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Deacon P1, Roberts S2, Dearne R1, Keen S3, Littlewood C4, Taylor S2
1Midlands Partnership Foundation Trust, Integrated Physiotherapy, Orthopaedic and Pain Service, Lichfield, United Kingdom, 2Midlands Partnership Foundation Trust, Integrated Physiotherapy, Orthopaedic and Pain Service, Tamworth, United Kingdom, 3Midlands Partnership Foundation Trust, Integrated Physiotherapy, Orthoapedic and Pain Service, Tamworth, United Kingdom, 4Keele University, Arthritis Research UK Primary Care Centre, Newcastle Under Lyme, United Kingdom
Background: Frozen shoulder is a common condition seen by physiotherapists and current guidelines state that it is a diagnosis of exclusion. Along with a history and clinical examination, routine x-ray is mandated to rule out any masquerading pathology such as fracture, dislocation, metastatic lesions or severe OA. Despite the certainty of the guidelines there is a lack of evidence to support the use of routine x-rays in this situation.
Purpose: The purpose of this retrospective review was to analyse all routine x-rays of patients with a provisional clinical diagnosis of frozen shoulder in an Integrated Musculoskeletal service over a 42 month period to identify the prevalence of masquerading pathology that might change the provisional diagnosis and thus confirm or challenge the role of routine x-ray in the diagnostic pathway.
Methods: A retrospective review was performed of all x-rays obtained in the diagnosis of frozen shoulder between February 2014 and August 2017. All x-ray requests and results were recorded on a secure confidential database. The radiologists' reports were screened for red flags by an Extended Scope Physiotherapist (ESP), who then inputted the conclusion onto the database. All clinical terms for frozen shoulder terms were manually searched in the database. Results were analysed to determine the prevalence of serious pathology in the clinical diagnosis of suspected frozen shoulder. The NHS number was then searched on an electronic x-ray system to gain further demographic information including patient age and sex which was then used for statistical analysis. Where serious pathologies/masquerades were recorded on the database, the patient notes where reviewed for further clinical information.
Results: 750 shoulder x-rays were analysed with 350 (46%) performed with a differential diagnosis of frozen shoulder. 213 were from female patients (60.9%), mean age was 57.7 years (SD 10.4). 342 (97.7%) did not have any concerning features. Six (1.7%) had severe OA, one (0.3%) had a fracture and one (0.3%) had a lucency. All 8 patients with 'masquerading' pathology had findings from the history and clinical examination that would have warranted an x-ray regardless of differential diagnosis of frozen shoulder.
Conclusion(s): Despite a general consensus that frozen shoulder is a diagnosis of exclusion following a “normal” x-ray, the data from this retrospective review of a large number of x-rays does not support the rationale of a routine x-ray in the early stages of the clinical pathway to rule out serious or masquerading pathology to confirm the diagnosis.
Implications:As a consequence the retrospective review can state that masquerading pathology when x-raying routinely in the diagnosis of frozen shoulder is rare. The day to day clinical data can challenge/ evidence national guidelines (without additional time required) and has provided a cost saving of £25 per patient x-ray (the national tariff for an x-ray) and an unnecessary radiation dose to the patient. Consequently, the lead authors' service pathway has been remodelled and patients with suspected frozen shoulder, and no clinical suspicion of serious pathology or masqueraders, are no longer routinely x-rayed.
Keywords: frozen shoulder, adhesive capsulitis, x-ray imaging
Funding acknowledgements: This retrospective review was carried out unfunded
Purpose: The purpose of this retrospective review was to analyse all routine x-rays of patients with a provisional clinical diagnosis of frozen shoulder in an Integrated Musculoskeletal service over a 42 month period to identify the prevalence of masquerading pathology that might change the provisional diagnosis and thus confirm or challenge the role of routine x-ray in the diagnostic pathway.
Methods: A retrospective review was performed of all x-rays obtained in the diagnosis of frozen shoulder between February 2014 and August 2017. All x-ray requests and results were recorded on a secure confidential database. The radiologists' reports were screened for red flags by an Extended Scope Physiotherapist (ESP), who then inputted the conclusion onto the database. All clinical terms for frozen shoulder terms were manually searched in the database. Results were analysed to determine the prevalence of serious pathology in the clinical diagnosis of suspected frozen shoulder. The NHS number was then searched on an electronic x-ray system to gain further demographic information including patient age and sex which was then used for statistical analysis. Where serious pathologies/masquerades were recorded on the database, the patient notes where reviewed for further clinical information.
Results: 750 shoulder x-rays were analysed with 350 (46%) performed with a differential diagnosis of frozen shoulder. 213 were from female patients (60.9%), mean age was 57.7 years (SD 10.4). 342 (97.7%) did not have any concerning features. Six (1.7%) had severe OA, one (0.3%) had a fracture and one (0.3%) had a lucency. All 8 patients with 'masquerading' pathology had findings from the history and clinical examination that would have warranted an x-ray regardless of differential diagnosis of frozen shoulder.
Conclusion(s): Despite a general consensus that frozen shoulder is a diagnosis of exclusion following a “normal” x-ray, the data from this retrospective review of a large number of x-rays does not support the rationale of a routine x-ray in the early stages of the clinical pathway to rule out serious or masquerading pathology to confirm the diagnosis.
Implications:As a consequence the retrospective review can state that masquerading pathology when x-raying routinely in the diagnosis of frozen shoulder is rare. The day to day clinical data can challenge/ evidence national guidelines (without additional time required) and has provided a cost saving of £25 per patient x-ray (the national tariff for an x-ray) and an unnecessary radiation dose to the patient. Consequently, the lead authors' service pathway has been remodelled and patients with suspected frozen shoulder, and no clinical suspicion of serious pathology or masqueraders, are no longer routinely x-rayed.
Keywords: frozen shoulder, adhesive capsulitis, x-ray imaging
Funding acknowledgements: This retrospective review was carried out unfunded
Topic: Musculoskeletal; Orthopaedics; Primary health care
Ethics approval required: No
Institution: NA
Ethics committee: NA
Reason not required: The study was not considered research by the NHS due to: No participants in the study being randomised, the study protocol did not demand changing treatment/ changing care from accepted standards for any patients involved and the findings from the review were not going to be generalisable
All authors, affiliations and abstracts have been published as submitted.
