Frozen Shoulder

History:

• •Insidious onset of shoulder pain, often poorly localised
• •Night pain disrupting sleep (especially when lying on the affected side)
• •Progressive functional impairment: reaching behind back, overhead reach, fastening bra, reaching for seatbelt
• •Primary frozen shoulder typically has no clear precipitant; secondary forms follow trauma, surgery, or immobilisation

Examination:

• •Global restriction of both active AND passive range of movement - the defining clinical finding
• •Capsular pattern of loss: external rotation > abduction > internal rotation
• •External rotation is the earliest and most restricted movement
• •No true weakness (limitation is by pain or stiffness, not muscle pathology)

Three overlapping phases:

Red flags to exclude:

• •Significant trauma - fracture, dislocation, acute rotator cuff tear
• •Weight loss, night sweats - malignancy (Pancoast tumour)
• •Fever, warmth, acute swelling - septic arthritis
• •Rapidly progressive weakness - neurological cause

Frozen shoulder is a clinical diagnosis. Investigations exclude other pathology, not confirm the diagnosis.

• •X-ray (AP + axillary): First-line. Excludes glenohumeral OA, calcific tendinopathy, fracture. Normal in frozen shoulder (may show mild osteopenia from disuse).
• •Bloods: Consider HbA1c if diabetes status is unknown. TFTs only if clinically indicated. Inflammatory markers if inflammatory arthritis suspected.
• •USS: Not routinely required. Useful if rotator cuff tear needs excluding. Cannot assess the capsule well.
• •MRI: Not first-line. May show capsular thickening of the rotator interval and coracohumeral ligament. Indicated if diagnosis uncertain or pre-surgical planning needed.

First-line (community) - per NICE CKS:

• •Education: explain natural history, variable timeframes, generally self-limiting nature. Managing expectations is the single most important intervention.
• •Active self-management: pendular exercises, gentle stretching within pain tolerance.
• •Analgesia: paracetamol, short-course oral NSAIDs.

Intra-articular corticosteroid injection:

• •Glenohumeral (not subacromial) corticosteroid injection is effective for pain relief in the freezing phase and creates a window for rehabilitation.
• •Both ultrasound-guided and landmark-guided (posterior approach) techniques are acceptable.
• •Caveats: warn diabetic patients about 24-48 hours of temporary hyperglycaemia. Avoid repeating if a well-delivered injection gave minimal or no benefit.

Oral corticosteroids: Not recommended by NICE CKS for frozen shoulder.

Referral: NICE CKS suggests review at around 6 months; BESS guidance allows referral at around 3 months if conservative care is failing or symptoms severely affect quality of life or work.

Secondary care options:

• •Hydrodilatation (distension arthrography)
• •Manipulation under anaesthesia (MUA) - risks include fracture, dislocation, rotator cuff tear
• •Arthroscopic capsular release (ACR)
• •Per the UK FROST trial, no clear superiority of one procedure over another at 12 months.

• •Freezing phase: Gentle ROM exercises within pain limits. Avoid aggressive stretching. Focus on pain control.
• •Frozen phase: Progressive stretching and mobilisation. Sustained end-range holds. External rotation stretching is the priority.
• •Thawing phase: Active ROM and strengthening. Progressive functional rehabilitation.
• •Home exercise programme is the cornerstone - daily stretching matters more than weekly physiotherapy appointments alone.
• •Set realistic expectations about slow recovery.

• •NICE CKS: Frozen shoulder - Conservative first-line; consider intra-articular glenohumeral steroid injection in the freezing phase; refer if not improving by around 6 months.
• •BESS Frozen Shoulder Pathway - Allows earlier specialist referral (around 3 months) when symptoms are severe or quality of life is heavily affected.
• •UK FROST trial (Rangan et al, Lancet 2020) - Multicentre RCT comparing MUA, hydrodilatation, and arthroscopic release: no clear superiority at 12 months, supporting shared decision-making and case-by-case selection.
• •Diabetes association - Prevalence 10-38% in diabetes mellitus; bilateral disease in up to 40-50% of diabetic patients; HbA1c screening is reasonable in new presentations of unknown diabetic status.

• •Global restriction of both active AND passive ROM in a capsular pattern - this distinguishes frozen shoulder from rotator cuff pathology, which has weakness with relatively preserved passive ROM.
• •External rotation is the earliest and most restricted movement - frequently tested.
• •Glenohumeral (not subacromial) corticosteroid injection is correct for frozen shoulder - common exam trap.
• •Per the UK FROST trial: MUA and arthroscopic capsular release have similar 12-month outcomes - shared decision-making rather than guideline-superior choice.
• •Know the three phases (freezing 2-9 months, frozen 4-12, thawing 5-42) and that the condition is generally self-limiting.