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Rapid response to:

Practice Uncertainties

What is the most effective treatment for frozen shoulder?

BMJ 2016; 354 doi: (Published 23 August 2016) Cite this as: BMJ 2016;354:i4162

Rapid Response:

Accurate diagnosis and effective treatment in frozen shoulder

It is disappointing that decades after accurate diagnostic criteria and treatment have been described (1,2,3), this article is almost a counsel of despair.

The authors note the absence of good evidence for effective treatment. That is the point. The trials have not been done, so we are left with empirical treatments based on individual clinicians’ experience.

If the patient has a frozen shoulder (better called adhesive capsulitis), a systematic clinical examination will reveal restriction of passive elevation and both rotations, with pain at the extremes of these movements. There is no painful arc and resisted movements are normal.

What is the best way to treat it? The authors say that with one intra-articular steroid injection there is moderate evidence of benefit. But why stop at one? If a series of injections (I use 2ml triamcinolone acetonide, 10mg/ml) is given at gradually increasing intervals – typically at 0, 1, 2, 3, 4 weeks – the inflammation and pain can thereby be safely aborted and the stiffness will thereafter gradually recover, without pain.

Since this simple treatment, which any interested GP can be trained to use, in my experience is regularly effective, there is no need to resort to risky interventions such as hydrodilatation or manipulation under general anaesthesia, and much suffering can be relieved.

1. Cyriax J, Textbook of Orthopaedic Medicine, Vol I. Diagnosis of soft tissue lesions. London: Baillière Tindall,1982: 127–67. 11th ed, vol II. Treatment by Manipulation, Massage and Injection. London: Baillière Tindall,1984: 88–106.

2. Ombregt L, Bisschop P, et al. A System of Orthopaedic Medicine. Churchill Livingstone 2003: 305, 310.

3. Symonds G, Accurate diagnosis and treatment in painful shoulder conditions. J Int Med Res 1975;3: 261–5.

Competing interests: No competing interests

02 October 2016
Gabriel Symonds
General practitioner