Routine X‐rays for suspected frozen shoulder offer little over diagnosis based on history and clinical examination alone

Abstract

Introduction Frozen shoulder is a common condition, 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 osteoarthritis. Despite the certainty of the guidelines there is a lack of evidence to support the use of routine X‐rays in this situation. Methods A retrospective review was performed of all X‐rays obtained in the diagnosis of frozen shoulder between February 2014 and August 2017 in an integrated musculoskeletal interface service. Results were screened and the prevalence of masquerading pathology was determined. Results A total of 350 shoulder X‐rays that had been performed for patients with a provisional diagnosis of frozen shoulder were reviewed. Of these, 213 were from female patients (60.9%), the mean age was 57.7 (standard deviation 10.4) years and 342 (97.7%) did not have any concerning features. Six (1.7%) had severe osteoarthritis, one (0.3%) had a fracture and one (0.3%) had a lucency. All eight patients with masquerading pathology had findings from the history and clinical examination which would have warranted an X‐ray, regardless of a differential diagnosis of frozen shoulder. Conclusions The findings of this retrospective review of a large number of X‐rays do not support the requirement of a routine X‐ray to rule out masquerading pathology to confirm the diagnosis. The data suggest that it is unnecessary for patients without a relevant clinical history suggestive of serious or masquerading pathology to undergo routine imaging.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

“…In the upper limb, shoulder MRI in patients with shoulder pain or rotator cuff tear had a low impact on treatment [ 157 – 159 ]. X-ray of the shoulder in atraumatic shoulder pain or frozen shoulder had a low impact on clinical management [ 160 , 161 ]. Further, orthopedic trauma, post-op, or post-splinting X-ray gave little to no change in management [ 162 – 169 ].…”

Pain-related beliefs are associated with arm function in persons with frozen shoulder

“…Since the exact etiology of FS is still unknown, there is no gold standard for the diagnosis of this condition which is, therefore, primarily based on clinical criteria. 2,39 Moreover, the differentiation of FS from other shoulder disorders is difficult in the initial stage. 1 Since we only included patients with a gradual onset of symptoms, which were stable or got worse, and were present for longer than two months, it is unlikely that we recruited persons with a shoulder condition other than FS.…”

Risk Factors for the Onset of Frozen Shoulder in Middle-Aged and Elderly Subjects Within 1 Year of Discharge From a Hospitalization That Involved Intravenous Infusion: A Prospective Cohort Study

“…Previous studies showed frozen shoulder is more common in women than men, with women comprising an estimated 58.0–60.9% of subjects with frozen shoulder ( 34 , 35 ). Rawat et al ( 36 ) found 68.75% of subjects with frozen shoulder were women.…”