Contracted shoulder

Also referred to as Frozen Shoulder or Adhesive Capsulitis.

In Primary Contracted Shoulder patients present with pain of insidious onset that can be constant, and may refer below the elbow as far as the wrist/hand. Patients with known trauma or pre-existing medical condition, such as Diabetes, may develop a secondary shoulder contracture.

Consider differential diagnosis of Osteoarthritis (OA) of the Glenohumeral Joint when a capsular pattern exists. Subjective markers for degenerative change may include the presence of morning stiffness or previous proximal humeral fracture.

Clinical examination reveals a capsular pattern of restriction (Cyriax.1982) i.e. Restricted External Rotation> Abduction> Internal Rotation. The limitation of active and passive movement should be similar and it is well documented that the limitation of external rotation from neutral is the most significant objective measure (Hanchard et al 2011).

It is not unusual to have false positive impingement tests in the presence of a Contracted Shoulder and clinicians should regard signs of Contracted Shoulder over impingement (Hanchard et al, 2011).
Anecdotal evidence suggests palpation is painless even in the most painful patients, and clinicians should note the presence of any joint crepitus on movement which may aid differential diagnosis from that of Glenohumeral OA.

An X-ray is the only method of excluding Arthritis or Avascular Necrosis. An X-ray is not essential prior to commencing intervention but should be considered if the patient fails to improve. A Contracted Shoulder will have a normal X-ray.

Overview

• Optimise pain management
• Advice/education/supervised neglect
• Consider CSI if pain problematic
• Consider CSP guidelines

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status.  Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Pharmacology - advice re NSAIDS/Analgesia. Patient to discuss with pharmacist/GP if suboptimal.

Corticosteroid Subacromial Injection (CSI)  - intra-articular steroid injection has been demonstrated to be the only evidence-based course of conservative treatment (Buchbinder et al, 2003, and Carette et al, 2003). It is used where pain is the dominant feature, regardless of the extent of stiffness. It is important to advise patients that the CSI is performed for pain relief only. Any improvement in range of movement (ROM) is unlikely, and if experienced would be a bonus and perhaps the result of reduced muscle spasm.
Patients with severe pain sleep disturbance and functional limitation should be offered early CSI.

Exercise/Stretching - rarely can the patient tolerate stretching unless it is in the latter stages. If stretching/exercise increases pain post exercise, or does not improve range then it should be discontinued.  Physiotherapy applied inappropriately has been shown to prolong the course of the process (Diercks at al, 2004).

Supervised neglect- patients who are coping well can be reassured and advised on exercise and discharged/given an open appointment (Diercks et al,2004). Patients should not require much input.

Use of Support Workers 
There is no evidence to recommend use of Ti3 staff specifically but they could be used to check on a patient’s Home Exercise Programme if indicated (See Supervised neglect).

Non-evidence based strategies

Electrotherapy- There is insufficient evidence to support any electrotherapy input.
Acupuncture- There is insufficient evidence to support acupuncture.
Addition of mobilisations -There is insufficient evidence to support the addition of mobilisations to home exercise.

For a comprehensive review supporting this guidance staff are advised to access The CSP endorsed guideline: 'Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder v.1.6 'standard' physiotherapy' (Hanchard et al, 2011).

OA shoulder

Pharmacology - advice re NSAIDS/Analgesia. Patient to discuss with pharmacist/GP if suboptimal.
CSI -  if Glenohumeral OA is suspected/known,  CSI should be considered from the outset (Buchbinder et al,2003) along with an exercise programme including local muscle strengthening and general aerobic fitness (NICE,2008).
Exercise/Stretching - an exercise programme including local muscle strengthening and general aerobic fitness is recommended (NICE,2008).
Insufficient Evidence:
There is no evidence for the use of U/S, Laser and SWD in OA.

Progressing as expected (up to 3 Rxs) before discharge or onward referral. 

Refer to ortho, GP, other

Contracted Shoulder
Escalation within MSK Physiotherapy:
CSI should be offered as a first option if pain severity warrants and /or patient not coping. It should be discussed with an injecting PT/Senior if patient fails to progress as expected. Follow local policy.

Escalation to outwith MSK Physiotherapy:
It is a quality of life decision. Patients who fail to progress after PT +/ or steroid injections, who have severe pain and functional limitation and WHO WOULD CONSIDER SURGICAL INTERVENTION should be referred to Orthopaedics.

OA Shoulder
Escalation within MSK Physiotherapy:
CSI should be offered as a first option if pain severity warrants and /or patient not coping. It should be discussed with an injecting PT/Senior if patient fails to progress as expected.

Escalation outwith MSK Physiotherapy:
If OA is known or considered as a differential diagnosis and the patient has severe pain and functional limitation and has not progressed with CSI/PT, then staff should refer to Orthopaedics. The patient should be willing to consider surgery.
The NICE guideline on the management of OA recommends:
‘Referral for joint replacement surgery should be considered for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment. Referral should be made before there is prolonged and established functional limitation and severe pain’ (NICE 2008 pp6).

National Institute for Health and Clinical Excellence. (2008) Osteoarthritis: Care and management of adults (CG177).

Buchbinder,R., Green,S. and Youd,J.M. 2003. Corticosteroid injections for shoulder pain. Cochrane Database of Systematic Reviews 2003, issue 1. UKDOI: 10.1002/14651858 CD004016 . Link Here (link correct as of 12/07/19).

Carette, S., Moffet,H., Tardiff,J., Bessette, L., Morin, F., Fremont, P., Bykerk, V., Thorne, C., Bell, M. Bensen, W., and Blanchette, C. 2003. Intra-articular steroids, supervised physiotherapy or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo -controlled trial. Arthritis and rheumatism, 48(3) 829-838. Link Here (link correct as of 12/07/19). 

Cyriax, J.H. 1982. Textbook of Orthopaedic Medicine : Vol. 1: Diagnosis of Soft Tissue Lesions.

Diercks,R.C., Steven,M. 2004. Gentle thawing of the frozen shoulder: A prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. Journal of Shoulder and Elbow Surgery 13(5) 499-502. Link Here (link correct as of 12/07/19). 

Hanchard, N., Goodchild, L., Thomson, J., O'Brien, T., Richardson, C., Davison, D., Watson, H., Wragg, M., Mtopo,S., Scott, M. 2011. Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder v.1.6 'standard' physiotherapy. Endorsed by the Chartered Society of Physiotherapy.

NHS GGC Physiotherapy Service - shoulder https://www.nhsggc.scot/hospitals-services/services-a-to-z/musculoskeletal-msk-physiotherapy/msk-self-help-and-information-shoulder/

NHS Inform may provide useful information, especially for those presenting to physiotherpay within the time frames of natural recovery.
https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/shoulder-problems (link correct as of 18/03/2024).

Patient education on the self-limiting nature of contracted shoulder in terms of time frames and prognosis is paramount. Consider use of local/national publications to support this.