When should I refer a patient with frozen shoulder to a specialist for further evaluation or treatment?

Refer a patient with frozen shoulder to a specialist for further evaluation or treatment if:

• They have had pain and/or stiffness for up to 3 months and have not benefited from conservative measures such as analgesia and physiotherapy. Consider earlier referral if symptoms are severe or significantly impact quality of life.
• There is uncertainty about the diagnosis that cannot be resolved in primary care.
• They require an intra-articular corticosteroid injection but this cannot be performed in primary care due to lack of expertise.
• Red flags are present, such as trauma with pain and weakness or sudden loss of active arm elevation (suspected acute rotator cuff tear), shoulder mass or swelling (suspected malignancy), red skin with fever (suspected septic arthritis), trauma causing abnormal shoulder shape (possible dislocation), or new symptoms of inflammatory arthritis.
• There is undiagnosed severe shoulder pain or severe restriction of movement.
• There is a history of trauma and the patient is being seen acutely.

Referral should be urgent if red flags or suspected serious pathology are present, and routine if symptoms persist despite appropriate primary care management or diagnosis is unclear.