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Frozen Shoulder


Referrals for USS guided steroid injections to RCHT Clinical Imaging have restarted.  Please note there is limited capacity so referrals should be reserved for patients with significant disabling and persistent symptoms.  Please click here for full details



Covid-19 Update: Corticosteroid Injections During The Coronavirus Pandemic  

Please ensure and document that a discussion has happened that the patient is aware corticosteroid injections pose a possible and quantifiably unknown increased risk of, and complications from, Covid and the possible risk of reduced Covid vaccine efficacy prior to performing.  Secondary care referrals for steroid injection, including image guided injections, require the patient to be counselled and risk assessed prior to referral and this documented in the referral.  Please see guidance available here for detailed information. 


 

Clinical Presentation and Causes

Primary                                  Idiopathic


Secondary associated with Trauma

                                                Rotator cuff disease and impingement

                                                Cardiovascular disease

                                                Hemiparesis

                                                Diabetes (incidence 10-36%)1

Phase 1

Progressive constant pain on movement

Lasts 2 to 9 months

Phase 2

Stiffening/freezing phase with restriction in all planes of movement

Gradual reduction in pain to end of range of movement

Lasts 4 to 12 months

Phase 3

Resolution/thawing phase

Improvement in range of motion and stiffness, end range pain may persist until resolved1

Lasts 12 to 42 months

 

 

Primary Care Management

  • Self care advice2

Continue to use the arm to maintain movement and ease spasm, avoid movements that worsen the pain

Take analgesia as advised when required

Hot packs may be helpful

Support the arm with pillows at night to prevent rolling onto the affected shoulder

  • Appropriate tailored analgesia
  • Xray to exclude OA as very similar presentation.  If moderate to severe OA Glenohumeral Joint on Xray refer Orthopaedics (link to OA GHJ Guidelines)
  • Physiotherapy
  • Consider a trial of steroid injections into the glenohumeral joint in-house or via the inter-practice referral system. 

http://rms.kernowccg.nhs.uk/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/orthopaedics/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/orthopaedics/alternative_orthopaedic_related_services/musculoskeletal_corticostero

Do not give a steroid injection if:
A steroid injection has already been given and there was minimal or no benefit
The pain has settled and stiffness is the predominant feature
Contraindications present
  • Patient education and information leaflets

 

Acupuncture, electrical stimulation and hyaluronic injections have unknown effectiveness.1

 

 

MSK Interface

  • Significant pain affecting sleep, activities of daily living and employment
  • Diagnostic uncertainty
  • Local physiotherapy should be tried first unless there is diagnostic uncertainty

 

An X ray within 6 months is required for the referral. 

If a steroid injection has been performed please detail the exact site and response.

Exclusion Criteria

  • Red flag pathology
  • Severe symptoms with functional limitations and willingness for surgery
  • Previous joint replacement or significant major surgery to the same joint
  • Patients under 16 years
  • Hand and foot problems
  • Multiple/inflammatory arthropathy
  • Lumps, bumps, ganglia

All referrals for secondary care management need to go through MSK Interface.  MSK Interface can directly refer to Orthopaedics if then required. 

 

Primary care referral to Orthopaedics for Frozen Shoulder will not be accepted. 

 

Patient Information Leaflets

Patient Information Leaflet https://patient.info/health/frozen-shoulder-leaflet

NHS Choices http://www.nhs.uk/Conditions/Frozen-shoulder/Pages/Introduction.aspx

Arthritis Research UK Shoulder Pain Leaflet http://www.arthritisresearchuk.org/arthritis-information/conditions/shoulder-pain.aspx

British Elbow and Shoulder Society exercise videos Frozen Shoulder – British Elbow & Shoulder Society (bess.ac.uk)

 

 

References

  1.  BESS/BOA Patient Care Pathways Frozen Shoulder, Shoulder & Elbow 2015; 7(4) 299-307
  2. National Institute Of Clinical Excellence.  Clinical Knowledge Summaries Shoulder Pain, April 2017

 

 

Review Date                            11/03/2022

Next Review Date                    11/03/2023

Author                                      Dr Rebecca Hopkins

Contributors                              Mr Mark Norton, Mr Tim Powell, Dr Rebecca Hopkins

 

Version 1.2