Acute onset of pain and severe tenderness over the cuff

Investigations

AP and lateral plain radiographs to exclude (in the main) osteoarthritis may be considered

Management

The following strategies/interventions are suitable for employment in primary care (by either GP or physiotherapist):

  • Simple advice (rest/activity modification/heat packs)
  • Analgesia/NSAIDs
  • Landmark guided steroid injection into the glenohumeral joint
  • Physiotherapy exercise programme: Therapy in the early phase of acute pain tends not to be beneficial. Later on when stiffness predominates and pain is not disabling, it may be highly beneficial. The decision regarding when or whether to manage in primary care with symptomatic care/injection and/or rehab is highly dependent on the severity of the condition and the level of disability in the individual case, and cannot be "automated" but should be made by a clinician with some experience in managing the condition.

In a patient who is either severely disabled by pain and stiffness (severe night pain unrelieved by analgesia and inability to work or undertake activities of daily living without help), onward referral can be considered.

Referral

Referral Instructions

Refer to Orthopaedics e-Referrals Service Selection

  • Speciality: Orthopaedics
  • Clinic type: Shoulder
  • Service: DRSS-South Devon & Torbay-Orthopaedics-Shoulder & Elbow- Devon CCG - 15N

Referral Forms

Shoulder condition - PCT Referral form

DRSS referral form


Supporting Information

Pathway Group

This guideline has been signed off by South Devon and Torbay CCG.

Publication date: December 2017

 

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