Clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder


Have you ever had a painful shoulder? Did it get better on its own? I have a friend, not another Elf, who had bilateral frozen shoulders. It was a most functionally limiting and painful problem. Fortunately intra-articular steroid injections saved the day and made a huge difference to both pain and function.

woman with painful shoulder

Overhead activities become a problem, from brushing your hair to getting things out of the high cupboards.

If you have ever suffered from shoulder pain or an injury to your shoulder you will know how restricted movement and activities  become. It can happen spontaneously or gradually but all of a sudden you have to review how to tackle almost every daily activity. Overhead activities become a problem, from brushing your hair to getting things out of the high cupboards. Even the decision about what to wear becomes even more challenging, especially when everything is made so tight! Sometimes the diagnosis is straight forward and uncomplicated by other pathologies, but what guidelines do we have to help us with diagnosis, assessment and physiotherapy management of the contracted (frozen) shoulder

So thank goodness an old friend of the Musculoskeletal Elf, Nigel Hanchard, and colleagues have published a quick reference to their full guidelines that were developed using the highest quality evidence available at the time of publication. The quick reference guide – not intended to be considered in isolation – lists key points and recommendations.

Three aspects of the management of the contracted shoulder were considered.

  • Diagnosis
  • Assessment
  • Physiotherapy treatment

Summary of key points in diagnosis and assessment

  • There is no single agreed diagnostic reference standard for contracted (frozen) shoulder. However based on the evidence available, established practice and expert opinion the principal diagnostic test is passive external rotation which is painful and restricted in the contracted (frozen shoulder)
  • A positive passive lateral rotation test should be corroborated by history (screening for substantial trauma/serious pathologies, palpation (screening for gross crepitus suggestive of osteoarthritis) and ideally an X-ray which should be negative
  • Passive external rotation is difficult to measure and this should be acknowledged. It is recommended that the test be performed in standing; the range estimated to the nearest 30 degrees; and some indication of how limit of range was defined should be recorded. i.e. onset of pain or where pain becomes unbearable
  • It is recommended that the terms ‘pain predominant’ and ‘stiffness predominant’ be used to classify the stage of the condition
  • As a minimum a valid outcome measure specific to the region should be used to evaluate patients’ status, progress and outcome

Physiotherapy management

A variety of recommendations were made using the Grades of Recommendation, Assessment and Evaluation (GRADE) methodology. However due to a combination of imprecision inconsistency or inconclusive results from the studies identified the majority of recommendations were weak and in some circumstances no recommendations could be made. Thus no conclusions can be drawn from the evidence in terms of interventions.

The Musculoskeletal Elf’s view

The Musculoskeletal Elf

GRADE methodology provides guidance for rating quality and grading strength of recommendation in health care. The GRADE Working Group is made up of a group of health professionals, researchers and guideline developers from around the world who work together to develop an optimal system for rating the quality of evidence related to health care. It provides a systematic and transparent framework for clarifying questions, determining the outcomes of interest, summarizing the evidence that addresses a question, and moving from the evidence to a recommendation or decision.

One of the biggest problems patients with frozen shoulder complain of is sleep disturbance caused by pain, is this perhaps the only area we should target in treatment? Could advice and education play a significant role in allaying patient’s anxiety and putting them back control of their own management? The Musculoskeletal Elf recently reported the launch of an app by NHS24 in Scotland for Musculoskeletal conditions ‘musculoskeletal help’.

So do you need to reconsider how you manage patients with frozen shoulders? Do you already successfully manage patients with a frozen shoulder? Are you of the view that the best we can offer is pain management i.e. advice on NSAIDs or a steroid injection? Let us know what you management strategies are?

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