Collaborative management of frozen shoulder

Physiotherapist Greg Turpin and Dr Mareeni Raymond discuss a multidisciplinary approach to a musculoskeletal disorder.

There is evidence that steroid injection can reduce the duration of symptoms of frozen shoulder (Photograph: Zephyr/SPL)
There is evidence that steroid injection can reduce the duration of symptoms of frozen shoulder (Photograph: Zephyr/SPL)

Frozen shoulder or adhesive capsulitis occurs in 3% of the population. It presents most commonly in people over the age of 40 and more often in women. Frozen shoulder usually affects the non-dominant shoulder but can affect either. Relapses in the same shoulder are unusual. For reasons that are not understood, it is more common in patients with diabetes.

The glenohumeral capsule thickens and contracts due to synovial inflammation followed by capsular fibrosis. The capsule will build up dense type-III collagen similar to Dupuytren's contracture.

Frozen shoulder has a very specific natural history and clinical presentation. Diagnosis depends on a good history and examination to rule out other causes. Management includes careful explanation, management of pain and mobilisation.

History
Frozen shoulder usually presents with a gradual onset of severe pain and stiffness in one shoulder. This lasts on average for 30 months and has three distinct phases.

Phase one: severe generalised pain in the shoulder associated with stiffness in the absence of a history of trauma. Functional limitations present as difficulty putting on a jacket, driving or carrying objects. It is important to ask about occupation and how the condition may affect the patient's job. This phase lasts up to nine months.

Phase two: pain subsides gradually but the shoulder remains stiff and movement may become more limited. On examination there is reduced movement, particularly on external rotation. This phase lasts four to 12 months.

Phase three: the final phase lasts for between one and three years. The shoulder becomes less stiff and there is an increased range of movement.

The GP's examination
Examine the neck and shoulder. The patient holds their arm stiffly by their side in adduction and internal rotation. On palpation the whole shoulder joint may be tender. The principal diagnostic test should be passive external rotation. The classic finding is an inability to externally rotate the shoulder. It is important to screen for the main intrinsic and extrinsic causes of shoulder pain, impingement and neck problems.

If the clinician can diagnose frozen shoulder based on history and examination, there is no need for an X-ray. However, an X-ray may be useful in cases where there is atypical presentation or if the person is unresponsive to treatment. If blood tests are carried out, they will be normal. The most important role of the GP is to diagnose the condition, explain the natural progression and refer if appropriate. For the first stage, the mainstay of treatment is regular painkillers and advice to avoid aggravating factors but continue activities that are painless.

There is evidence that steroid injection, given early, can reduce the duration of the symptoms. One study has shown that injection in combination with physiotherapy is even more effective.

For patients with severe pain who are unable to tolerate non-invasive management, referral to orthopaedics for manipulation under anaesthesia has been beneficial and more recently, arthroscopic surgical release has been effective.

The physiotherapist
Physiotherapy may be beneficial for some but consideration should be given as to who is referred and when (see box). There can be a vast improvement in mobility and functional ability following a course of treatment using end-of-range mobilisation techniques and mobilisation with movement. High-grade manual therapy is generally more effective.

PATIENTS TO REFER TO A PHYSIOTHERAPIST
  • Patients with low levels of pain or where pain control has been successful.
  • Patients who need further time for education and explanation.
  • Those with functional difficulties with everyday activities or work.
  • Those with a positive attitude to hands-on treatment.
  • Those with secondary problems as a result of frozen shoulder, for example, impingement.

There is, however, no exact physiotherapy treatment or combination of treatments that have been shown to be efficacious. When considering referral, it is important to consider the nature of likely treatments and whether they will be suitable for the individual. Patients with high levels of pain may not be appropriate; however, in combination with steroid injection, physiotherapy may help.

For patients suitable for physiotherapy, high-grade mobilisation increases range of movement and reduces pain. Exercise can retrain muscle function.

How to work together
Good management will involve close communication regarding advice and education and an appropriate pain management strategy.

Simply acknowledging the severity of symptoms may help provide peace of mind, as may education on the potential spectrum and variability of symptoms in frozen shoulder. Giving the patient an understanding of pain mechanisms can enhance their ability to cope with the symptoms.

Advice on activity modification and alternative means of completing everyday activities and avoiding aggravating factors will help to minimise the impact on quality of life. Early delivery of this advice by the GP may reduce the need for pain management and allow the physiotherapist to treat more aggressively at an earlier stage.

In conclusion, the GP can improve the patient's pathway by assessing their expectations and explaining the course of the condition. The physiotherapist can spend more time with the patient assessing their condition in detail, providing further education and support and actively managing the symptoms.

  • Dr Raymond is a GP in east London and Mr Turpin is a physiotherapist in Lymington, Hampshire.

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