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LETTERS: Simon J Mellor and Vipul R Patel Steroid injections are helpful in rotator cuff tendinopathy BMJ 2002; 324: 51 [Full text]

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The current practice on management of frozen shoulder in secondary care

Dimitrios G Kassimos, Gabriel Panayi, Ernest Choy, Ghada Yanni.   (18 May 2002)

The current practice on management of frozen shoulder in secondary care 18 May 2002
Dimitrios G Kassimos, Consultant Rheumatologist Guest Hospital, Tipton Road, Dudley DY1 4SE, Gabriel Panayi, Ernest Choy, Ghada Yanni. Send response to journal: Re: The current practice on management of frozen shoulder in secondary care	Editor, We read with interest the article of Speed CA on corticosteroid injections in tendon lesions (1) and the ensuing correspondence (2) . While intra-articular (IA) corticosteroid injection is often used to treat tendinopathy of the shoulder, our survey of Rheumatologists in the South East Thames Region showed that IA corticosteroid injection is used extensively to treat frozen shoulder (FS). FS is a common problem defined as “a self limited condition of unknown aetiology characterised by pain and restriction of all active and passive movements in all directions without an underlying arthritis” (3). A questionnaire was sent to 65 Rheumatologists (Registrar grade and above) in the South East Thames Region. The questions included definition, diagnosis and management of FS. Forty-seven Rheumatologists (72%) returned the completed questionnaire. Thirty-one (66%) gave the correct definition of FS and diagnosed it on clinical grounds only. Eight (16%) used radiographs to exclude underlying diseases. A significant proportion of those surveyed used simple analgesics and oral non-steroidal anti-inflammatory (NSAIDs) (72%) as the mainstay of treatment. Twenty-three (41%) used other medications including dothiepin, antidepressant and capsaicin. Widespread usage of intra-articular (IA) steroids was reported by 46 (98%), 35 (74%) used combination of lignocaine and steroids, 6 (13%) short acting and 32 (68%) long acting . Six (13%) used preparations other than steroids for IA injections but only three specified (one Marcain and two suprascapular nerve block). The timing, site and frequency of IA steroid injections were variable and although thirty-four (72%) injected at the onset of symptoms, 41 (87%) did so at any time. The glenohumoral joint was the preferred route for IA steroids by 20 (49%) more than once with an interval time of two to four months and 27 (57%) combined oral NSAIDs with IA injections. Thirty-six (77%) believed in the benefit of physiotherapy, mobilisation being the commonest reason for referral by 35 (74%). Two out of the ten (22%) Rheumatologists who did not believe in physiotherapy, still referred patients for treatment. Seven (14%) Rheumatologists believed physiotherapy to be the only means of therapy. Nineteen (41%) Rheumatologists referred patients to Orthopaedic Surgeons, the reason for referral in 13 (28%) being for manipulation under anaesthetic. Twenty-six (55%) Rheumatologists followed up patients with FS. This survey suggests that FS is recognised as a rheumatological entity. As expected intra-articular steroids are the most commonly used treatment modality for this condition. There is no consensus on the timing, site and frequency of IA steroid injections. As intraarticular corticosteroid injection is likely to be beneficial on Frozen Shoulder, research is needed on the management of this common cause of shoulder pain in primary and secondary care (4). Acknowledgement We are grateful to Rheumatologists in the South East Thames Region who responded to our request for information. Dr D Kassimos is on sabbatical leave from the Ministry of Defence of Greece REFERENCES 1. Speed CA. Corticosteroid injections in tendon lesions. BMJ 2001; 323: 382-6. 2. Mellor S. Patel V. Steroid injections are helpful in rotator cuff tendinopathy. BMJ 2002; 324: 51. 3. Risk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum. 1982; 11: 440-52. 4. Speed C, Hazelman B. Shoulder pain. Clinical Evidence 2001; 5: 850 -864.