12/05/2025
Hot off the Press 🔥
An International Consensus on the Etiology, Risk Factors, Diagnosis, and Management for Individuals with Frozen Shoulder: A Delphi Study 📑
Background and Objective: 🌟
Frozen shoulder (FS) is frequently characterized by chronic inflammation and fibrosis of the glenohumeral joint (https://pubmed.ncbi.nlm.nih.gov/17673588/). The term ‘FS’ was first introduced by Earnest Codman in 1934 to emphasize the debilitating loss of shoulder range of motion (ROM) in patients afflicted with this condition. Codman described this condition as ‘difficult to define, difficult to treat and difficult to explain from the point of view of pathology’ (https://pubmed.ncbi.nlm.nih.gov/2182257/).
Much of Codman’s sentiments around FS remain true today. Frozen shoulders are classified as primary or secondary, where primary FS is idiopathic and secondary FS is associated with a systemic disease such as diabetes (secondary systemic FS), following breast surgery or ipsilateral clavicular, humeral or scapular fracture (secondary extrinsic),or history of surgery (secondary iatrogenic FS).
📘 A brand-new Delphi study by aimed to establish an international, multiprofessional consensus on the etiology, risk factors, diagnosis, and management of FS to guide clinical practice and future research. 🩺 (https://pubmed.ncbi.nlm.nih.gov/40042389/)
Methods: 🔍
The study employed a three-round Delphi process (January to March 2024) involving 14 international experts (12 physiotherapists, 1 orthopedic surgeon, 1 physiatrist) from five countries. 🌐 A steering committee developed survey questions based on recent literature, covering etiology, risk factors (biophysical and psychosocial), diagnosis, and management. 📝 Consensus was set at ≥80% agreement, with 79% considered due to near-threshold responses. Surveys used a Likert scale and open-ended feedback, with 117, 101, and 59 questions in rounds 1, 2, and 3, respectively.
The study adhered to ACCORD guidelines for Delphi reporting. ✅
Results: 🎉
Consensus was reached on 101 items across four key areas:
Etiology (9 items): 🧬
Secondary FS is associated with diabetes mellitus, trauma, shoulder arthroscopy, thyroid disease, prolonged immobilization, adrenocorticotropic hormone deficiency, metabolic syndrome, connective tissue disorders, and hyperlipidemia. 🩺
Risk Factors (40 items): ⚠️
💡Biophysical factors (e.g., diabetes, thyroid disease, female s*x, menopause, contralateral FS history, hyperlipidemia, metabolic syndrome) were deemed more influential than psychosocial factors in FS development.
Biophysical factors like diabetes, thyroid disease, ipsilateral FS, and Parkinson’s disease impact management and outcomes. 🧠
Psychosocial factors (e.g., depression, anxiety, fear-avoidance, cultural views, self-efficacy, mental stress) influence management and outcomes but not FS development. 😔
Diagnosis (19 items): 🩻
FS diagnosis requires ruling out competing conditions (e.g., osteoarthritis, muscle guarding) but not necessarily rotator cuff tears or bursitis. 🚫
Key signs/symptoms include night pain, pain with rapid movements, discomfort lying on the affected shoulder, pain at end-range, age >35 years, global loss of active/passive range of motion (ROM), and reduced external rotation (decreased passive external rotation greater than active and decreased external rotation with increasing abduction). 😖
Management (33 items): 💉
FS does not resolve equally without treatment. 🚫
Early phase (pain > stiffness): Effective interventions include corticosteroid injections, patient education, and reassurance. 👍 Ineffective treatments include massage, surgery, immobilization, heat, ice, electrical stimulation, ultrasound, hydrodilatation, and manual therapy. 🙅♂️
Later phase (stiffness > pain): Effective treatments include surgery (capsular lysis/manipulation under anesthesia), hydrodilatation, manual therapy, and education/reassurance. 🙌 Ineffective treatments include massage, acupuncture, immobilization, ice, electrical stimulation, and ultrasound. 🚫
General recovery aids include provider education, initial evaluation, exercise plans, medication, hydrodilatation, follow-up ability, and reassurance of no sinister pathology. 🥳
Imaging is not effective for recovery. 📷🚫
Discussion: 🗣️
The study aligns with existing literature, confirming diabetes, trauma, and metabolic conditions as key secondary FS etiologies.
📚 Biophysical risk factors dominate FS development, while psychosocial factors influence management and outcomes.
Diagnosis relies on clinical examination, with specific signs/symptoms guiding identification.
🩺 Management varies by FS stage, with tailored interventions improving outcomes.
The consensus highlights the lack of recent, high-quality CPGs, with only two outdated guidelines available. 😕
Strengths and Limitations: 💪❓
Strengths: High response rate (100% after round 1), international expert input, and relevance due to outdated CPGs. 🌟
Limitations: Predominance of physiotherapists may bias results, and findings reflect expert opinion, not direct evidence of intervention effectiveness. 🤔
Conclusion: 🎯
This consensus provides a foundation for understanding FS etiology, risk factors, diagnosis, and stage-specific management, addressing gaps in current CPGs. 🏗️ It emphasizes biophysical factors, clinical diagnosis, and tailored interventions. Future research should explore precision-based approaches to optimize FS management. 🚀
